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J Hosp Palliat Care 2018; 21(2): 58-64
Published online June 1, 2018 https://doi.org/10.14475/kjhpc.2018.21.2.58
Copyright © Journal of Hospice and Palliative Care.
Hee Young Woo, Young Ran Yeun*
Department of Nursing, Hallym Polytechnic University, Chuncheon, Korea,
* Department of Nursing, College of Health Science, Kangwon National University, Samcheok, Korea
Correspondence to:Young Ran Yeun Department of Nursing, College of Health Science, Kangwon National University, 346 Hwangjo-gil, Dogye-eup, Samcheok 25949, Korea Tel: +82-33-540-3364 Fax: +82-33-540-3369 E-mail: yeunyr@kangwon.ac.kr
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
This study was conducted to evaluate the impact of a two-week palliative care education program on Korean Hospice volunteers. A total of 71 volunteers were assigned to two groups: Group A (intervention, n=34) and Group B (usual care, n=37). Group A received six sessions of palliative care education for two weeks. The level of volunteers’ motivation, death anxiety, and communication with the dying were measured at baseline and after the program ended. The palliative care education program had positive influence on the volunteers’ motivation (t=2.341, P=0.022), death anxiety (t=–2.166, P=0.034), and communication with the dying (t=–2.808, P=0.006). The findings of this study suggest that a palliative care education program may be an effective way to boost hospice volunteers’ motivation, ease their death anxiety and improve their communication with the dying.Purpose:
Methods:
Results:
Conclusion:
Keywords: Hospices, Volunteers, Motivation, Anxiety, Communication
The demand for hospice palliative care is increasing worldwide, as the mortality rate increases every year due to chronic diseases (e.g., cancer, cardiovascular diseases, stroke, and chronic respiratory disease). There are approximately 400,000 hospice volunteers in the United States and more than 125,000 hospice volunteers working in the UK (1,2). In 1963, hospice volunteer activities were established in South Korea when the sisters of the ‘Little Company of Mary’ in Gangneung started to provide end-of-life care for their patients. There have been national volunteer education and activities since the 1990s (3).
Hospice activity is characterized by providing care through a multidisciplinary team (e.g., doctors, nurses, social workers, clergy, nutritionists, volunteers, etc.). Among them, hospice volunteers have a very important position. Recipients of palliative care want a dignified death while receiving physical, mental, and social assistance and relief during their last days of life. However, it is difficult for the medical professionals to provide them with intensive care in the current medical system due to the limited time. Hospice volunteers spend the longest time together with the dying among the hospice members. They also provide various care to the patients’ physical, emotional, social, and spiritual needs, excluding medical care, as well as for the bereaved family, and provide financial support activities, public relations, and community linkage projects, which are necessary for the hospice business development (1,4). However, hospice volunteer activity does not rely on compassion alone, but it also requires training and education as a profession. Therefore, a systematic education for hospice volunteers is deemed necessary.
Volunteer activities are motivated by mental interests, and highly motivated volunteers have higher satisfaction and persistence with the hospice (5,6). Therefore, the hospice volunteer education should serve as an opportunity for education recipients to regularly participate in hospice volunteer activities after receiving their education by increasing the motivation. Death anxiety is a psychological process that causes negative emotions, such as anxiety, disgust, rejection, and negation of death and the process of dying. When hospice volunteers barely experience death anxiety, they exhibit more positive attitudes toward providing end-of-life care to the dying patients, and they are capable of effectively communicating with palliative care recipients (7-9). Communication skills are the most important approach of hospice services. Effective communication enhances the understanding between the patient and their family, strengthens therapeutic relationships, and enables an accurate assessment of the services that are being provided. It also promotes the implementation of treatment and the quality of life of the patients (10-12). Therefore, hospice education should enable volunteers to have positive attitudes toward life and death, to overcome death anxiety, and to effectively communicate with the dying, so that they can help terminal ill patients to pass away peacefully.
