Background
Novice oncology nurses are a vital part of the clinical nursing workforce, and preparing them to competently provide critical care to cancer patients is a significant challenge [1‐3]. Their competence is crucial for their transition into skilled healthcare professionals and making significant contribution [3]. However, evidence suggests that these nurses often find it stressful and challenging to provide care for patients, particularly those who are dying [2, 4]. Caring for dying cancer patients and handling their deaths is a daunting and distressing experience even for experienced oncology nurses [5, 6], let al.one those new to the field. These challenges can lead to reduced patient interactions and a lower level of care provided by novice oncology nurses [7, 8]. Moreover, such experiences can contribute to emotional and psychological withdrawal, job dissatisfaction, increased burnout, decreased professional quality of life [9, 10], and symptoms of poor health [2]. Hence, developing death competence is essential for ensuring both the quality of professional healthcare and the well-being of novice oncology nurses.
Currently, there is no internationally accepted term for death competence, also used as death competency, coping with death competence, coping with death, or death coping ability. However, it generally refers to the skills and attitudes necessary for managing one’s own and others’ deaths [11, 12], commonly measured by the Coping with Death Scale developed by Bugen [13]. In this study, we define death competence of oncology nurses as their ability to cope with cancer patients’ deaths, including handling death-related events, communicating with bereaved families, managing negative emotions caused by death, and providing hospice care [14]. Existing evidence highlights that various demographic and psychological factors influence oncology nurses’ ability to cope with patient death or end-of-life care [15, 16]. For instance, male nurses, those over the age of 31, those employed in cancer hospitals, those with positive attitudes toward death, and those who have received sufficient death education and training typically exhibit higher levels of death competence [16]. However, novice oncology nurses who may lack these advantages, often struggle the most, highlighting the need for targeted support and training to enhance their death competence. Further to this, the role of social or work-related factors that might predict these nurses’ death competence in a culture where death is a taboo subject, remain underexplored.
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Personality traits also play a significant role in coping with complex situations, such as death, serving as buffers against stress [16]. These traits, which influence emotional expression, thinking styles, and behavioral patterns, affect nurses’ work engagement, the quality of nursing care, and patient outcomes. For example, nurses with a psychotic personality, marked by a tendency for risk-taking and antisocial or non-conformist behavior, may find it challenging to cope with death [16]. Additionally, traits like neuroticism and introversion, characterized by emotional instability, negative emotional responses, and stress sensitivity, are strongly correlated with adverse health outcomes. Individuals with high levels of neuroticism experience increased exposure and reactivity to stressors [17]. This condition may be worsened by inadequate support and poor coping skills [18], leading to depression, low self-esteem, anxiety, irritability, and a lack of self-care and self-awareness among nurses [19]. Despite the recognized links between personality and ability of coping with death, there remains a limited understanding of how nurses’ personality traits interact their competence in dealing with death. This gap is particularly evident within cultural contexts where discussing death is taboo, such as in mainland China.
The 2015 Economist Intelligence Unit Report ranked mainland China 71st out of 80 countries and territories in terms of quality of death [20], a condition that may not have significantly improved till now. Death is historically considered a taboo in mainland China, heavily influenced by Confucian, Taoist, and Buddhist philosophies, as well as superstitious beliefs [21]. This cultural context leads to a widespread avoidance of discussions about dying and death, rooted in fears of attracting misfortune or evil spirits [22]. Consequently, Chinese oncology nurses often refrain from engaging in conversations about death to maintain hope among patients and their families [21, 23]. This disengagement not only affects these nurses’ comfort and competence in handling death professionally [24] but also perpetuates the avoidance of improving their own death competence within the local cultural context [25]. Although death education has been shown to improve nurses’ ability to cope with death [16], oncology nurses in mainland China report receiving minimal palliative care training [10, 15]. This deficiency is due to a low level of awareness and a lack of sufficient, high-quality palliative care educational programs [26, 27], particularly among local novice oncology nurses.
While existing studies have explored various factors influencing oncology nurses’ death competence, most have relied on variable-centered analysis methods [28, 29], often overlooking personality traits that vary across cultural contexts. Furthermore, there is a noticeable lack of targeted interventions for novice oncology nurses, who consistently exhibit a low level of death competence. To address these gaps, latent profile analysis, a person-centered approach, could prove beneficial. This method acts as a cluster analysis technique aimed at categorizing individuals into distinct groups, each defined by specific characteristics, often relying on a single factor, which is a common practice in many existing studies [30, 31]. It facilitates a comprehensive understanding of the distribution of different subgroups within the overall population and helps detect characteristics and heterogeneity that might go unnoticed when focusing solely on variables [32]. By applying this method, novice oncology nurses with varying levels of death competence could be classified into distinct subgroups, enabling nurse managers and educators to provide tailored death education or end-of-life care training based on these nurses’ specific characteristics and needs.
Therefore, this study will adopt latent profile analysis to (1) explore potential variations in death competence profiles, (2) identify the traits of each profile, and (3) compare the personality traits across latent profiles. This study aims to provide targeted guidance for interventions to enhance death competence among novice oncology nurses, offering actionable insights for policymakers and nurse practitioners in cultures where death is taboo.
