Background

Death, suffering, and pain in others evoke a wide range of emotions in all people, but more so in healthcare workers [1]. Nurses work on the frontline of healthcare and often encounter patient deaths [2]. Previous studies have reported that nurses in different work settings from several countries showed low or moderate death anxiety [3]. Moreover, when nurses are confronted with “loss and death,” it could lead to feelings of fear, frustration, and distress, and even job burnout [4, 5]. Therefore, given the emotional and psychological pressures that a patient's death places on nurses [6], death education is necessary to successfully manage the emotional responses to death and dying.

In the USA, 52% of medical schools and 78% of nursing schools had mandatory courses in death education by 2004 [7]. In 2002, the UK government included death and dying education in the formal national and school curriculum, clarifying the standardized content of death and dying education for students. In addition to Europe and the USA, many Asian countries, such as Japan and South Korea, have also introduced death education courses in medical schools. South Korea advocates the “experiential” death education method [7]and has established a relatively systematic death education curriculum and teaching system, the teaching effectiveness of which has been recognized worldwide. Compared with relatively mature foreign death education, China has long been limited by traditional concepts such as “rebirth and death,” “unknown life, how to know death.” The development of death education in China is backward, and lacks practical education [8]. Death education for medical students, especially nursing students, is mainly at the theoretical stage. Currently, there are only a few provinces in China where medical schools conduct death education activities, and they are mainly in the form of elective courses. For example, Shandong University offers a course on “Death Culture and Life and Death Education,” and the School of Nursing at Southern Medical University offers a course on “Human Death.”

As for nursing students entering their internship, studies have reported death anxiety, fear of death, and reluctance to care for dying patients among nursing trainees [9,10,11,12]. Furthermore, some scholars have found that death anxiety among nursing trainees is higher than among medical school students in general [13], and their level of death anxiety affects not only the quality of care but also their future career choices. Therefore, adequate professional education and training in areas related to death are needed from the undergraduate level [14, 15], which is considered a critical period for the formation of professional identity and attitudes toward death [16]. However, so far, the literature on the best teaching strategies for death education for nursing trainees is limited [17]. In summary, death education in China is mainly theoretical, with no mature teaching system as in foreign countries, and there are few studies on death education models for nursing trainees. Therefore, it is of great significance to construct a model of nursing students’ death education combined with clinical practice.

In 2014, the Chinese American Coalition for Compassionate Care used Heart to Heart (HTH) cards (the Coda Coalition's Wish cards combined with playing cards and designed as a Chinese version for each stage of life) [18] to conduct a tea party where participants could talk about end-of-life, life, and death issues over a cup of tea, based on the reality of dying patients. This kind of practical death education can raise participants’ awareness about death and allow them to discuss their personal choices regarding medical care, quality of life, and afterlife arrangements at the end of life, similar to the Death Café [19]. In clinical practice, healthcare professionals can achieve communication between patients and their families in the form of HTH cards, which allow both parties to open up and reveal their true feelings, and the Peace of Mind Tea House is currently used mainly by dying patients in Taiwan and Chinese Americans in China [20].Although the implementation of death education mediated by the Peace of Mind Tea House is still in the developmental stage, it has been used and well evaluated at the nurse and patient levels. In terms of application to clinical nurses, Cheng et al. [21] provided death education to oncology nurses using HTH cards, which allowed them to release death-related emotions and stress while thinking about and facing death. At the end of the study, most nurses rated this educational model highly as a meaningful death education activity. In another study, Tao et al. [8] implemented the HTH cards workshop with oncology nurses. The results showed statistically significant differences in nurses’ attitudes toward death before and after implementing the HTH cards workshop.

Some researchers have also applied the workshop to clinical patients. For instance, Cheng et al. [22] selected lung cancer patients to participate in the Peace of Mind Tea House, and the intervention found that using the Peace of Mind Tea House could help to better open up the topic of death, understand patients’ end-of-life needs, and improve patients’ agreement with advance directives for medical care. In addition, some researchers evaluated the effect of using HTH cards with a scale. For instance, Liu et al. [20] implemented HTH cards-guided dignity care among patients with malignancy. Through the intervention, the scores of five factors of the dignity scale in the observation group were significantly lower than those in the control group, which not only improved the sense of dignity in terminally ill patients with malignancy but also reduced anxiety and depression in primary caregivers. Similarly, researchers [23] used the HTH cards among oncology radiotherapy patients in a tertiary hospital in China to assess patient preferences for end-of-life care, and the results showed that more than 70% of participants rated the cards highly. The researchers concluded that the cards could be used as a communication tool to facilitate end-of-life discussions between Chinese cancer patients and healthcare providers. In conclusion, the HTH cards are easy to use and suitable for people from different cultural backgrounds. When conducting activities, the cards can be used to avoid talking about sensitive content that one does not want to mention and to freely express inner views about death and fear, which has a high application value [20].

