1.1. Background of the Japanese Aging Population
The Ministry of Public Management, Home Affairs, Posts and Telecommunications announced that the proportion of individuals aged 65+ throughout Japan reached a record high of 26.7% in 2016. This demographic shift is likely the result of increased life expectancy through medical advances.
1.2. The Current State of Life and Death Education for Nursing Practice
Education regarding post-mortem treatment in Japan is conducted in 75.2% of schools. Primary lesson methods include lectures, viewing VTRs, and discussing hands-on experience, and operation time accounts for a sizable proportion of class time (i.e., for those that run for 90 minutes). Education on post-mortem treatment in Japan is not available for around 25% of schools. Reasons for this include, “other items are given priority”, “not enough time available”, and “post-mortem training is done on-clinical site” (Hirano  ).
The number of patients over the age of 65 undergoing surgery has increased year by year  . Based on a population survey conducted by the Ministry of Health, Labor and Welfare in Japan, 80.3% of people die at hospitals or clinics, with only about 12% of Japanese residents dying at home  . Thus, nurses working at acute care hospitals frequently experience patient mortality, providing ample opportunities for thinking about death.
Based on these aforementioned details, education regarding death is important for nursing practice. However, such educational opportunities are quite limited, as noted by Hirano et al., whereby only 75.2% of nursing schools provide education regarding post-mortem treatment. Furthermore, when education is provided, it is not addressed extensively during 90-minute sessions.
“Hence, many nurses are puzzled by how to aid patients who are at the end of life, as well as the appropriate attitudes needed regarding terminal care and death.” Oyama  . Additionally, cultural shifts in the Japanese nuclear family has changed the exposure nurses have to death experiences in their day-to-day lives. Thus, nurses may experience death for the first time in their lives when witnessing a patient’s death. Furthermore, there is little research in this area. One prior study focused on life and death attitudes among nurses working on terminal wards, but little else is available.
Therefore, the present analysis was conducted to assess attitudes toward life and death among nurses working on acute care hospital wards in Japan.
1) Definition of terms
Thanatology is “a way of thinking about life and death.” Yamamoto  mentioned that one’s view of life and death is a fundamental human value that does not change throughout one’s lifetime. This viewpoint develops throughout the lifespan, and some motivational components are important. In the present study, the idea of life and death was defined as a “way of thinking about how to live and how to die.”
2) Review of literature on life and death based on Hirai et al. 
Several measures, such as the DAS (Death Anxiety Scale; Templer  ) and Death Attitude Profile-revised method (DAP-R; Wong et al.  ) have been developed to measure life and death conceptions. However, few studies have quantitatively measured Japanese individuals’ life and death views.
Hirai and colleagues developed a new measure for assessing Japanese views of life and death. Surveys of this nature are generally devised for college and vocational school students, and scale reliability has been previously addressed. High reproducibility has been observed across factors. Thus, basic life/death scale factors are highly reliable. The scale assessed in the present study comprised 7 factors: 1) belief in an afterlife, 2) death anxiety, 3) death relief, 4) death avoidance, 5) life purpose, 6) death concern, and 7) supernatural beliefs. Furthermore, reliability and validity of this scale has been previously confirmed.
The main aim of the present study was to clarify the factor structure of a life and death scale for female nurses working in acute care wards in Japan.
3. Materials and Methods
1) Question content and data analytic method
Basic participant attributes (i.e., years of experience, age, gender; Table 1) were assessed in addition to factors underlying life and death conceptualizations. Items were rated on 7-point Likert scales  . The scale comprised 27 items across the seven subscales (Table 2)  . Permission was granted from the questionnaire’s author. Further, informed consent among participants was also distributed along with a questionnaire form.
In terms of data analyses, we first examined basic demographic statistics. Next, an exploratory factor analysis for death and longevity scores (promax rotation, main factor method) was conducted. This analysis extracted factors with an eigenvalue greater than 1 and factor loadings greater than 0.4. Factors that were difficult to interpret were excluded. From the above10 items were judged as no correlation from the factor coefficients.
Those with a factor loading factor of 0.4 or less were excluded, and analysis was conducted again for the remaining 17 items.
The scores of each factor represent the strength of consciousness, respectively, and factor analysis was carried out by assuming the Likert scale as an interval scale.
IBM SPSS Statistical Package for the Social Sciences for WINDOWS was used for all analyses.
And significance was set at p < 0.05 (two tailed).
