Introduction
Death is a universal phenomenon among all living things and refers to the complete cessation of vital functions. Death can be perceived differently depending on cultural differences and generally categorised as good or bad [1‐3]. Good death is desired for all peoples and is a fundamental human right [2, 4]. A good death is defined as a process in which the person is free from physical pain and discomfort, in which they experience spiritual peace and satisfaction, with personalized end-of-life care and social participation. It also includes elements such as being with loved ones and fulfilling personal wishes [1, 3, 4]. For nurses, a good death is one of the main goals and considerations in end-of-life care. Nurses manage the process of good death in team collaboration also involving the loved ones of the patient, ensuring that the individual receives professional care without suffering while preserving human dignity and respect [1, 5]. Krikorian et al.’ s (2020) [3] in their systematic review study in which they defined good death from the patients’ perspective, patients defined good death as control of pain and symptoms, clear decision-making, being seen and perceived as a person, preparation for death, and still being able to give something to others. In this regard, nurses have the responsibility to understand the emotional needs of the patient and their family, protect the dignity and privacy of the patient, provide open and honest information to the patient and their family, ensure their active participation in the decision-making process, deliver care that considers the patient’s cultural and religious beliefs, and help the patient and their family accept the dying process as a natural part of life [3, 5]. Nurses should display a professional attitude by integrating their perceptions of good death with nursing values [3, 6, 7].
The concept of value is a set of judgments and decisions accepted by the society or community. It is also a set of principles and beliefs that guide individuals’ behaviours, including attitudes, preferences, desires, goals, and common thoughts [6, 8]. Nursing is based on professional values [7, 9]. Nursing values aim to identify and meet the emotional and physical needs of patients with compassion, empathy and respect. In addition, providing the highest standards of care by adhering to the principles of professional ethics and continuous learning are part of these values [7‐9]. The professional values that nurses possess define their professional moral knowledge and create a philosophical framework, rules and standards for their behaviours in practice [6, 8, 10]. In the literature, the fundamental values that a nurse should have are listed as human dignity, autonomy, equality, justice, altruism, aesthetics, realism and integrity [11‐13]. These professional values act as a guide in protecting and developing nurses’ professionalism and increasing the quality of care [9, 14]. Providing care in line with professional care standards may be possible by acquiring nursing values and adopting a value-based care approach [6, 13, 15].
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Professional values guide ethical behaviour in providing safe care. Nurses are expected to reflect their professional values in care in their decision-making processes and are considered an essential component of quality care [6, 13]. In line with professional values, they should provide individualised patient care in the terminal period, inform and involve the family and caregivers in the process, and support the good death process. Nursing values such as respect, compassionate care, sensitivity, reliability and integrity play an essential role in supporting this process [5, 9]. Zheng et al.’s (2018) systematic review and meta-synthesis studies indicate that the patient’s death process and coping with this process is a personal experience that is perceived differently by each nurse [16]. According to the systematic review of Zorba Bahçeli et al. (2022), nurses’ perceptions of end-of-life care processes are also influenced by their values and cultural characteristics [17]. Additionally, the good death process often requires making complex and sensitive ethical decisions. Nursing values provide guidance in this process, helping nurses make ethically and morally sound decisions and offer more humane and comprehensive care to patients. Determining the impact of nursing values on nurses’ perceptions of a good death is believed to contribute to increasing nurses’ knowledge about good death and values, enhancing the content of educational programs, and raising awareness among nurses on this subject. Therefore, given that nurses are the primary caregivers responsible for ensuring the realisation of a good dying process, determining nurses’ perceptions regarding a good death and their relationship with nursing values will be an important source of data for strategies to achieve the goal of a good dying process.
Purpose of the study
This study aimed to determine the effect of nursing values on nurses’ perceptions of a good death. It is anticipated that enhancing professional values in nursing education will positively impact the quality of nursing care provided to terminally ill patients. Additionally, examining the impact of professional values on the perception of a good death will clearly demonstrate the role of values in end-of-life care. This evidence will underscore the importance of instilling professional values in developing nurses’ perceptions of a good death, and the findings are expected to guide research, practice, and educational activities.