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Methods
Study design
A cross-sectional descriptive study was conducted using a convenient cluster sampling method from August 2021 to July 2022. The study focused on novice oncology nurses in six tertiary cancer hospitals or centers, located in Beijing, Tianjin, Shanghai, Nanjing, Zhengzhou, and Xi’an, mainland China. These hospitals had 1,150 to 2,500 inpatient beds and employed between 1,130 and 1,760 oncology nurses as of 2021.
Participants
A total of 506 novice oncology nurses from these hospitals and centers were included in the study, meeting the recommended sample size criteria. The inclusion criteria were: newly commencing full-time registered nurses in the oncology department engaged in frontline clinical cancer nursing within 24 months of employment [33] and with a minimum of one month of clinical experience, possession of a nursing practice license, provision of care to adults aged 18 years and above, and voluntary participation in the study. The one-month clinical experience requirement reflects the standard preceptorship period in China, during which novice nurses receive intensive foundational training, including death competence—an area often lacking in formal nursing education [34]. By the end of this period, novice nurses gain essential skills in managing end-of-life care, ensuring they have adequate exposure to contribute meaningfully to the study. Novice oncology nurses working in the pediatric and maternity settings and those undergoing further education or serving as interns were excluded.
Measures
Demographic and coping with work-related characteristics
Based on a review of the literature [15, 25], the measures in this category included general demographic characteristics such as age, gender, marital status, educational level, working department, years of work experience, professional title, monthly income, experience with the death of a relative, and information related to experiences with patient death (e.g., number of times experienced patient death) and previous training on death education and palliative care.
Coping with death scale
The Coping with Death Scale, developed by Bugen [13] in the United States, was initially used to assess the effectiveness of death education for medical students and later for evaluating the death competence of palliative and hospice care staff. Zheng [35] and colleagues translated this scale into Chinese and tested it among Chinese oncology nurses. The Chinese version of the scale includes 28 items under six dimensions: Dimension 1 (items 1 to 5), ‘Self-perception and expression of death’ which captures an individual’s awareness, feelings, and ability to articulate thoughts about their own end-of-life and death; Dimension 2 (items 6 to 9), ‘Ability to handle post-mortem affairs’ which assesses an individual’s competence in managing matters following death, such as funerals; Dimension 3 (items 10 to 14), ‘Self-acceptance of death’, which reflects an individual’s capacity to accept and prepare for their own mortality; Dimension 4 (items 15 to 16), ‘Life conservation ability’ which pertains to an individual’s ability to contemplate the meaning of life and death; Dimension 5 (items 17 to 20), ‘Death coping ability’, which outlines how individuals manage their responses to the concept of death; and Dimension 6 (items 21 to 28), ‘Ability to communicate about dying or death with others’, which describes an individual’s capacity to engage in discussions about end-of-life topics with others. The overall Cronbach’s alpha coefficient of the scale is 0.905, with individual dimensions ranging from 0.692 to 0.849; the overall split-half reliability is 0.784; the retest reliability after three weeks is 0.973; the content validity index (S-CVI) is 0.99, and the item-level CVI (I-CVI) ranges from 0.83 to 1.00. The scale uses a Likert 7-point scale, where 1 to 7 correspond to “strongly disagree” to “strongly agree.” Item 12 is reverse scored, and the sum of all item scores gives the total score, ranging from 28 to 196 points. A higher score indicates stronger death competence. In this study, the Cronbach’s α coefficient of this scale was 0.786, indicating good internal consistency, and the Cronbach’s α coefficient of its six dimensions was 0.708, 0.879, 0.795, 0.748, 0.894, and 0.822 respectively.
Chinese big five personality inventory
The Chinese Big Five Personality Inventory, based on the international Big Five Personality Inventory and adapted for the Chinese cultural context, was tested by Wang and colleagues [36]. This scale, a popular psychometric instrument used to measure the personality traits of Chinese nurses, includes five dimensions: Neuroticism, Conscientiousness, Agreeableness, Openness, and Extraversion, each with 8 items, totaling 40 items. The Cronbach’s alpha coefficients for the dimensions range from 0.764 to 0.814. It uses a Likert 6-point scoring system, where “1” indicates “completely disagree” and “6” indicates “completely agree.” Items 4, 9, 20, 21, 23, 34, and 35 are reverse scored; the rest are scored positively. Each dimension is scored independently, with a higher score indicating a stronger inclination towards that personality trait. In this study, the Cronbach’s alpha coefficient for the entire scale is 0.868, indicating high internal consistency. For the five dimensions of the scale, the Cronbach’s alpha coefficients range from 0.772 to 0.853, demonstrating good reliability across different dimensions.
Data collection
The researchers first established connections with the hospitals and centers and secured research approval from their nursing department. Before initiating the study, the researchers organized face-to-face sessions to clearly communicate the research purposes, potential risks, and benefits to potential participants as well as to the hospital directors. One thoroughly trained research assistant from each hospital or center was tasked with collecting the data. They adhered to a standardized protocol throughout the distribution process of the questionnaires. Data collection was conducted using online surveys, which included a brief introduction to the project followed by the main questionnaire. The research assistants distributed the survey link through a WeChat group that included all the recruited registered nurses who met the inclusion criteria from the participating hospitals and centers. To ensure data integrity, each questionnaire could only be submitted once per IP address. Participants were reassured about the confidentiality of their responses and informed that they could withdraw from the study at any time without any consequences. Additionally, the anonymity of all participants was maintained, and their participation was completely voluntary.