2) Sample size
The sample size was 95% confidence level, it was calculated assuming that everyone answered, and it turned out that 385 or more was necessary.
Table 1. Investigate the items about the basic attributes.
Table 2. Death attitude inventory.
From: A survey of the death attitude of pharmacy students finished clinical training using the Death Attitude Inventory Palliative Care Research 2013; 8(2):319-25.
There are 840 nurses working in the hospital.
Questionnaires were distributed to 720 nurses working in acute care hospital A in the Kansai area. Distribution destinations were all wards except for operating rooms and outpatient clinics.
3) Research timeline
The time required for survey completion was about 10 to 15 minutes, including explanations and informed consent. The research implementation period was from April 2016 to March 2017 (registration deadline: January 2017).
4) Ethical consideration
After describing the purpose of the study, orally and in writing, to the nursing manager of the particular facility, we distributed questionnaires to the target hospital nursing department, ward manager, and individual nurses. In a written statement, we documented that all data collected was only for research purposes. We also ensured that participants’ privacy would be protected.
In order to ensure privacy, individual nurses were given an anonymous envelope that would be sealed (by the nurse) and placed in a rest room box within 2 to 3 weeks after administration. The present study was approved by the Tottori University Ethics Review Committee (1603 A 156).
1) Collection status and participant characteristics
Of the 720 questionnaires distributed, 405 were completed (56.2%). As our analyses were focused solely on female respondents, questionnaires from 30 men (17%) were excluded, leaving us with a total of 370 valid questionnaires (83%)  (Table 3).
Average participant age was 34.8 years (SD ± 11.7; range = 21 to 64), and average nursing experience was 12.0 years (SD = ±10.8; range = 1 to 42 years; Table 4). Two hundred students graduated from professional and vocational schools (54.0%), 110 from universities (29.8%), 46 from junior colleges (12.4%), 10 from high school nursing departments (2.7%), and 4 from graduate schools (1.1%; Table 5).
2) Confirming scale reliability and validity
The Kaiser-Meyer-Olkin value (hereinafter referred to as the KMO value) was 0.8; a Bartlett’s test produced a significant result (p < 0.001), and the α coefficient was 0.8. Hence, scale reliability and validity was initially confirmed with the present sample.
3) Factor analysis of nurses’ views on life and death
We initially classified the 27 items from Hirai et al.’s death and life scale into the initial seven factors (via promax rotation). The initial factor analysis revealed that 10 of the 27 items were inadequate. Thus, a second analysis was conducted on the remaining 17 items. The KMO analysis produced a value of 0.8. A Bartlett’s test produced a significant result (p < 0.001), and Cronbach’s α was 0.8, which was the result obtained by Hirai et al. during initial scale validity checks. The present analysis led to the extraction of 4 factors with eigenvalues greater than 1, with a cumulative contribution rate of 62.8% (Table 6).
Table 3. Sex difference.
Table 4. Age and nursing experience years.
Table 5. Comparing by school graduation.
Table 6. factor analysis of seventeen subjects with death and life observation and Cronbachs coefficient α.
Promax rotation, main factor method n = 370 KMO = 0.802, Rotation method: Promax method with Kaiser’s normalization, *** = p < 0.001.
The first factor was called, “A comprehensive view of life and death” and comprised the following seven items: “I think about my death,” “People’s span of life considers beforehand I am decided by it.” “I think that death releases pain from this world.” “I have found out the mission and purpose of life.” “I think that there is an afterlife.” “A lifespan is decided from the original.” “I think that death is a terrifying thing.”
The second factor was called, “Sharing the fate of death and liberation,” and comprised the following three factors: “People’s life and death are decided by a higher power (fate, God, etc.), which is not a foregone conclusion,” “Death is pain, and this pain can be relieved,” “I often talk about a household, a friend, and death.”
The third factor was called, “Death fear, anxiety, and avoidance,” and comprised the following four items: “I am uneasy about dying,” “I avoid considering death,” “No matter what, I would like to avoid considering death,” “I think that there are ‘souls’ and ‘curses’ in this world.”
The fourth factor was called, “Liberation from life and a world after death,” and comprised the following three items: “For me, significance in life, purpose, and mission includes existing sufficiently,” “I regard death as relief from the pressure of this life,” “I think that a soul remains even when one dies.”