In the United States and Europe, many studies are being performed on the factors such as communication, motivation, or empathy that can influence the relationship between the volunteers and the patients (13-15). However, in Korea, where there is relatively little awareness about hospice among the general public and medical practitioners, many studies have been conducted in order to study the changes in social perceptions through an education program that provides accurate information about hospice (16-18). Furthermore, there are some studies that have examined the correlation between motivation, death anxiety or commination (19,20), but almost no intervention studies that have been conducted both internationally and domestically to enhance the volunteers’ motivation or improve their communication with the dying. Thus, intervention studies mainly focusing on improving the quality of hospice services are needed in Korea. Accordingly, this study aimed to evaluate the effects of the palliative care education program (PCEP) on motivation, death anxiety, and communication apprehension of the volunteers in Korea hospice volunteers.
This research is a quasi-experimental study for identifying the effects of PCEP on motivation, death anxiety, and communication apprehension of the volunteers.
Hospice volunteers who had registered at S hospital in Seoul, South Korea were eligible for inclusion in the study. G*Power version 3.1.9.2 program was used to estimate the required sample size for t-test with a significance level of 0.5, a medium effect size of 0.80, and statistical power of 0.80. The results showed that 26 subjects were required for each group, but 40 were assigned to Group A (experimental group) and Group B (control group) to account for potential dropout. However, 6 volunteers dropped from Group A and 3 from Group B prior to the follow-up examination, because of scheduling conflicts. Ultimately, 71 subjects (Group A: n=34; Group B: n=37) were included in the analysis.
This study was conducted after obtaining the approval from the Institutional Review Board (IRB) of the S hospital (IRB No. SYMC IRB 1601-002) was performed. Written informed consent was obtained from each participant.
The PCEP applied to this study was developed based on the hospice volunteer program that was being conducted at the hospice palliative care research center at S University in Seoul, South Korea and the previous studies (21,22). This program consisted of 16 contents with a total of 6 sessions for 2 weeks (3 sessions per week), and each session was composed of theorecical education using lectures, discussions, case studies, and practical training and field trip. A 3-hour education was given for each session. The core education contents and procedures of each session are presented in Table 1.
Table 1 Program Contents.
| Session | Objectives | Contents items | Detailed contents | Methods |
|---|---|---|---|---|
| 1 | Hospice and palliative care | • Understanding life and death | • Life toward death | L&D |
| • The dying process | ||||
| • Bioethics and preparation for a dignified life | • Ethics related to terminal patients | L&D | ||
| • Preparation for death | ||||
| • Attitudes and roles of the volunteers, and stress management | • Origin of palliative care | L&D | ||
| • Purpose of palliative care | ||||
| • Stress management strategies | ||||
| 2 | Physical care | • Physical symptoms of palliative care recipients | • Signs of near death | L&D |
| • End of care | ||||
| • Cancerous disease and nursing care | • Kinds of cancer | L&D | ||
| • Pain evaluation and management | ||||
| • Physical care for palliative care recipients | • Physical needs of terminal patients | L&D | ||
| • Physical care for terminal patients | ||||
| • Nutrition management for palliative care recipients | • Needs of nutrition | L&D | ||
| • Guidance of nutrition management | ||||
| 3 | Psychological and spiritual care | • Psychological needs of palliative care recipients and provision of care | • Psychological needs of terminal patients | L&D |
| • Good death | ||||
| • Psychological care for terminal patients | ||||
| • Spiritual needs of palliative care recipients and provision of care | • Spiritual l needs of terminal patients | L&D | ||
| • Spiritual care for terminal patients | ||||
| 4 | Communication methods | • Communication process with palliative care recipients | • Communication with terminal patients | L&P |
| • Communication with terminal patients’ family | ||||
| • Bereaved family management | • Stages of bereavement or grief | L&D | ||
| • Feelings of grief | ||||
| • Coping with grief | ||||
| 5 | Complementary and alternative medicine | • Foot massage lecture and practice | • Effects & method of foot massage | L&P |
| • Foot massage practicum | ||||
| • Laughter therapy lecture and practice | • Effects & method of Laughter therapy | L&P | ||
| • Laughter therapy practicum | ||||
| 6 | Field trip and curriculum evaluation | • Field trip to the hospice center | • Visiting to hospice center | FT |
| • Curriculum evaluation | • Discussion and evaluation of the program | Conf. |
L&D: Lecture and discussion, L&P: Lecture and practice, FT: Field trip, COnf.: Conference.