Research questions:
1.
How are nurses’ perceptions of good death?
2.
How are nurses’ perceptions of nursing values?
3.
Do nursing values impact nurses’ perception of a good death?
4.
Do nurses’ perceptions of a good death differ according to their sociodemographic characteristics?
5.
Do nurses’ perceptions of nursing values differ according to their sociodemographic characteristics?
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Method
Design
The study was planned as a descriptive and cross-sectional type because it provides nurses with the opportunity to evaluate the cause and effect variables related to good death and nursing values in the same time period.
Research population and sample
The population of the research consists of nurses working in hospitals throughout Türkiye. Using the snowball technique, the sample consisted of 210 nurses who voluntarily participated in the study and completed the data collection forms entirely. In the study, an attempt was made to reach nurses across Türkiye over a three-month period using the snowball sampling method without calculating the sample size beforehand. Upon completion of the study, a post-hoc analysis revealed that the study, completed with 210 nurses, had an effect size of 0.72 and a power of 1.00. Based on these results, the sample size was deemed sufficient (n = 210). Nurses who agreed to participate in the research gave their consent via Google Forms and completed the survey. Criteria for inclusion in the study were being a registered nurse, actively working as a nurse and volunteering to participate in the research.
Data collection
The study’s data was collected between 15 December 2022 and 15 March 2023 by sharing the data collection form prepared with Google Forms among nurses using the snowball technique. Participants gave their consent to participate in the study with an option via Google Forms, and they confirmed their consent by clicking an online voluntary consent button before starting to answer the survey.
Data collection tools
Nurse information form
This form was created by researchers in line with the literature [4, 8, 14, 18]. The Nurse Information Form consists of seven closed questions. It includes questions about gender, marital status, educational background, the department where the participant worked, their position within the department, work schedule, and weekly working hours.
Good death scale
The scale was developed by Schwartz et al. (2003) to measure nurses’ perceptions of a good death [19]. Turkish validity and reliability were established by Fadıloğlu and Aksu (2010) [4]. It is a 4-point Likert-type scale with 17 items, answered as ‘not at all important’ (1), ‘somewhat important’ (2), ‘important’ (3), and ‘very important’ (4). Higher scores indicate an increased perception of a good death. A minimum of 17 and a maximum of 68 points can be obtained from the scale. The Good Death Scale has three sub-dimensions: Personal Control, Clinical, and Psychosocial and Spiritual. The total Cronbach’s alpha reliability coefficient was found to be 0.91 in the adaptation study conducted by Fadıloğlu and Aksu (2010) [4], while in this study, it was 0.85.
The revised nursing professional values scale (NPVS-R)
The scale was developed by Weis and Schank (2009) [20] based on the American Nurses Association Nursing Ethics Codes to evaluate nurses’ and nursing students’ perceptions of their professional values. It was adapted to Turkish, and its validity and reliability were tested by Acaroğlu (2014) [8]. The five-point Likert-type scale has 26 items and one dimension. Scale items are answered as ‘not important’ (1), ‘somewhat important’ (2), ‘important’ (3), ‘very important’ (4) and ‘extremely important’ (5). A minimum of 26 and a maximum of 130 points can be obtained from the scale, with higher scores showing better compliance with professional values. In the adaptation study of the scale, the total Cronbach Alpha reliability coefficient was found to be 0.96 [8]. This value was 0.96 in this study.
Ethics approval and consent to participated
Ethical approval was obtained from the Scientific Research Ethics Committee of a state university’s Health Sciences Scientific Research Ethics Committee (Date: 22.11.2022, Number: 33) to conduct the research. Online informed consent was obtained from nurses who volunteered to participate in the study. Permission was obtained from the authors via e-mail for the scales used as data collection tools. The principles of the Declaration of Helsinki were followed at all stages of the research.