Based on the background introduction above, it is evident that negative attitudes among nurses and nursing students may arise from a lack of knowledge about end-of-life issues [24]. Therefore, researchers have been developing end-of-life education programs to address this knowledge gap [12]. Scholars have discovered that nurses overcame their pre-intervention fear of death and were able to better support their patients by applying relevant educational intervention models [25]. To sum up, it is crucial to develop a death education model that integrates with clinical practice, and there is currently limited research on the Peace of Mind Tea House as a death education model in China [21]. From the perspective of nursing interns, this study explores the application effect of death education based on the Peace of Mind Tea House for nursing trainees, which can play a certain role in promoting the development of death education model and enrich the research on death education in China.

The study’s research hypotheses are as follows:

First, is it feasible and effective to apply the HTH cards to carry out death education to nursing trainees?

Second, does death education in a hospital in Xiamen promote nursing trainees’ respect for life and understanding of the value of life, and does it have an effect on their attitudes towards death, death anxiety and the meaning of life?

Method

Aim

This study aims to explore the impact of the death education model based on the Peace of Mind Tea House on nursing trainees’ attitudes toward death, death anxiety, and life meaning to provide enlightenment for constructing a death education model combined with clinical practice.

Design

Convenience sampling was used to recruit 92 nursing students who chose to practice at a hospital in Xiamen during the academic year 2020/062021/03.46 students were in the intervention group and 46 in the control group. At the end of the two-month intervention period, 13 participants were lost to follow-up (six in the intervention group and seven in the control group), representing 14% of the total study participants. After excluding the pre-follow-up data, 79 student nurses were included (40 in the intervention group and 39 in the control group).

Setting and sample

According to the assumption of test level bilateral α = 0.05 and test efficacy 1-β = 0.90, the number of sample cases required for the intervention and control groups respectively can be calculated by the following simple formula [26]:

$$\mathrm N1=\mathrm N2=2\;\left[\;\left({\mathrm t}_{\mathrm\alpha/2}+{\mathrm t}_{\mathrm\beta/2}\right)\;\mathrm S/\mathrm\delta\right]\;^2$$

Taking the combined score of death anxiety as the calculation index [27], S took the square root of the combined variance of the two groups after the intervention as 2.83, δ as the difference of the two means as 2.1, checking the table to get tα/2 = 1.96, tβ = 1.282, getting the sample size of 38 cases needed for each group, while accounting for potential sample attrition, taking the sample attrition rate of 20%, calculating the sample size of final was 92 cases, and each group was 46 cases.

Convenience sampling was used to recruit participants.The inclusion criteria were: (1) individuals without communication or reading disabilities, (2) those who had not previously been exposed to the Heart to Heart cards, (3) those who voluntarily participated in the study and completed the informed consent form (refer to Appendix A). The study excluded nursing trainees from different academic years, healthcare placements, and institutions, as well as those absent during the survey period due to health issues, personal events, or other leaves.

Intervention and control group

The trainees who met the inclusion exclusion criteria were uniformly numbered and random numbers were generated using Research Randomizer to determine those included in this study. Randomization was carried out in SPSS28.0 software using the study participant numbers, with one group being the intervention group and the other group being the control group.

Study intervention

The intervention group received death education based on the Peace of Mind Tea House in the hospital departmental classroom during their internship, while the control group had a normal internship with no intervention treatment. The intervention included a death education theory course and a Peace of Mind Tea House practice course.

Death education theory course

The course was regularly posted on a public WeChat account through professional articles commented on by medical ethics experts, combined with popular science videos. A total of six course contents were prepared, two contents were pushed each week, and the duration of each content study was approximately thirty minutes, with an intervention period of three weeks.