Data analysis
Statistical analysis was performed using SPSS 25.0 software. Descriptive statistics were represented by means ± standard deviations, frequencies, and proportions. Chi-square tests and analysis of variance (ANOVA) were used to explore the characteristics of subgroups. When more than 15% of cells had an expected count less than 5, Fisher’s exact test was adopted; otherwise, the Chi-squared test was applied. The Student–Newman–Keuls (SNK) post-hoc tests [37] were employed for comparisons between subgroups. A multinomial logistic regression was conducted to determine sociodemographic and work-related factors that influence subgroup membership. In this study, the dependent variables were derived from the Chi-square tests and ANOVA analyses that revealed significant differences between the profiles. All significance tests were 2-sided, and a P value of less than 0.05 was considered statistically significant.
Latent profile analysis was carried out using Mplus 8.3 software to identify potential profiles of death competence among novice oncology nurses. This method groups individuals with similar response patterns into the same latent profile based on probabilities [38]. Initially, five models were estimated by gradually increasing the number of profiles from one (1 profile) to five (5 profiles) until the fitness metrics reached their optimal levels. The optimal model was selected by comparing fit indices across different classification models, ensuring the accuracy and objectivity of the profile results [38]. The fit indices include the Akaike Information Criterion (AIC), Bayesian Information Criterion (BIC), the sample size adjusted Bayesian information criterion (aBIC), Entropy index, the Lo-Mendell-Rubin Adjusted Likelihood Ratio Test (LMRT), and the Bootstrap Likelihood Ratio Test (BLRT) [38]. Lower values of AIC, BIC and aBIC indicate a better model fit, while an Entropy index, between 0 and 1, closer to 1 indicates more precise classification. A statistically significant LMRT (P < 0.05) suggests that a model with K profiles is superior to a model with K-1 profile [38]. The probability of category, referring to the likelihood that an individual belongs to a specific latent profile, was also estimated to provide insights into the prevalence of each latent profile among novice oncology nurses, with each profile typically comprising more than 5% of the total population [39].
Ethics considerations
This research was approved by Ethics Committee of Tianjin Medical University Cancer Institute & Hospital approved the study (Grant No. bc2020126). Informed consents were obtained from all participants, and all methods were performed in accordance with the relevant guidelines and regulations.
Results
Identification of subgroups
Based on 28 items across six dimensions of the Coping with Death Scale, or death competence scale, five models were established sequentially, with fit metrics shown in Table 1. As the number of profiles increased, the values of Entropy were all > 0.9, and the values of AIC, BIC, and aBIC decreased. The P-value of LMRT for the five-profile model did not reach a significant level (P = 0.313). The value of Entropy of the three-profile model was larger than that of the two-profile model and the four-profile models, and the LMRT value of the three-profile model was 0.004. Given that the three-profile model aligns more closely with actual clinical practice, it was deemed the most preferable and optimal model. Detailed mode metrics are presented in Table 1.
Table 1
Fit metrics of each model
Model | k | Log(L) | AIC | BIC | aBIC | Entropy | LMRT | BLRT | Probability of category |
|---|---|---|---|---|---|---|---|---|---|
1 profile | 56 | -26049.09 | 52210.19 | 52446.87 | 52269.12 | -- | -- | -- | 1 |
2 profiles | 85 | -24365.85 | 48901.70 | 49260.95 | 48991.15 | 0.923 | 0.001 | 0.000 | 0.570/0.430 |
3 profiles | 114 | -23781.11 | 47790.21 | 48272.04 | 47910.19 | 0.934 | 0.004 | 0.000 | 0.215/0.520/0.265 |
4 profiles | 143 | -23509.46 | 47304.92 | 47909.31 | 47455.42 | 0.927 | 0.048 | 0.000 | 0.164/0.335/0.361/0.140 |
5 profiles | 172 | -23262.79 | 46869.59 | 47596.55 | 47050.60 | 0.931 | 0.313 | 0.000 | 0.15/0.14/0.28/0.30/0.13 |
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Figure 1 displays the scores for three distinct profiles of death competence among novice oncology nurses, detailed in Table 2. Profile 1 comprised 21.5% of participants (the probability of category = 0.215, n = 109) with a mean score of 91.39 ± 12.32. Novice oncology nurses in this profile scored highest on item 3, ‘My attitude toward living has recently changed,’ but lowest on all other items. Thus, this profile was labeled as the ‘Low Death Competence with Attitude Change toward Living’ group. Profile 2 represented 52.0% of participants (the probability of category = 0.520, n = 264) with a mean score of 121.64 ± 9.76. Scores in this profile were consistently higher than those in Profile 1, except for item 3. Then this profile was named as the ‘Moderate Death Competence’ group. Profile 3 accounted for 26.5% of the sample (the probability of category = 0.265, n = 133) with an average score of 155.23 ± 13.59. This profile generally scored higher than Profile 2, though it had the lowest score on item 3. Therefore, ‘High Death Competence with No Attitude Change toward Living’ group was named for this profile.