Analysis
The data were evaluated in the SPSS 26.0 statistical software package. Descriptive statistical methods were used to assess the data, including frequency, percentage, mean, median, standard deviation, and minimum and maximum values. The data fit for normal distribution was evaluated with the Kolmogrov-Smirnov test. Differences in independent groups were analysed with non-parametric data and the Kruskal Wallis and Mann Whitney U test. LSD (Least Significant Difference Test) was conducted to determine which group the significance originated from within the group. The relationship between continuous variables was evaluated using Spearman correlation analysis. Additionally, linear regression analysis was used to evaluate the cause-and-effect relationship between dependent variables. In the study, a significance level of p < 0.05 was considered statistically significant. This study data was collected via Google forms. Each survey question was marked with a mandatory response feature. Thus, the survey was completed when the options were answered without skipping any questions. Therefore, in this study, a data set was created without missing data and no participant survey was excluded.
Results
In this study, 84.8% of the nurses were women. Their mean age was 30.30 ± 6.06, and 51.4% were married. Their mean years of experience were 6.96 ± 6.42. Regarding professional characteristics, 59.5% had a bachelor’s degree, and 25.2% worked in internal units. In the study, 84.3% served as bedside nurses. Additionally, 71.9% of nurses worked in shifts and 34.3% worked 51 h or more per week (Table 1).
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Table 1
Distribution of socio-demographic characteristics of nurses
Socio-Demographic Characteristics | ||
|---|---|---|
Age | Mean ± SD: 30.30 ± 6.06 | |
n | % | |
Gender | ||
Female | 178 | 84.8 |
Male | 32 | 15.2 |
Marital Status | ||
Married | 108 | 51.4 |
Single | 102 | 48.6 |
Education Level | ||
Health Vocational High School/Associate’s Degree | 28 | 13.3 |
Bachelor’s Degree | 125 | 59.5 |
Postgraduate Education | 57 | 27.1 |
Unit Type | ||
Intensive Care | 38 | 18.1 |
Internal Units | 53 | 25.2 |
Surgical Unit | 51 | 24.3 |
Emergency Unit | 28 | 13.3 |
Operating Room | 26 | 12.4 |
Other* | 14 | 6.7 |
Duty in the Clinic | ||
Charge Nurses | 20 | 9.5 |
Bedside Nurses | 177 | 84.3 |
Training Nurse | 10 | 4.8 |
Other** | 3 | 1.4 |
Worked in Shift | ||
Always Daytime | 45 | 21.4 |
Always Night | 14 | 6.7 |
Both Night and Day | 151 | 71.9 |
Weekly Working Hours | ||
40 h | 62 | 29.5 |
Between 41–50 h | 76 | 36.2 |
51 h or More | 72 | 34.3 |
The nurses’ total median score on the Good Death Scale was 53.00 (32–68). Their scores from the subscales were 9.00 (3–12) for Personal Control, 18.00 (10–24) for Clinical, and 28.00 (17–36) for Psychosocial and Spiritual subscales. The NPVS-R total mean score was 97.00 (49–125) (Table 2).
Table 2
Nurses’ good death scale and NPVS-R scores (n = 210)
Scales | Median (Min-Max) | Q1-Q3 | Cronbach’s Alpha Reliability Coefficient |
|---|---|---|---|
Good Death Scale (17–68) | 53.00 (32–68) | 49–58 | 0.850 |
Personal Control Subscale | 9.00 (3–12) | 8–11 | |
Clinical Subscale | 18.00 (10–24) | 17–21 | |
Psychosocial and Spiritual Subscale | 28.00 (17–36) | 26–32 | |
NPVS-R (26–130) | 97.00 (49–125) | 89–109 | 0.962 |
Statistically significant differences were observed in Good Death Scale scores based on nurses’ sociodemographic characteristics, particularly regarding gender and the department where they worked (p = 0.007 and p = 0.041, respectively, p < 0.05). Female nurses and nurses working in the operating room had higher good death perception mean scores than other nurses. Additionally, when the NPVS-R scores were analysed according to the sociodemographic characteristics, a statistically significant difference was noted between the scale scores by education level (p = 0.015) (p < 0.05). The nurses with postgraduate education had higher mean scores for perceptions of professional values than other nurses (Table 3).