Motivation assessed using Hospice Palliative Care Volunteerism (IMHPCV) developed by Claxton-Oldfield et al. (23). To facilitate its use in our study, a bilingual nursing progessor translated the IMHPCV from English and Korean. The translated draft was then back-translated into English by an English expert. A subsequent comparison of the original and back-translated IMHPCV yielded no substantial differences. The IMHPCV consists of 25 items with a 5-point Likert-type scale from ‘strongly disagree’ (1 point) to ‘strongly agree’ (5 points). The higher the score means the higher the motivation to become a volunteer. The Cronbach’s α representing the reliability was 0.85 by Claxton-Oldfield et al. (23), and 0.87 in this study.
Death anxiety assessed using Death Anxiety Scale (DAS) developed by Templer (24) and verified the reliability and validity of a Korean version by Ko et al. (25). DAS consists of 15 items with a 5-point Likert-type scale from ‘strongly disagree’ (1 point) to ‘strongly agree’ (5 points). The higher the score means the higher the death anxiety. The Cronbach’s α was 0.83 by Templer (24), and 0.86 in this study.
Communication apprehension with the dying assessed using Communication Apprehension with the Dying (CA-Dying) scale developed by Hayslip (26). A bilingual nursing progessor translated the CA-Dying from English and Korean. The translated draft was then back-translated into English by an English expert. A subsequent comparison of the original and back-translated CA-Dying yielded no substantial differences. This instrument consists of 30 items with a 5-point scale from ‘strongly disagree’ (1 point) to ‘strongly agree’ (5 points). The higher the score means the higher the apprehension level while communicating with the dying. The Cronbach’s α was 0.86 by Hayslip (26), and 0.88 in this study.
All of the data were expressed as means±standard deviations. The homogeneity of Groups A and B was analyzed using t-tests or Chi-square tests. The effects of the intervention on motivation, death anxiety, and communication apprehension with the dying were analyzed using t-tests. Data analysis was performed using SPSS Statistics for Windows version 20.0 (IBM Corp., Armonk, USA). The significant level was set at P<0.05.
The general characteristics of the subjects and the homogeneity test result at baseline are presented in Table 2. Females constituted 62.0% (n=44), and 47.9% (n=34) of participants were 50~59 years old. According to the homogeneity test result, there was no statistically significant difference between Group A and Group B.
Table 2 Subjects’ General and Clinical Characteristics at Baseline (N=71).