The content of this course was designed with reference to the three levels of death education proposed by the American psychologist Daniel Leviton, with the three objectives of “cognitive”, “emotional” and “motor skills” progressing step by step. The video learning was mainly designed with reference to the content of each education, mainly for the purpose of introducing the theoretical part of the course and increasing the interest of trainees in learning.The courses include understanding death, establishing a correct view of death, understanding death emotions, learning bereavement counseling, mastering the skills of communicating death information, and psychosocial suicide prevention interventions. See Appendix B for course specifics.To improve the teaching quality of the course, we established the WeChat group of the corresponding intervention group. After each death education course, we sent a group of reading reminders via WeChat to promote the independent learning of trainees in the intervention group.

To strengthen the review of the course content and let the trainees share their inner feelings about the intervention activity, an offline summary forum was held two weeks after the end of the course.

The Peace of Mind Tea House practice course

The Peace of Mind Tea House practical course was scheduled before the death education theory sessions. The practical team consists of two facilitators (including an oncology nurse and a palliative care nurse) and a data collector. HTH cards, personal summary notes, tissues, pens, fruit, and tea are prepared in the classroom to create a comfortable, quiet, private, and relaxing space.

The intervention consisted of the following main steps:

  1. (1)

    Rule training: a 10-min session was utilized by the facilitator to introduce the basic rules of the Peace of Mind Teahouse to the participants as a way to complete the training.

  2. (2)

    Contextual immersion: Immediately afterward, the facilitator introduced the end-of-life situation to the participants, and encouraged them to think about life and death by playing a short life education video and a game called “Lifeline”, which allowed them to assume that they were end-stage patients and thus immerse themselves in the activity. This process takes about 20 min.

  3. (3)

    Card selection: There were a total of two card selection processes. The 1st card selection was to select 3 of one’s wishes from each of the 4 suits, Joker may be used instead of any other wish not mentioned on the deck, totaling 12 cards. And record the 12 cards in the card selection column of the reassurance card form; the 2nd card selection is to select the most important 3 cards from the selected 12 cards and rank them in order of importance. Each card selection is limited to 15 min and takes a total of half an hour.

  4. (4)

    Sharing session: the facilitator organizes the participants to share, the content of sharing mainly includes the selected cards and the reasons for the selection, the facilitator should give appropriate guidance when necessary. This session takes about half an hour.

  5. (5)

    Summarization: Participants fill in the personal summary record of the reassurance card. This session takes about 10 min.

  6. (6)

    Disengagement: A 10-min meditation led by a palliative nurse to bring the intern back to reality and disengage from the end-of-life situation.

The entire practical session lasts about 2 h, and there is no need for special training or examination for the participants, as the rules are simple and easy to understand.

Questionnaires

Demographic questionnaire

Referring to the death related background survey designed by Chen Lingling et al. [28]. This questionnaire included questions about age, gender, region of residence, family status, level of education, education about death, and experience caring for dying patients.

Death Attitude Profile-Revised (DAP-R)

The Death Attitude Profile-Revised scale (DAP-R) was used to measure death attitude among nursing trainees. The DAP-R scale was developed by Wong, Reker and Gesser [29]. The Death Attitude Profile-Revised (DAP-R) scale contains 32 items from the five domains of attitudes: fear of death, death avoidance, natural acceptance, approaching acceptance, and escape acceptance. Each item is rated on a five-point Likert scale from strongly disagree (1 point) to strongly agree (5 points). Each dimension is scored separately, and the higher the score, the more the research subject accepts this attitude.Previous studies have shown that the Cronbach's coefficient of the Chinese DAP-R is 0.868, and the overall reliability is 87.5%, indicating that the Chinese DAP-R has good internal consistency [30].

The Chinese version of Templer's Death Anxiety Scale (CT-DAS)

The Chinese version of Templer's Death Anxiety Scale (CT-DAS) was used to measure death anxiety among nursing trainees. The CT-DAS was derived from the Templer-Death Anxiety Scale (T-DAS) [31], which was adapted into the Chinese T-DAS (CT-DAS) in 2012 through cross-cultural adaptation. There were 15 questions in the questionnaire, with a total score of 75, and 35 points were defined as death anxiety. The higher the score, the higher the level of anxiety. Hong Yang et al. showed that the Cronbach's coefficient of the CT-DAS was 0.713 [32].