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Table 3
Evaluation of good death scale and NPVS-R scores according to socio-demographic characteristics of nurses (n = 210)
Socio-Demographic Characteristics | ||||
|---|---|---|---|---|
Good Death Scale | NPVS-R | |||
Median (Min-Max) | Q1-Q3 | Median (Min-Max) | Q1-Q3 | |
Gender | ||||
Female | 53.00 (39–68) | 49-59.25 | 98.00 (49–125) | 88.50–109 |
Male | 50.00 (32–65) | 46-55.75 | 96.00 (62–125) | 90–102 |
Test | U = 2001.000 | U = 2633.500 | ||
p value | p = 0.007 | p = 0.498 | ||
Marital Status | ||||
Married | 52.00 (32–68) | 49–56 | 96.50 (49–125) | 86–106 |
Single | 54.00 (37–68) | 49–60 | 98.00 (63–125) | 90.75–109 |
Test | U = 4765.000 | U = 4942.000 | ||
p value | p = 0.091 | p = 0.198 | ||
Education Level | ||||
Health Vocational High School/Associate’s Degree | 51.00 (43–67) | 49.25–53.75 | 94.00 (49–116) | 81.25–103.50 |
Bachelor’s Degree | 52.00 (32–68) | 48.50–59 | 97.00 (63–125) | 89–106 |
Postgraduate Education | 54.00 (41–68) | 50–60 | 102.00 (74–125) | 93-114.50 |
Test | KW = 4.869 | KW = 8.406 | ||
p value | p = 0.088 | p = 0.015, b > a, c > a | ||
Unit Type | ||||
Intensive Care | 52.00 (41–68) | 49–58 | 105.50 (74–125) | 90.75-109.25 |
Internal Unit | 52.00 (32–67) | 48.50–55.50 | 96.00 (49–125) | 84.50–106 |
Surgical Unit | 54.00 (43–68) | 50–62 | 96.00 (69–123) | 89–109 |
Emergency Unit | 49.50 (41–68) | 46.25–54.50 | 92.00 (62–125) | 85.25–103.50 |
Operating Room | 55.00 (42–67) | 50.75–60.75 | 101.50 (62–125) | 97-111.25 |
Other* | 53.00 (39–68) | 47.75–59.75 | 99.00 (69–125) | 88.75–123 |
Test | KW = 11.612 | KW = 7.896 | ||
p value | p = 0.041, c > b, e > b, c > d, e > d | p = 0.162 | ||
Duty in the Clinic | ||||
Charge Nurses | 50.50 (42–62) | 48–54 | 95.50 (49–125) | 84-99.25 |
Bedside Nurses | 52.00 (32–68) | 49–59 | 98.00 (62–125) | 89.50–109 |
Training Nurse | 53.00 (48–68) | 50.75–57.25 | 105.50 (75–125) | 98-119.50 |
Other** | 63.00 (53–65) | 53–60 | 92.00 (79–121) | 79–100 |
Test | KW = 4.875 | KW = 7.009 | ||
p value | p = 0.181 | p = 0.072 | ||
Worked in Shift | ||||
Always Daytime | 54.00 (42–68) | 50-59.50 | 97.00 (49–125) | 79–113 |
Always Night | 51.00 (46–58) | 49-55.25 | 93.50 (81–125) | 90.50-99.25 |
Both Night and Day | 52.00 (32–68) | 49–59 | 98.00 (63–125) | 90–109 |
Test | KW = 2.197 | KW = 1.420 | ||
p value | p = 0.333 | p = 0.492 | ||
Weekly Working Hours | ||||
40 h | 53.50 (32–68) | 49-63.25 | 97.50 (49–125) | 80.75-116.25 |
Between 41–50 h | 53.00 (37–68) | 49–59 | 99.00 (62–125) | 91.25–111.50 |
51 h or More | 52.00 (41–68) | 48–55 | 95.00 (74–125) | 90–101 |
Test | KW = 4.679 | KW = 3.157 | ||
p value | p = 0.096 | p = 0.206 | ||
A moderate, positive and statistically significant relationship was found between the nurses’ Good Death Scale total mean scores and NPVS-R total mean scores (r = 0.522; p = 0.000) (Table 4).