| Characteristics | Categories | Group A (n=34) | Group B (n=37) | P |
|---|---|---|---|---|
| n (%) or M±SD | n (%) or M±SD | |||
| Gender | 0.464 | |||
| Male | 11 (32.4) | 16 (43.2) | ||
| Female | 23 (67.6) | 21 (56.8) | ||
| Age (yrs) | 0.928 | |||
| 20~29 | 2 (5.9) | 3 (8.1) | ||
| 30~39 | 1 (2.9) | 1 (2.7) | ||
| 40~49 | 7 (20.6) | 5 (13.5) | ||
| 50~59 | 15 (44.1) | 19 (51.4) | ||
| ≥60 | 9 (26.5) | 9 (24.3) | ||
| Religion | 0.547 | |||
| Yes | 27 (79.4) | 25 (67.6) | ||
| No | 7 (20.6) | 12 (32.4) | ||
| Educational level | 0.319 | |||
| Middle school | 4 (11.8) | 1 (2.7) | ||
| High school | 7 (20.6) | 11 (29.7) | ||
| College | 8 (23.5) | 12 (32.4) | ||
| ≥University | 15 (44.1) | 13 (35.2) | ||
| Economic status | 0.590 | |||
| Good | 5 (14.7) | 6 (16.2) | ||
| Fair | 21 (61.8) | 27 (73.0) | ||
| Poor | 8 (23.5) | 4 (10.8) | ||
| Health status | 0.113 | |||
| Good | 8 (23.5) | 6 (16.2) | ||
| Fair | 25 (73.6) | 31 (83.8) | ||
| Poor | 1 (2.9) | 0 (0.0) | ||
| Motivation | 75.17±13.15 | 76.16±13.36 | 0.679 | |
| Death anxiety | 44.41±7.13 | 43.48 ±5.04 | 0.528 | |
| CAD | 56.82±7.01 | 55.89±7.86 | 0.601 |
CAD: Communication apprehension with the dying.
The motivation, death anxiety and communication apprehension with the dying significantly improved after the intervention, as shown in Table 3. The mean motivation of group A was 90.17±13.15 before and 98.88±8.76 after intervention (t=2.341, P=0.022). In addition, the mean death anxiety of group A was 44.41±7.13 before and 41.21±3.65 after intervention (t=–2.166, P=0.034). Similarly, there were significant decreases in the communication apprehension with the dying scores (group A: before=56.82±7.01 and after=51.41±8.35; t=–2.808, P=0.006).
Table 3 Clinical Outcomes of Baseline and Follow-Up Examination in Groups A and B (N=71).
| Variable | Group | Examination | Changes | t | P | |
|---|---|---|---|---|---|---|
| Baseline | Follow-up | |||||
| M±SD | M±SD | |||||
| Motivation | A (n=34) | 75.17±13.15 | 83.88±8.76 | 8.11±2.81 | 2.341 | 0.022 |
| B (n=37) | 76.16±13.36 | 76.48±10.50 | 0.47±2.89 | |||
| Death anxiety | A (n=34) | 44.41±7.13 | 41.21±3.65 | -3.20±1.37 | -2.166 | 0.034 |
| B (n=37) | 43.48±5.04 | 43.39±5.42 | -0.91±1.27 | |||
| CAD | A (n=34) | 56.82±7.01 | 51.41±8.35 | -6.50±1.97 | -2.808 | 0.006 |
| B (n=37) | 55.89±7.86 | 56.92±8.12 | 0.43±1.99 | |||
CAD: Communication apprehension with the dying
This study was conducted in order to identify the effects of PCEP on the hospice volunteers’ motivation, death anxiety, and communication apprehension with the dying.
The result of this study showed that the mean motivation score of the Korean volunteers, who received a 6-session PCEP for 2 weeks, increased. Since there was no study that investigated the change of motivation after providing a program to the hospice volunteers, a direct comparison is difficult to achieve. However, these results confirmed those of previous study. Kim et al. (13) showed that a 15-hour hospice volunteer education, which was composed of overview and ethics of hospice, family management, physical management, psychological management, bereavement management, spiritual management, and role of the volunteers, significantly increased the volunteers’ awareness of hospice and value of life. Yeun et al. (22) reported that a hospice palliative medicine education program, which consisted of a total of 5 sessions (3 sessions per week), increased the nurses’ awareness of hospice. According to a study that was conducted on 351 hospice volunteers, the major factor that enabled them to continue to participate in volunteer activities was the positive experience with the hospice organization (27). It means that continuous support and supervision are important for motivating them to continue their hospice volunteer services. Therefore, it is necessary to constantly develop program to enhance the motivation of hospice volunteers in the future.