Fig. 1
Latent profiles of death competence among novice oncology nurses. Note: For the data analysis, the original scale items were reorganized based on the dimensions they represent. Items 1 through 5 were grouped under Dimension 1 ‘Self-perception and Expression of Death’, items 6 through 9 were categorized as Dimension 2 ‘Ability to Handle Post-mortem Affairs’, items 10 through 14 were classified under Dimension 3 ‘Self-acceptance of Death’, items 15 and 16 were aligned with Dimension 4 ‘Life Conservation Ability’, items 17 through 20 were designated for Dimension 5 ‘Death Coping Ability’, and items 21 through 28 focused on the Dimension 6 ‘Ability to Communicate about Dying or Death with Others’
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Table 2
Results of the latent profile analysis
Variables | Overall (N = 506) | Profile 1 (n = 109) | Profile 2(n = 264) | Profile 3 (n = 133) | F | P | SNK |
|---|---|---|---|---|---|---|---|
M ± SD | M ± SD | M ± SD | M ± SD | ||||
Death Competence | 123.95 ± 24.89 | 91.39 ± 12.32 | 121.64 ± 9.76 | 155.23 ± 13.59 | 944.60 | < 0.001 | 1 < 2 < 3 |
Dimension 1 | 21.37 ± 3.45 | 18.65 ± 3.14 | 21.14 ± 2.69 | 24.04 ± 3.12 | 104.48 | < 0.001 | 1 < 2 < 3 |
Dimension 2 | 14.58 ± 4.75 | 9.80 ± 3.32 | 14.35 ± 3.28 | 18.96 ± 4.21 | 200.41 | < 0.001 | 1 < 2 < 3 |
Dimension 3 | 21.62 ± 6.73 | 14.26 ± 3.93 | 21.17 ± 4.91 | 28.56 ± 4.38 | 295.10 | < 0.001 | 1 < 2 < 3 |
Dimension 4 | 10.77 ± 2.20 | 9.22 ± 1.86 | 10.44 ± 1.97 | 12.72 ± 1.37 | 122.50 | < 0.001 | 1 < 2 < 3 |
Dimension 5 | 17.97 ± 4.67 | 13.43 ± 3.91 | 17.35 ± 2.86 | 22.92 ± 3.49 | 260.62 | < 0.001 | 1 < 2 < 3 |
Dimension 6 | 37.64 ± 9.34 | 26.03 ± 5.45 | 37.20 ± 5.22 | 48.04 ± 5.86 | 491.23 | < 0.001 | 1 < 2 < 3 |
Differences in sociodemographic, clinical characteristics and personality traits among subgroups
Table 3 outlines the demographic, work-related characteristics, and personality traits across each profile. The group identified as ‘Low Death Competence with Attitude Change toward Living’ tended to be older, had the smallest representation of male nurses (2.8% vs. 6.8% vs. 12.0%), and consisted of fewer nurses employed in ICU and Palliative Care Units (6.4% vs. 8.3% vs. 15.8%). Conversely, the group labeled as ‘High Death Competence with No Attitude Change toward Living’ had the largest proportion of nurses with a diploma degree (39.1% vs. 22.9% vs. 22.7%) and had the fewest who had never experienced patient death (28.6% vs. 33.0% vs. 34.1%).
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Table 3
Demographic, work-related features, and personality traits by latent profiles
Variables | Profile 1 (n = 109) | Profile 2 (n = 264) | Profile 3 (n = 133) | F/X2 | P | |||
|---|---|---|---|---|---|---|---|---|
Age | 23.46 ± 1.23 | 23.11 ± 1.29 | 23.08 ± 1.34 | 3.34a | 0.036* | |||
Gender | 7.81b | 0.020* | ||||||
Female | 106 (97.2%) | 246 (93.2%) | 117 (88.0%) | |||||
Male | 3 (2.8%) | 18 (6.8%) | 16 (12.0%) | |||||
Marital status | 1.32 c | 0.517 | ||||||
Unmarried | 104 (95.4%) | 257 (97.3%) | 127 (95.5%) | |||||
Married | 5 (4.6%) | 7 (2.7%) | 6 (4.5%) | |||||
Education level | 16.05 c | 0.003* | ||||||
Diploma | 25 (22.9%) | 60 (22.7%) | 52 (39.1%) | |||||
Bachelor | 70 (64.2%) | 184 (69.7%) | 71 (53.4%) | |||||
Master | 14 (12.8%) | 20 (7.6%) | 10 (7.5%) | |||||
Working department | 15.25 c | 0.018* | ||||||
Medical department | 29 (26.6%) | 59 (22.3%) | 29 (21.8%) | |||||
Surgical department | 56 (51.4%) | 151 (57.2%) | 56 (42.1%) | |||||
ICU, Palliative Care Unit | 7 (6.4%) | 22 (8.3%) | 21 (15.8%) | |||||
others | 17 (15.6%) | 32 (12.1%) | 27 (20.3%) | |||||
Professional title | 2.724 c | 0.256 | ||||||
Nurse | 85 (78.0%) | 223 (84.5%) | 113 (85.0%) | |||||