Table 4
The relationship between nurses’ perception of a good death and their professional values scores (n = 210)
NPVS-R Total | Good Death Scale Total | Clinical Subscale | Personal Control Subscale | ||
|---|---|---|---|---|---|
Good Death Scale Total | r | 0.522** | |||
p | 0.000 | . | |||
Clinical Subscale | r | 0.489** | 0.812** | ||
p | 0.000 | 0.000 | . | ||
Personal Control Subscale | r | 0.364** | 0.702** | 0.422** | |
p | 0.000 | 0.000 | 0.000 | . | |
Psychosocial and Spiritual Subscale | r | 0.505** | 0.919** | 0.672** | 0.526** |
p | 0.000 | 0.000 | 0.000 | 0.000 | |
Gender (β = 0.210) and level of professional values (β = 0.502) were found to be predictors of nurses’ perceptions of a good death (R = 0.563, R2 = 0.317, F = 23.748, p = 0.000) (Table 5).
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Table 5
Predictors of nurses’ perceptions of good death
B | SE | β | t | P value | |
|---|---|---|---|---|---|
(Constant) | 34.509 | 3.169 | 10.890 | 0.000 | |
Gender | -4.136 | 1.143 | − 0.210 | -3.617 | 0.000 |
Education Level | 0.320 | 0.676 | 0.028 | 0.474 | 0.636 |
Working Clinic | 0.298 | 0.277 | 0.062 | 1.076 | 0.283 |
NPVS-R | 0.227 | 0.027 | 0.502 | 8.484 | 0.000 |
Discussion
This study, which was conducted to examine the effect of nurses’ professional values on their perception of a good death, revealed that nurses’ perception of a good death is above mean. Menekli et al. (2021) found in their research with nurses caring for palliative care patients and their families that nurses held moderate perceptions of a good death [21]. Likewise, Ceyhan et al. (2018), in their study with intensive care nurses caring for terminally ill patients, found that nurses’ attitudes towards the concept of a good death were moderately positive [22]. However, Türkben Polat’s (2022) study with nurses working in intensive care and oncology services found that nurses’ perceptions of a good death were high [23]. While this finding aligns with some previous studies, it is lower than the perception levels towards a good death in some studies. This finding suggests that although nurses’ perceptions of a good death are at an acceptable level, there is a need to elevate the quality of nursing care in managing the good death process as a fundamental human right, thus emphasising the importance of raising nurses’ perceptions of a good death. Nurses have roles in their professional processes such as improving the quality of life of patients, ensuring physical comfort and providing emotional support. In line with these roles, the fact that nurses’ perception of good death is above mean can be interpreted as nurses not seeing their profession as just a job, but having a perspective that respects and values people. In line with this result, conducting studies to compare death perceptions in different nursing areas (surgical care, intensive care, emergency room care) may provide comparative results.
In this study, nurses’ perceptions of professional values were found to be above average, although there are studies with conflicting results in the literature [14, 24, 25]. Studies by Dündar et al. (2019) [14] and Çetinkaya Uslusoy et al. (2017) [24] have reported nurses’ perceptions of professional values to be above average, similar to the findings of this study, while Poorchangizi et al. (2017) [25] found them to be at a high level. In light of these results, the variation in nurses’ perceptions of professional values may stem from their pre- and postgraduate professional education and the care culture in the clinical setting. Conducting more detailed studies on the effects of pre-service and graduate nursing education programs on nurses’ professional values, including evaluations of educational content, teaching methods, and practical opportunities, will strengthen these study findings. Additionally, research should be conducted to assess how the culture of care in clinical settings influences nurses’ professional values.