PCEP was effective on reducing the death anxiety of the volunteers. This is similar to the result of a study, in which a 6-session death education was provided to the junior year nursing students and resulted in a reduced death anxiety (28). It is also similar to the study result of Lee et al. (21), in which a 7-session hospice palliative care education program was provided to the nursing students and resulted in an improved attitude toward death. In addition, Yoon (29) reported that after a 5-day death preparation education program for the hospice volunteers 6 hours every day, death anxiety was significantly lowered, thereby supporting the result of this study. The education program of this study includes the content to help in the overall understanding of death, and it is believed that anxiety about death was reduced by discovering the positive feeling and meaning of death through various activities.
PCEP was also effective on improving the volunteers’ communication apprehension with the dying. It is difficult to direct compare the results of this study with previous studies because there is no study that verifies the effect of volunteers’ communication apprehension with the dying after intervention. Compared with similar studies, Wittenberg et al. (30) found that a training that used the Communication, Orientation and options, Mindful communication, Family, Openings, Relating, and Team (COMFORT) communication for the palliative care teams’ curriculum enhanced the communication ability of nurses, social workers, doctors, military chaplains, and psychologists with the dying. Brown et al. (31) reported that simulation-based palliative care communication skill workshops improved the hospice communication skills of the internal medicine residents, medicine subspecialty fellows, nurse practitioner students, and community-based advanced practice nurses. According to a previous study, the communication ability with the dying was correlated with the volunteers’ intention to continue participating in volunteer activities (32). Therefore, it is believed that education programs should be developed continuously in order to improve the volunteers’ communication ability.
The study had several strengths. For example, it was the first study to investigate the effects of hospice palliative care education on the volunteers’ motivation, death anxiety, and communication apprehension with the dying of the Korean hospice volunteers. In addition, the program could be used as an effective method for the volunteers to promote their participation in the community. Based on the above results, suggestions for further studies are as follows. First, the mean volunteer motivation score of this study subjects was higher than those of the volunteers in France (16), and the United Kingdom (33). We suggest a study exploring the factors associated with motivation enhancement through comparison of the motivation levels by country or culture. Second, this study measured the changes in variables only at baseline and 2-week follow-up. It is necessary to carry out a study that measures the variable changes over time in order to identify the lasting effects of education and determine the re-education schedule in the future.
J Hosp Palliat Care 2018; 21(2): 58-64
Published online June 1, 2018 https://doi.org/10.14475/kjhpc.2018.21.2.58
Copyright © Journal of Hospice and Palliative Care.
Hee Young Woo, Young Ran Yeun*
Department of Nursing, Hallym Polytechnic University, Chuncheon, Korea,
* Department of Nursing, College of Health Science, Kangwon National University, Samcheok, Korea
Correspondence to:Young Ran Yeun Department of Nursing, College of Health Science, Kangwon National University, 346 Hwangjo-gil, Dogye-eup, Samcheok 25949, Korea Tel: +82-33-540-3364 Fax: +82-33-540-3369 E-mail: yeunyr@kangwon.ac.kr
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
This study was conducted to evaluate the impact of a two-week palliative care education program on Korean Hospice volunteers. A total of 71 volunteers were assigned to two groups: Group A (intervention, n=34) and Group B (usual care, n=37). Group A received six sessions of palliative care education for two weeks. The level of volunteers’ motivation, death anxiety, and communication with the dying were measured at baseline and after the program ended. The palliative care education program had positive influence on the volunteers’ motivation (t=2.341, P=0.022), death anxiety (t=–2.166, P=0.034), and communication with the dying (t=–2.808, P=0.006). The findings of this study suggest that a palliative care education program may be an effective way to boost hospice volunteers’ motivation, ease their death anxiety and improve their communication with the dying.Purpose:
Methods:
Results:
Conclusion:
Keywords: Hospices, Volunteers, Motivation, Anxiety, Communication
The demand for hospice palliative care is increasing worldwide, as the mortality rate increases every year due to chronic diseases (e.g., cancer, cardiovascular diseases, stroke, and chronic respiratory disease). There are approximately 400,000 hospice volunteers in the United States and more than 125,000 hospice volunteers working in the UK (1,2). In 1963, hospice volunteer activities were established in South Korea when the sisters of the ‘Little Company of Mary’ in Gangneung started to provide end-of-life care for their patients. There have been national volunteer education and activities since the 1990s (3).