Senior nurse | 24 (22.0%) | 41 (15.5%) | 20 (15.0%) | |||||
Years of experience (months) | 10.58 c | 0.102 | ||||||
< 6 | 44 (40.4%) | 112 (42.4%) | 67 (50.4%) | |||||
7–12 | 41 (37.6%) | 97 (36.7%) | 35 (26.3%) | |||||
13–18 | 6 (5.5%) | 23 (8.7%) | 6 (4.5%) | |||||
19–24 | 18 (16.5%) | 32 (12.1%) | 25 (18.8%) | |||||
Employment type | 7.85 c | 0.097 | ||||||
Authorized employment | 27 (24.8%) | 62 (23.5%) | 19 (14.3%) | |||||
Personnel agency | 60 (55.0%%) | 163 (61.7%) | 93 (69.9%) | |||||
Labor dispatching | 22 (20.2%%) | 39 (14.8%) | 21 (15.8%) | |||||
Monthly income (RMB) | 5.60 c | 0.231 | ||||||
< 5000 | 57 (52.3%) | 152 (57.6%) | 85 (63.9%) | |||||
5001–10,000 | 44 (40.4%) | 95 (36.0%) | 36 (27.1%) | |||||
≥ 10,001 | 8 (7.3%) | 17 (6.4%) | 12 (9.0%) | |||||
Having experienced a close relative’s death | 2.544 c | 0.280 | ||||||
Yes | 71 (65.1%) | 170 (64.4%) | 96 (72.2%) | |||||
No | 38 (34.9%) | 94 (35.6%) | 37 (27.8%) | |||||
Having received training in end-of-life care | 1.15 c | 0.563 | ||||||
Yes | 17 (15.6%) | 53 (20.1%) | 27 (20.3%) | |||||
No | 92 (84.4%) | 211 (79.9%) | 106 (79.7%) | |||||
Frequencies of experiencing patient death | 16.33c | 0.012* | ||||||
Several times per month | 17 (15.6%) | 19 (7.2%) | 10 (7.5%) | |||||
Several times per year | 33 (30.3%) | 68 (25.8%) | 51 (38.3%) | |||||
Once a year | 23 (21.1%) | 87 (33.0%) | 34 (25.6%) | |||||
Never experienced patient death | 36 (33.0%) | 90 (34.1%) | 38 (28.6%) | |||||
Big-Five Personality Traits | ||||||||
Neuroticism | 27.36 ± 8.29 | 25.13 ± 8.29 | 22.02 ± 9.44 | 11.93 a | < 0.001* | |||
Conscientiousness | 34.05 ± 6.34 | 36.87 ± 5.28 | 40.74 ± 5.95 | 42.77 | < 0.001* | |||
Agreeableness | 35.81 ± 5.88 | 36.95 ± 5.43 | 40.47 ± 6.08 | 23.89 a | < 0.001* | |||
Openness | 31.10 ± 5.97 | 33.73 ± 5.18 | 36.77 ± 8.06 | 25.19 a | < 0.001* | |||
Extraversion | 27.39 ± 6.16 | 29.98 ± 5.99 | 33.47 ± 7.50 | 27.36 a | < 0.001* | |||
The scores for the five dimensions of the Big-Five Personality Traits Scale varied significantly across the three profiles (P < 0.001). The SNK tests showed that the mean scores for the ‘High Death Competence with No Attitude Change toward Living’ group were notably higher than those of the ‘Low Death Competence with Attitude Change toward Living’ and ‘Moderate Death Competence’ groups in all dimensions, with the exception of ‘Neuroticism,’ where the pattern was reversed (P < 0.001).
Predictors of subgroups
Variables that showed statistically significant differences in the univariate analysis were used as independent variables, while profiles were treated as dependent variables in the multinomial logistic regression analysis. The reference category for each variable was the last set, with the ‘Low Death Competence with Attitude Change toward Living’ group serving as the overall reference point. The significant predictors are indicated in bold within Table 4. Novice oncology nurses who were male (OR = 5.794, P = 0.016) and not exhibiting an ‘agreeableness’ personality trait (OR = 5.985, P = 0.014) were more inclined to be in Profile 2, the ‘Moderate Death Competence’ group. Those working in ICU and Palliative Care Units (OR = 5.736, P = 0.017), and those who displayed ‘openness’ (OR = 3.957, P = 0.047) or ‘extraversion’ (OR = 4.947, P = 0.026) personality traits were more likely to be associated with Profile 3, the ‘High Death Competence with No Attitude Change toward Living’ group. In comparison to the individuals in the ‘Low Death Competence with Attitude Change toward Living’ group, those who did not encounter patient death several times per month, and possessed a ‘conscientiousness’ personality trait (all P < 0.05), were more likely to fall in both Profile 2 and Profile 3.