Personal Meaning Index (PMI)

The Personal Meaning Index (PMI) was used to measure the Meaning of Life among nursing trainees. The PMI was developed by Reker in 1992 [33]. The PMI consists of 16 items and two factors: Value of life and clear meaning. The total score ranges from 16 to 112. A total score of ≥ 90 was classified as high, while a total score of ≤ 72 was classified as low. The higher the score, the greater the sense of achieving life goals, having a mission, having a sense of direction, having a sense of order, and having a sense of presence in life. The Chinese version of the PMI was 0.925, and the retest reliability was 0.890 [34].

Heart to Heart Cards (HTH Cards)

The HTH cards are a novel, culturally adapted, community-based advance care planning tool endorsed by the Chinese American Care Alliance [18]. The HTH cards consists of 54 playing cards (including Joker), each card has a need written on it. Spades are for physical and therapeutic needs at the end of life; Hearts are mainly for emotional needs; Clubs are for spiritual needs; Diamonds are for requests for one's own possessions; and Joker represent special wishes.

Four clinical hospice nurses and professors from Xiamen University School of Medicine were invited to evaluate the content validity of the content design of the HTH cards from December 2020 to January 2021. The results demonstrated that the mean value of the content validity index was greater than or equal to 0.9, indicating good content validity. The expert discussion revealed that all items in the card deck were clearly expressed and reliable, and that the intervention content was appropriately designed to reflect the hospice care situation.

Data analysis

SPSS 28.0 statistical software was used to create a database for statistical analysis, with a significance level of p < 0.05. Mean and standard deviation were used to describe continuous measures, and frequency and percentile were used to summarize categorical measures. The chi-squared test was used to compare count data, and the paired samples t-test was used for measurement data.

Results

Analysis of demographic characteristics

As shown in Table 1, the mean age of the study subjects was 21.34 years.There were no significant demographic differences compared to the control group, except for the item “family climate,” where death was discussed (p > 0.05).

Table 1 Demographic characteristics data of the study subjects
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Description of the current situation in attitudes toward death, death anxiety, and the meaning of life

Tables 2, 3 and 4 show the mean scores of the pre-intervention intervention and control groups for attitude towards death, death anxiety and meaning of life. We found that in the survey of attitude towards death, the total score of the intervention group was (96.95 ± 12.63) and the highest mean score was Approach acceptance (28.27 ± 5.72), while the total score of the control group was (94.93 ± 15.73) and the highest mean score was again Approach acceptance (28.00 ± 6.39). In the mean score of death anxiety, the total score of the intervention group was (44.67 ± 6.71), with the highest score of emotion (16.20 ± 3.39) and the lowest score of time awareness (5.60 ± 1.64); and in the control group, the total score was (46.79 ± 6.21), with the highest score of emotion (16.33 ± 2.93) and the lowest score of know (8.87 ± 1.67). In the meaning of life survey, the total score of the intervention group was (75.8 ± 14.32); the mean score of clear goals was (28.52 ± 5.62), which was lower than the value of life (47.27 ± 8.89); the total score of the control group was (73.97 ± 11.88); the mean score of clear goals was (27.61 ± 4.59), which was lower than the value of life ( 46.35 ± 7.60).

Table 2 The mean score of death attitude before intervention (n = 79)
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Table 3 The mean score of death anxiety before intervention
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Table 4 The mean score of meaning of life before intervention (n = 79)
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Analysis of the intervention’s effect after its implementations

We calculated the progress score by subtracting the pre-test score from the post-test score and then performed a t-test on the progress score between the intervention and control groups. Table 5 shows the numerical difference calculation for each dimension comparison. For the fear of death item on the Death Attitude Scale, the post-test score minus the pre-test score was 2.50 ± 3.90 in the intervention group and 0.10 ± 1.20 in the control group (p = 0.011). In the domain of clear goals in meaning of life, the post-test score minus the pre-test score was 8.90 ± 11.07 in the intervention group and 1.71 ± ficantly different (p < 0.05). Specifically, the post-test scores minus the pre-test scores of death avoidance, time consciousness, and overall total meaning of life were 1.25 ± 3.34, 1.42 ± 1.64, and 6.15 ± 7.09, respectively, in the invention group, whereas they were -0.97 ± 3.70, 0.25 ± 1.99, and 1.23 ± 7.46 in the control group, respectively (p = 0.006,p = 0.006, p = 0.004). These data show that death education and HTH cards had a positive effect on attitudes toward death and 17.89 in the control group (p = 0.035), both values being statistically signithe meaning of life and reduced death anxiety in nursing trainees.