Hospice activity is characterized by providing care through a multidisciplinary team (e.g., doctors, nurses, social workers, clergy, nutritionists, volunteers, etc.). Among them, hospice volunteers have a very important position. Recipients of palliative care want a dignified death while receiving physical, mental, and social assistance and relief during their last days of life. However, it is difficult for the medical professionals to provide them with intensive care in the current medical system due to the limited time. Hospice volunteers spend the longest time together with the dying among the hospice members. They also provide various care to the patients’ physical, emotional, social, and spiritual needs, excluding medical care, as well as for the bereaved family, and provide financial support activities, public relations, and community linkage projects, which are necessary for the hospice business development (1,4). However, hospice volunteer activity does not rely on compassion alone, but it also requires training and education as a profession. Therefore, a systematic education for hospice volunteers is deemed necessary.
Volunteer activities are motivated by mental interests, and highly motivated volunteers have higher satisfaction and persistence with the hospice (5,6). Therefore, the hospice volunteer education should serve as an opportunity for education recipients to regularly participate in hospice volunteer activities after receiving their education by increasing the motivation. Death anxiety is a psychological process that causes negative emotions, such as anxiety, disgust, rejection, and negation of death and the process of dying. When hospice volunteers barely experience death anxiety, they exhibit more positive attitudes toward providing end-of-life care to the dying patients, and they are capable of effectively communicating with palliative care recipients (7-9). Communication skills are the most important approach of hospice services. Effective communication enhances the understanding between the patient and their family, strengthens therapeutic relationships, and enables an accurate assessment of the services that are being provided. It also promotes the implementation of treatment and the quality of life of the patients (10-12). Therefore, hospice education should enable volunteers to have positive attitudes toward life and death, to overcome death anxiety, and to effectively communicate with the dying, so that they can help terminal ill patients to pass away peacefully.
In the United States and Europe, many studies are being performed on the factors such as communication, motivation, or empathy that can influence the relationship between the volunteers and the patients (13-15). However, in Korea, where there is relatively little awareness about hospice among the general public and medical practitioners, many studies have been conducted in order to study the changes in social perceptions through an education program that provides accurate information about hospice (16-18). Furthermore, there are some studies that have examined the correlation between motivation, death anxiety or commination (19,20), but almost no intervention studies that have been conducted both internationally and domestically to enhance the volunteers’ motivation or improve their communication with the dying. Thus, intervention studies mainly focusing on improving the quality of hospice services are needed in Korea. Accordingly, this study aimed to evaluate the effects of the palliative care education program (PCEP) on motivation, death anxiety, and communication apprehension of the volunteers in Korea hospice volunteers.
This research is a quasi-experimental study for identifying the effects of PCEP on motivation, death anxiety, and communication apprehension of the volunteers.
Hospice volunteers who had registered at S hospital in Seoul, South Korea were eligible for inclusion in the study. G*Power version 3.1.9.2 program was used to estimate the required sample size for t-test with a significance level of 0.5, a medium effect size of 0.80, and statistical power of 0.80. The results showed that 26 subjects were required for each group, but 40 were assigned to Group A (experimental group) and Group B (control group) to account for potential dropout. However, 6 volunteers dropped from Group A and 3 from Group B prior to the follow-up examination, because of scheduling conflicts. Ultimately, 71 subjects (Group A: n=34; Group B: n=37) were included in the analysis.