Table 4
Multinomial logistic regression analysis of latent profiles in novice oncology nurses (n = 506)
Variables | B | SE | OR | P | 95%CI |
|---|---|---|---|---|---|
Profile 2 (vs. Profile 1) | |||||
Age | -0.239 | 0.126 | 3.565 | 0.059 | 0.615–1.009 |
Gender | |||||
Male | 1.725 | 0.717 | 5.794 | 0.016 | 1.378–22.869 |
Femalea | -- | -- | -- | -- | -- |
Education level | |||||
Diploma | -0.761 | 0.656 | 1.344 | 0.246 | 0.129–1.691 |
Bachelor | -0.355 | 0.539 | 0.434 | 0.510 | 0.244–2.017 |
Master degreea | -- | -- | -- | . | -- |
Working department | |||||
Medical department | 0.308 | 0.462 | 0.445 | 0.505 | 0.551–3.363 |
Surgical department | 0.672 | 0.420 | 2.560 | 0.110 | 0.860–4.456 |
ICU, Palliative care Unit | 1.237 | 0.636 | 3.787 | 0.052 | 0.991–11.970 |
Othersa | -- | -- | -- | -- | -- |
Frequencies of experiencing patient death | |||||
Several times per month | -1.194 | 0.477 | 6.262 | 0.012 | 0.119–0.772 |
Several times per year | -0.498 | 0.351 | 2.007 | 0.157 | 0.305–1.210 |
Once a year | -0.103 | 0.371 | 0.077 | 0.782 | 0.436–1.867 |
Never experienced patient deatha | -- | -- | -- | -- | -- |
Perceived ability to cope with patient death | |||||
Excellent | 0.587 | 0.475 | 1.529 | 0.216 | 0.709–4.567 |
Good | 1.791 | 0.369 | 23.583 | 0.000 | 2.910-12.353 |
Poora | -- | -- | -- | -- | -- |
Big-Five Personality Traits | |||||
Neuroticism | -0.009 | 0.016 | 0.275 | 0.600 | 0.960–1.024 |
Conscientiousness | 0.108 | 0.030 | 13.252 | 0.000 | 1.051–1.180 |
Agreeableness | -0.072 | 0.029 | 5.985 | 0.014 | 0.879–0.986 |
Openness | 0.021 | 0.025 | 0.756 | 0.385 | 0.974–1.072 |
Extraversion | 0.044 | 0.024 | 3.266 | 0.071 | 0.996–1095 |
Profile 3 (vs. Profile 1) | |||||
Age | -0.131 | 0.155 | 0.714 | 0.398 | 0.648–1.188 |
Gender | |||||
Male | 1.118 | 0.796 | 1.972 | 0.160 | 0.642–14.576 |
Femalea | -- | -- | -- | -- | -- |
Education level | |||||
Diploma | -0.430 | 0.807 | 0.284 | 0.594 | 0.134–3.162 |
Bachelor | -0.702 | 0.680 | 1.067 | 0.302 | 0.131–1.878 |
Master degreea | -- | -- | -- | -- | -- |
Working department | |||||
Medical department | 0.418 | 0.558 | 0.563 | 0.453 | 0.509–4.535 |
Surgical department | 0.454 | 0.492 | 0.851 | 0.356 | 0.600–4.130 |
ICU, Palliative care Unit | 1.713 | 0.715 | 5.736 | 0.017 | 1.365–22.539 |
Othersa | -- | -- | -- | -- | -- |
Frequencies of experiencing patient death | |||||
Several times per month | -1.266 | 0.619 | 4.190 | 0.041 | 0.084–0.948 |
Several times per year | 0.052 | 0.423 | 0.015 | 0.903 | 0.459–2.414 |
Once a year | -0.431 | 0.465 | 0.858 | 0.354 | 0.261–1.617 |
Never experienced patient deatha | -- | -- | -- | -- | -- |
Big-Five Personality Traits | |||||
Neuroticism | -0.011 | 0.020 | 0.296 | 0.586 | 0.952–1.028 |
Conscientiousness | 0.180 | 0.036 | 25.513 | 0.000 | 1.116–1.283 |
Agreeableness | -0.041 | 0.035 | 1.412 | 0.235 | 0.896–1.027 |
Openness | 0.058 | 0.029 | 3.957 | 0.047 | 1.001–1.122 |
Extraversion | 0.064 | 0.029 | 4.947 | 0.026 | 1.008–1.128 |
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Discussion
To our knowledge, this study is the first to use Latent Profile Analysis to identify the latent profiles of death competence among novice oncology nurses. We identified three distinct groups: ‘Low Death Competence with Attitude Change toward Living,’ ‘Moderate Death Competence,’ and ‘High Death Competence with No Attitude Change toward Living.’ This classification not only highlights the varying levels of death competence among these nurses but also illustrates the heterogeneity in their demographic, work-related characteristics, and personality traits. This approach contrasts with previous studies that have treated novice oncology nurses as a homogeneous group [10]. These findings offer fresh insights that can inform tailored death-related education and training programs aimed at enhancing death competence based on these identified profiles. Additionally, this study enriches the understanding of death competence among novice oncology nurses within the culturally sensitive context of mainland China.