Table 5 Comparison of each dimension after intervention
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Personal summary records about the Peace of Mind Tea House

In total, 129 cards and 43 personal summary records were selected. The top 10 HTH cards selected were as shown in Table 6. These percentages indicated how frequently students selected these cards. The top priority (7.8%) was “I’d like to travel if possible,” the next was “I hope my family will accept that I'm going to die soon” (7.0%), and “If I'm beyond help, don't be kept alive by machines,” “I don't want to suffer,” “I don't want to be a burden to my family” were in third place (rate were all 6.2%).

Table 6 The top 10 Peace of Mind cards selected among nursing trainees
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In the sharing section, 41 trainees (95.3%) felt the activity was meaningful, 34 trainees (79.1%) felt they were relaxed during the activity, and 34 trainees (79.1%) felt they were expressing their true thoughts in the Peace of Mind Tea House. Regarding the acceptance of talking about death, 41trainees (95.3%) felt that their views were respected, 39 (90.1%) found that it was easy to talk about death when using the HTH cards, and 38 (88.4%) indicated that they would follow their own medical wishes.

Discussion

The positive guiding effect of death education on nursing trainees

In terms of attitudes toward death, the results showed that the score of approach acceptance was the highest among the five dimensions in both the intervention and control groups, which meant that nursing trainees had a positive attitude towards approach acceptance. Some researchers have proposed that acceptance of the approach is often influenced by cultural beliefs [35]. The traditional Chinese concept of life and death has rich connotations because it is rooted in the deep traditional cultural soil. As representatives of traditional Chinese culture, Confucianism, Taoism, and Buddhism have expressed their views on life and death from different perspectives. There are different views, but they all express the concept of not fearing death and pursuing the value of life. In this study, nursing trainees scored higher on this dimension than on other dimensions of attitudes toward death, which may be related to Chinese traditional cultural beliefs. Furthermore, a consistent result was found in previous studies where the highest score on the Death Attitudes Scale was approach acceptance [36]. Another study by Zhang et al. [37], which compared nurses' attitudes toward death with their subjective well-being, found that nurses scored highest on the natural acceptance dimension, which differs from the results of this study. A possible explanation for this is that, compared with nurses, student nurses do not have sufficient experience in hospital practice, whereas nurses have systematically acquired medical knowledge, have been involved in long-term clinical work, and have had closer and more frequent contact with critically ill patients than other groups. Nurses correctly recognized that the end of life is a natural phenomenon.

Escape acceptance is the desire to end the painful life in this world as soon as possible [38]. However, the score of escape acceptance was the lowest in both groups, indicating that most students do not accept the idea of death to end their lives. There was little change in these two dimensions after the intervention, as religious and cultural beliefs cannot be changed in a short period. Although the total score for attitudes toward death after the intervention was not significant, there were significant differences in the scores for avoidance of death and fear of death in the intervention group, indicating that nursing students had some psychological preparation for death after the intervention and could face death calmly, which was similar to Guo's study [39]. A researcher [40] conducted a study on death anxiety, death attitude, and post-traumatic stress response. The results of the research confirmed that attitudes toward death are a relatively stable psychological state that is formed over a long period and does not change immediately due to sudden events, such as reminders of death. In light of this finding, it is necessary to extend the duration of death education in the future to achieve a significant change in attitudes toward death.

The results of this baseline survey showed that nursing trainees were generally in a state of high anxiety in both the intervention and control groups.In Ireland, a study exposed medical students to the scene of a human donation ceremony [41]. The results showed that levels of death anxiety measured immediately after exposure were significantly higher than before exposure. For nursing students, clinical practice requires direct care of critically ill or dying patients, in contrast to medical theory courses at school. Their first exposure to this environment may increase their death anxiety, which may be one of the reasons for the high death anxiety of nursing students. In the study of death education by Gao et al. [42], the total score of death anxiety decreased after the intervention. In the current study, the post-intervention score of death anxiety was not significant, which may be due to the relatively short intervention time, while the intervention time in Gao et al.’s study was 30 classroom hours. From the analysis of the research results, it appears that nursing students have had more opportunities to approach death and are taught that their role is to save lives. This makes it more difficult for them to emotionally accept death.