In the present study, we examined life and death views with respect to the death of one’s relatives; however, there were no significant differences regarding factor composition. Furthermore, there were no differences in terms of item composition based on years of nursing experience.
1) Response rates
We obtained suitable response rates from the target hospitals, wards, and nurses. Yoshida et al.  and Takigawa  also collected questionnaires using the same death and life scale used in the present study, observing response rates of 70% to 80%, respectively. Our present response rate was 56.2%; one possibility for this lower rate could have been the relative short data collection period implemented. Additionally, a survey from the Japan Nursing Association revealed that ward nurses’ weekly overtime work often exceeds 12 hours  . Thus, a ward nurse’s busy work schedule may limit the time available to complete a survey. Thus, future work should consider questionnaire content and number of items to help facilitate greater response rates.
2) Participant characteristics.
According to a survey from the Japan Nursing Association, the average age of acute ward nurses was 34.8 years old, which is similar to the present sample  (Table 3 and Table 5). Furthermore, years of experience and education background was comparable between our sample and what was observed within the prior Japan Nursing Association survey.
3) Scale results
The concept of death and life scale (Hirai et al.) demonstrated adequate reliability and validity based on Cronbach’s α, KMO, and Bartlett’s test results. However, our factor analysis suggested that a better fit to the data was obtained through a 17-item, rather than the original 27-item, scale.
4) Nurses’ concepts of life and death
The first factor extracted was, “A comprehensive view of life and death.” This factor comprised all characteristics other than “death avoidance,” which fit better within our fourth factor. Furthermore, when compared to factors derived from previous studies assessing nurses’ views of life and death (i.e., Hirai et al.), our factors were constructed from various viewpoints, rather than from a constrained framework.
The second factor was termed, “Sharing the fate of death and liberation,” which comprised three items. This concept argues that life and death are not voluntary actions, and death is a liberation from the pain and suffering experienced while living. Furthermore, death experiences and anxiety can be shared with family and friends.
Thethird factor was named, “Death fear, anxiety, and avoidance,” which comprised four items. This factor not only dealt with fear surrounding death, but there was also a spiritual component (i.e., “I think that there are spirits and talents in the world”).
Finally, the fourth factor was, “Liberation from life and a world after death,” which comprised three items. Content included living with a purpose and being released from life after death. This concept focused on the shirking of burdens through entry into an afterlife.
Previous studies from Oyama et al.  and Negishi et al.  revealed that items assessing death avoidance were endorsed less frequently than in the present study. Furthermore, Okamoto et al.  observed that clinical nurses believe in a post-mortem world and have a greater fear of death when younger. However, in the present study, age and years of nursing experience did not influence death anxiety endorsement. Such a result could be described based on a multifaceted view of life and death. Through contact with death during one’s early career stages (e.g., 1st and 2nd year working in an acute ward), avoidance is limited, and death concepts can be formulated more fully. Furthermore, nurses have diverse perspectives regarding life and death. This is exemplified by the fact that the factor loadings observed in the present study for each subscale were different from what has been observed in previous studies. However, Tange  argues that indirect death experiences can help shape one’s views of life and death. Opportunities for experiencing people close to death are also influential. In other words, opportunities to indirectly learn about death are important. Thus, future work should expand upon nursing education, postgraduate education, and preparatory education in order to bolster and formulate nurses’ adaptive views of life and death.
We surveyed female nurses (n = 370) from acute wards using a questionnaire based on Hirai et al.’s death and life scale. A factor analysis (promax rotation) revealed a 4-factor structure. The first factor comprised all subscales except for the “death avoidance” subscale, which fit better within the fourth factor. These factors included “A comprehensive view of life and death” “Sharing the fate of death and liberation” “Death fear, anxiety, and avoidance”, and “Liberation from life and a world after death”.
7. Limitations and Future Directions
A few study limitations should be noted. First, the present survey was only conducted at one facility, limiting generalizability of our findings. Future work is needed that includes additional facilities and departments (i.e., chronic and palliative care wards, etc.). Other characteristic factors should also be considered in the future, such as sex differences, patient disease and symptom profiles, patient age, etc., to more comprehensively determine how nurses’ views of life and death emerge. Finally, a larger and more diverse participant sample would be useful for expanding nurses’ manifestation of life and death viewpoints.
We deeply appreciate cooperation from the nursing departments and wards sampled, along with Professor Yamamoto Miwa, Professor Masami Chujo, and Professor Kumiko Sasaki, for their guidance.
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