The ‘Low Death Competence with Attitude Change toward Living’ group accounted for 21.5% of the sample. These novice oncology nurses scored the lowest in all six dimensions of death competence, significantly lower than new graduates in previous studies that considered all new graduates as a homogeneous sample in China [25]. This group was characterized by relatively older nurses, which contrasts with previous studies suggesting that nurses’ death competence increases with age and experience [25, 40]. One possible explanation is that these older nurses’ long-standing beliefs about death, shaped by cultural taboos and personal experiences [1], were not supported by professional training in death competence. This group’s low scores reflect their self-perceived inadequacy in managing death, indicating an acute awareness of their limitations. Additionally, novice oncology nurses with neurotic personality traits in this group might find dealing with patient death particularly challenging and be more prone to experiencing negative emotions such as death anxiety and depression [16]. The correlation between neuroticism, death anxiety, and low frustration tolerance [16], further complicates their ability to manage patient death.
Surprisingly, the ‘Low Death Competence with Attitude Change toward Living’ group scored highest on the item 3, ‘My attitude about living has recently changed’ among the three profiles. This suggests a profound impact of patient death on their perspectives on life. This response might indicate that these nurses, through their exposure to patient death, have become more aware of life’s fragility and the limitations of human efforts against diseases like cancer. Such experiences could lead to a shift in their personal philosophy, possibly resulting in feelings of helplessness that alter their outlook on life [8]. These nurses may experience complex emotional reactions including guilt, self-blame, or a sense of powerlessness after a patient’s death. These feelings could be intensified by their upbringing in cultures where death is a taboo subject, which might also deepen the fear of death [10, 25]. The combination of these factors can lead to a significant shift in how they view life and their profession. However, it is crucial to note that while this change in attitude towards living might signify personal growth, it does not necessarily correlate with improved professional competence in managing death.
The ‘Moderate Death Competence’ group, comprising 52.0% of the participants, exhibited relatively balanced scores across all dimensions, similar to the death competence scores of oncology nurses from a mainland China study [41]. This group included male nurses and those who displayed higher levels of the conscientiousness personality trait. Conversely, those who encountered patient death several times per month and had an agreeableness personality trait were likely to be less competent in dealing with death. Male nurses, potentially socialized to be more stoic and less expressive, may maintain a higher sense of competence in dealing with death compared to their female counterparts, finding the handling of patient death less overwhelming [42], which is also consistent with findings from international literature [43]. Those with high conscientiousness are typically organized, responsible, empathetic, and supportive, making them more thorough in their care practices and more adept at managing the complexities of end-of-life care [44]. In contrast, individuals with an agreeableness trait tend to be sympathetic and eager to assist others, often forming strong emotional bonds with their dying patients due to their empathetic nature. While this can be beneficial for patient care, it might also make it more emotionally taxing when patients deteriorate or die, potentially leading to greater emotional distress for these nurses and hindering their ability to cope with repeated losses.
The ‘High Death Competence with No Attitude Change toward Living’ group, accounting for 26.5% of the sample, scored the highest on death competence metrics. Their scores not only surpassed those of palliative care nurses from the United Kingdom [45] but also matched those of Canadian palliative care professionals [46], indicating superior death competence. Similar to those in the ‘Moderate Death Competence’ group, these nurses typically worked in ICU or Palliative Care Units. ICU nurses often provide advanced care for critically ill patients, giving them more opportunities to develop technical skills and knowledge, making them competent in dealing with death. Meanwhile, nurses from Palliative Care Units frequently encounter patient deaths, offering more chances to face dying, communicate with bereaved families, and develop strong coping abilities, thereby strengthening their death competence, as supported by recent studies [25, 47]. The novice oncology nurses in this study also showed higher levels of openness and extraversion traits. Those exhibiting traits of openness and extraversion tend to be more sociable and assertive [44], which enhances their adaptability and receptiveness to new experiences [16]. This predisposition improves their communication skills and relationship-building with patients and their families, thereby enhancing their competence in managing death-related situations.
Interestingly, experiencing patient death several times per month was identified as a hindering factor that negatively impacts the death competence of novice oncology nurses in both the ‘High Death Competence with No Attitude Change toward Living’ group and the ‘Moderate Death Competence’ group. This finding is rarely reported in international literature and contrasts with previous studies [4, 48]. Typically, frequent exposure to patient death provides nurses more opportunities to learn, acquire adequate skills, and enhance professional knowledge [41, 48]. One possible explanation for this discrepancy is the fear of dying and death among novice oncology nurses, particularly within a cultural context where talking openly about death is taboo [49]. Repeated exposure to patient death, especially in such a high-stress field like oncology, can lead to emotional exhaustion more rapidly among novices [10]. These novice nurses may not have yet developed the emotional resilience or coping competence necessary to handle the frequent loss of patients [34]. This emotional toll can impede their ability to engage effectively with patients, thereby reducing their death competence [48]. While exposure to death is supposed to offer learning opportunities, without adequate mentorship and support, this exposure can become overwhelming rather than educational.