This study was conducted after obtaining the approval from the Institutional Review Board (IRB) of the S hospital (IRB No. SYMC IRB 1601-002) was performed. Written informed consent was obtained from each participant.
The PCEP applied to this study was developed based on the hospice volunteer program that was being conducted at the hospice palliative care research center at S University in Seoul, South Korea and the previous studies (21,22). This program consisted of 16 contents with a total of 6 sessions for 2 weeks (3 sessions per week), and each session was composed of theorecical education using lectures, discussions, case studies, and practical training and field trip. A 3-hour education was given for each session. The core education contents and procedures of each session are presented in Table 1.
Table 1 . Program Contents..
| Session | Objectives | Contents items | Detailed contents | Methods |
|---|---|---|---|---|
| 1 | Hospice and palliative care | • Understanding life and death | • Life toward death | L&D |
| • The dying process | ||||
| • Bioethics and preparation for a dignified life | • Ethics related to terminal patients | L&D | ||
| • Preparation for death | ||||
| • Attitudes and roles of the volunteers, and stress management | • Origin of palliative care | L&D | ||
| • Purpose of palliative care | ||||
| • Stress management strategies | ||||
| 2 | Physical care | • Physical symptoms of palliative care recipients | • Signs of near death | L&D |
| • End of care | ||||
| • Cancerous disease and nursing care | • Kinds of cancer | L&D | ||
| • Pain evaluation and management | ||||
| • Physical care for palliative care recipients | • Physical needs of terminal patients | L&D | ||
| • Physical care for terminal patients | ||||
| • Nutrition management for palliative care recipients | • Needs of nutrition | L&D | ||
| • Guidance of nutrition management | ||||
| 3 | Psychological and spiritual care | • Psychological needs of palliative care recipients and provision of care | • Psychological needs of terminal patients | L&D |
| • Good death | ||||
| • Psychological care for terminal patients | ||||
| • Spiritual needs of palliative care recipients and provision of care | • Spiritual l needs of terminal patients | L&D | ||
| • Spiritual care for terminal patients | ||||
| 4 | Communication methods | • Communication process with palliative care recipients | • Communication with terminal patients | L&P |
| • Communication with terminal patients’ family | ||||
| • Bereaved family management | • Stages of bereavement or grief | L&D | ||
| • Feelings of grief | ||||
| • Coping with grief | ||||
| 5 | Complementary and alternative medicine | • Foot massage lecture and practice | • Effects & method of foot massage | L&P |
| • Foot massage practicum | ||||
| • Laughter therapy lecture and practice | • Effects & method of Laughter therapy | L&P | ||
| • Laughter therapy practicum | ||||
| 6 | Field trip and curriculum evaluation | • Field trip to the hospice center | • Visiting to hospice center | FT |
| • Curriculum evaluation | • Discussion and evaluation of the program | Conf. |
L&D: Lecture and discussion, L&P: Lecture and practice, FT: Field trip, COnf.: Conference..
Motivation assessed using Hospice Palliative Care Volunteerism (IMHPCV) developed by Claxton-Oldfield et al. (23). To facilitate its use in our study, a bilingual nursing progessor translated the IMHPCV from English and Korean. The translated draft was then back-translated into English by an English expert. A subsequent comparison of the original and back-translated IMHPCV yielded no substantial differences. The IMHPCV consists of 25 items with a 5-point Likert-type scale from ‘strongly disagree’ (1 point) to ‘strongly agree’ (5 points). The higher the score means the higher the motivation to become a volunteer. The Cronbach’s α representing the reliability was 0.85 by Claxton-Oldfield et al. (23), and 0.87 in this study.
Death anxiety assessed using Death Anxiety Scale (DAS) developed by Templer (24) and verified the reliability and validity of a Korean version by Ko et al. (25). DAS consists of 15 items with a 5-point Likert-type scale from ‘strongly disagree’ (1 point) to ‘strongly agree’ (5 points). The higher the score means the higher the death anxiety. The Cronbach’s α was 0.83 by Templer (24), and 0.86 in this study.