The baseline results of this study showed that the intervention group of nursing trainees were in a state of uncertainty about the meaning and goal of life, which was consistent with the research results of Chen & Wang [43] and others, indicating that most college students now have no clear goal and are relatively confused about the future.The death education in this study had a positive impact on the meaning of life of nursing trainees, similar to the results of the death education intervention carried out by Yin et al. [44] on a group of nursing students in higher vocational colleges. The result shows that the death education curriculum has promoted positive change in the meaning of life of nursing trainees to a certain extent and can help them to establish a scientific and correct view of life and death.However, compared to the intervention group, the control group had a low overall the meaning of life both before and after the intervention, probably because death education is not only about death itself, but also a process of deeper exploration of the meaning of life, values, and life goals. The control group, on the other hand, did not receive effective death education and did not receive enough information and guidance to reflect on the meaning of life.

The application of the Peace of Mind Tea House in death education

Family support, emotional support, symptom control, and physical comfort are essential at the end of life [45]. Most of the participants who took part in this intervention of the Peace of Mind Tea House chose the corresponding HTH cards, such as social needs (“I want my family to accept that I will die soon,” “I don’t want to be a burden to my family,” “I want a chance to say goodbye,” “I want my family to remember the happy times we had together,” and “I want someone to be there when I die”) and physical needs (“If I am beyond help, I don't want to be kept alive by machines,” “I don't want to suffer,” and “I want to be clean and comfortable”). “I don't want to be a burden to my family” expresses the desire not to be a financial, care, and emotional burden to their family [46]. “I hope my family will accept that I will die soon” and “I don't want to be a burden to my family” were both the top two most frequently selected preferences in this study. This family support is unique to the concept of filial piety in Chinese culture, which advocates the responsibility of mutual care, love, and giving among blood relatives [47]. Studies have shown that patients with terminal cancer have a poor quality of life due to cancer pain, high treatment costs, and concerns about burdening family members [48]. In this study, nursing trainees made choices similar to those likely to be made by clinical patients, providing evidence that the Peace of Mind Tea House can bring people closer to the end-of-life situation. This conclusion was validated by the fact that the majority of participants in the sharing session felt that “it is easy to talk about death using the Heart to Heart card”. In addition, the economic requirement “If possible, I would like to travel” had the highest probability of being selected among all the wish cards. As a spiritual life and a high-level leisure lifestyle, tourism expresses a positive attitude toward life and a love of life. This choice among nurse trainees in the intervention was consistent with the goal of death education, which is to “establish a correct concept of life and death, to maintain life with a correct attitude, and pursue the value and meaning of life [49].”

The contributions of the study

The innovative death education approach of this study can help nursing students to improve their knowledge and understanding of the end of life, thus guiding them to be able to form a sense of respect and care for life when they enter the workforce. Additionally, the university stage is a crucial period for students' personality formation and value shaping. It is essential to provide timely and accurate guidance on worldview, life view, and values to ensure that college students grow up in a healthy manner, explore the value of life, and understand the significance of existence. The questions in the HTH cards deck cover a variety of aspects, and nursing trainees can think about the meaning and value of life in the process of participating in the discussion, thus guiding them to form correct values.

Limitations

There are some limitations to this study. Due to insufficient sample size and limited intervention time, the effect of a death education intervention on death anxiety among nursing trainees was not statistically significant. Therefore, it is recommended to increase the sample size and intervention time in future research to better analyze the effect of death education.On the other hand, since the HTH cards came from the United States, this study conducted expert consultation on the content of the HTH cards to ensure that most of the topics were applicable before the intervention was conducted, but some of the cards still need to be followed up with further cross-cultural adaptation to be practical in China. Therefore, it is recommended that further design and research be conducted to explore death education tools that are suitable for each country for better application in death education in each country.

Conclusions

Death education based on the Peace of Mind Tea House was accepted and recognized by nursing trainees and had a positive effect on nursing trainees’ attitudes toward death, death anxiety, and the meaning of life. The content of death education should be integrated with traditional culture, and a new model of death education should be constructed with the HTH cards as its core.