In contrast to the ‘Low Death Competence with Attitude Change toward Living’ group, the novice oncology nurses in the ‘High Death Competence with No Attitude Change toward Living’ group scored the lowest on the item ‘My attitude about living has recently changed.’ This indicates their outlook on life remains stable after experiencing patient death. This consistency may suggest they maintain a positive perception of dying and death. However, it is still unclear how these nurses sustain such high levels of death competence, particularly in a culture where discussing death is taboo and where there is a lack of death education programs and training.
Implications for practice and research
The study’s findings offer valuable implications for clinical management and future research. Nurse managers should recognize the presence of three distinct groups among novice oncology nurses: ‘Low Death Competence with Attitude Change toward Living,’ ‘Moderate Death Competence,’ and ‘High Death Competence with No Attitude Change toward Living.’ Managers, along with mentors or preceptors, are advised to use the Coping with Death Scale to assess the death competence of novice oncology nurses. Special attention should be given to those in the ‘Low Death Competence with Attitude Change toward Living’ group, particularly older nurses, female nurses, and those with neurotic or agreeable personality traits. Identifying these characteristics is crucial for providing culturally sensitive death education and tailored training. Additionally, support should be given to those who frequently encounter patient death.
Agreeable nurses, being highly empathetic and sensitive, may find the emotional burden of patient death more intense and challenging. Therefore, novice oncology nurses with this personality trait should focus on building emotional resilience, setting appropriate boundaries, and managing stress to prevent burnout. By addressing these areas, they can transform their natural empathy and cooperativeness into strength rather than sources of vulnerability. Female nurses should concentrate on developing their death competence in clinical practice, and those frequently experiencing patient death should seek guidance from managers, mentors, or preceptors.
Nurse researchers are encouraged to delve deeper into the complex interplay between changes in living attitudes and death competence among novice oncology nurses. Understanding these dynamics can inform enhanced educational strategies and support systems, thereby boosting their competence in managing death. Further research is crucial to understand the mechanisms that underpin sustained death competence and identify factors that contribute to high proficiency in this field. Additionally, investigating why some novice oncology nurses do not improve their death competence despite frequent patient deaths is vital. Gaining these insights is crucial for developing and implementing culturally sensitive and customized education and training programs that strengthen death competence among novice oncology nurses. For instance, the units of death education for novice oncology nurses should include but not limited to several key areas, including how to care for dying patients, how to communicate with dying patients and their families within a culture that has taboos around death, and how to develop and express their own beliefs when dealing with death and dying patients.
This study also has international implications, particularly as an increasing number of nursing students of Chinese origin choose to work in Western countries [50]. Managers in these countries need to recognize the unique characteristics of novice nurses and identify those exhibiting low death competence, such as older individuals or those with agreeable personality traits. Understanding these nuances can help in developing targeted support and training programs that enhance their professional development and adaptability in diverse healthcare environments.
Limitations
This study has several limitations. First, the cross-sectional design prevents establishing causality between the variables examined. Longitudinal research is needed to clarify the causal links between death competence and personality traits. Second, the use of self-reported questionnaires to assess the death competence of novice oncology nurses may be subject to reporting bias, as it lacks objective metrics such as clinical performance in end-of-life care. Future research should include both subjective and objective assessments for a more precise evaluation of factors influencing death competence. Third, although participants were recruited from six tertiary cancer hospitals and centers across mainland China, the findings may not be applicable to other regions. Further research is needed to generalize these three classifications, as they were based on a convenience sample and may be only indicative of the current target population. Fourth, numerous factors can affect the death competence of novice oncology nurses, suggesting a need for further studies to explore additional influencing factors. Lastly, the ability to cope with death is a vital individual psychological resource, and its implications for clinical practice—particularly regarding the quality of end-of-life cancer care and the mental health outcomes of novice oncology nurses—are critical to address. Thus, future research should aim to investigate these interconnected issues in a thorough and integrated manner.
Conclusions
This study categorized death competence among novice oncology nurses into a three-profile model: ‘Low Death Competence with Attitude Change toward Living,’ ‘Moderate Death Competence,’ and ‘High Death Competence with No Attitude Change toward Living.’ It suggests that interventions should be person-centered, culturally sensitive, and tailored to match the demographic, work-related characteristics, and personality traits of each profile. Specifically, nurses who are female, older, frequently encounter patient death, or possess agreeable personality traits, especially within cultures that consider death a taboo, should prioritize enhancing their death competence. Future research is vital to uncover the underlying mechanisms of high death competence and identify factors that contribute to such proficiency. These findings are crucial for developing and implementing targeted education and training programs aimed at strengthening death competence among novice oncology nurses.
Acknowledgements
We would like to express our gratitude to Zhenqi Lu and Xiaoju Zhang from Fudan Cancer Hospital, Jiang Zhao from Shanxi Province Cancer Hospital, Funa Yang from Henan Cancer Hospital, for their assistance in coordinating the data collection. We also extend our thanks to all the novice oncology nurses who willingly took part in this study.
Declarations
Ethics approval and consent to participate
The Ethical Member Committee of Tianjin Medical University Cancer Institute & Hospital approved the study (Grant No. bc2020126). Informed consents were obtained from all participants, and all methods were performed in accordance with the relevant guidelines and regulations.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
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