This study determined that there was a moderate, positive relationship between nurses’ perceptions of a good death and their perceptions of professional values, and that professional values significantly affected nurses’ perceptions of a good death. Uzunkaya and Öztoprak (2024) [26] noted in their study with oncology nurses that attitudes towards caring for dying patients, principles of dignified dying, and opinions on a good death were influenced by professional experience, professional attitudes, and professional characteristics. Moran et al. (2021) found that nurses embraced the core values of nursing and strived to uphold them in end-of-life care [27]. While death is an individual concept, a good death embodies characteristics inherent to the cultural context in which nurses operate. It can be affected by the beliefs, attitudes and value judgments regarding the professional values of nurses [17]. Nurses possess professional values such as human dignity, autonomy, equality, justice, altruism, aesthetics, realism, and integrity [11, 12]. It is essential for nurses to uphold and embrace these values even during end-of-life situations, reflecting their professionalism. Park and Kim (2018) emphasise in their study that nursing professionalism is a key factor influencing nurses’ performance in caring for terminally ill patients [28]. Thus, it is expected that nurses who prioritise professional values and reflect them in their care practices have high perceptions of a good death. This result suggests the necessity of implementing regulations that support nurses’ professional values and improve the processes of achieving a good death. Because nurses’ increased perception of a good death leads them to adopt their professional values more and apply these values more effectively in nursing care. Additionally, recognising that nursing values are a significant force guiding nurses’ attitudes and caregiving behaviours, there is a need to focus more on instilling nursing values and reflecting them in caregiving behaviours to enhance nurses’ perceptions of a good death. Future research could specifically evaluate the relationship between different professional values and good death, and it is suggested that studies be conducted to investigate how nurses integrate their professional values into daily practice and the impact of this integration on their perceptions of a good death.
Gender and the type of unit where nurses worked were identified as predictors of nurses’ perceptions of a good death. In this study, it was found that female nurses had higher perceptions of a good death. Similarly, the study by Uzunkaya and Öztoprak (2024) found that female nurses had a more positive perception of a good death than male nurses [26]. However, in some studies, no significant difference in perceptions of a good death based on gender was found [21, 23]. Women may have a higher perception of a good death than men due to their historical social and caregiving roles. This study also revealed that nurses working in surgical units and operating rooms had higher perceptions of a good death than those in other clinics. Menekli and Fadıloğlu (2014) [29] found in their study with nurses working in internal and surgical intensive care units that the majority of nurses who described death as a difficult process that should be accepted worked in the internal intensive care units, while nurses working in surgical intensive care units regarded death as the beginning of a new life. Based on the results of this study, we suggest that factors such as the characteristics of patients’ illnesses, the frequency of death events, and the high turnover rate in surgical clinics and operating rooms, along with the attitudes of nurses towards death in these clinics, could be influential.
Limitations
This study has some limitations. It is a descriptive and correlational study, and data were collected from a limited number of nurses across Türkiye using an online survey method. Another limitation is that the cultural characteristics and care culture perceptions that affect the good death and professional values of nurses in the study could have influenced their responses to the survey questions. The study findings only cover the nurses in the included sample and therefore cannot be generalized. Another limitation of the study is that since snowball sampling was used in the sample of the study, the sample may consist of homogeneous groups or limited networks, and therefore may not accurately represent larger and diverse populations.
Conclusion
As a result of the research, it was determined that nurses’ perception of a good death was above the mean level. It was determined that nurses’ perceptions of their professional values were above mean. It has been determined that nurses’ professional value perceptions and some individual characteristics significantly affect their perception of a good death. In light of these findings, we recommend organising training programs for nurses on good death and qualified care during the dying process and adopting empowering policies to raise awareness and sensitivity about end-of-life care. In line with these results, standard protocols, care algorithms, and guidelines for good death and end-of-life care should be developed. In addition, mechanisms should be established to obtain feedback from nurses and patient relatives, and this feedback should be used to improve care processes. It is necessary to create value-based training and support resources regarding end-of-life care, especially for nurses who care for intensive care or terminally ill patients. Additionally, there seems to be a need for broader sampling and studies with different designs to identify factors influencing nurses’ perceptions of a good death and to enhance their perception levels. Knowledge and skills training and practices regarding professional values should be planned during nursing education and after graduation.
Acknowledgements
We appreciate all the nursing for their time and participating in this study.
Declarations
Ethics approval and consent to participated
Ethical approval was obtained from the Scientific Research Ethics Committee of a state university’s Health Sciences Scientific Research Ethics Committee (Date: 22.11.2022, Number: 33) to conduct the research. Online informed consent was obtained from nurses who volunteered to participate in the study. Permission was obtained from the authors via e-mail for the scales used as data collection tools. The principles of the Declaration of Helsinki were followed at all stages of the research.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
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