Communication apprehension with the dying assessed using Communication Apprehension with the Dying (CA-Dying) scale developed by Hayslip (26). A bilingual nursing progessor translated the CA-Dying from English and Korean. The translated draft was then back-translated into English by an English expert. A subsequent comparison of the original and back-translated CA-Dying yielded no substantial differences. This instrument consists of 30 items with a 5-point scale from ‘strongly disagree’ (1 point) to ‘strongly agree’ (5 points). The higher the score means the higher the apprehension level while communicating with the dying. The Cronbach’s α was 0.86 by Hayslip (26), and 0.88 in this study.
All of the data were expressed as means±standard deviations. The homogeneity of Groups A and B was analyzed using t-tests or Chi-square tests. The effects of the intervention on motivation, death anxiety, and communication apprehension with the dying were analyzed using t-tests. Data analysis was performed using SPSS Statistics for Windows version 20.0 (IBM Corp., Armonk, USA). The significant level was set at P<0.05.
The general characteristics of the subjects and the homogeneity test result at baseline are presented in Table 2. Females constituted 62.0% (n=44), and 47.9% (n=34) of participants were 50~59 years old. According to the homogeneity test result, there was no statistically significant difference between Group A and Group B.
Table 2 . Subjects’ General and Clinical Characteristics at Baseline (N=71)..
| Characteristics | Categories | Group A (n=34) | Group B (n=37) | P |
|---|---|---|---|---|
| n (%) or M±SD | n (%) or M±SD | |||
| Gender | 0.464 | |||
| Male | 11 (32.4) | 16 (43.2) | ||
| Female | 23 (67.6) | 21 (56.8) | ||
| Age (yrs) | 0.928 | |||
| 20~29 | 2 (5.9) | 3 (8.1) | ||
| 30~39 | 1 (2.9) | 1 (2.7) | ||
| 40~49 | 7 (20.6) | 5 (13.5) | ||
| 50~59 | 15 (44.1) | 19 (51.4) | ||
| ≥60 | 9 (26.5) | 9 (24.3) | ||
| Religion | 0.547 | |||
| Yes | 27 (79.4) | 25 (67.6) | ||
| No | 7 (20.6) | 12 (32.4) | ||
| Educational level | 0.319 | |||
| Middle school | 4 (11.8) | 1 (2.7) | ||
| High school | 7 (20.6) | 11 (29.7) | ||
| College | 8 (23.5) | 12 (32.4) | ||
| ≥University | 15 (44.1) | 13 (35.2) | ||
| Economic status | 0.590 | |||
| Good | 5 (14.7) | 6 (16.2) | ||
| Fair | 21 (61.8) | 27 (73.0) | ||
| Poor | 8 (23.5) | 4 (10.8) | ||
| Health status | 0.113 | |||
| Good | 8 (23.5) | 6 (16.2) | ||
| Fair | 25 (73.6) | 31 (83.8) | ||
| Poor | 1 (2.9) | 0 (0.0) | ||
| Motivation | 75.17±13.15 | 76.16±13.36 | 0.679 | |
| Death anxiety | 44.41±7.13 | 43.48 ±5.04 | 0.528 | |
| CAD | 56.82±7.01 | 55.89±7.86 | 0.601 |
CAD: Communication apprehension with the dying..
The motivation, death anxiety and communication apprehension with the dying significantly improved after the intervention, as shown in Table 3. The mean motivation of group A was 90.17±13.15 before and 98.88±8.76 after intervention (t=2.341, P=0.022). In addition, the mean death anxiety of group A was 44.41±7.13 before and 41.21±3.65 after intervention (t=–2.166, P=0.034). Similarly, there were significant decreases in the communication apprehension with the dying scores (group A: before=56.82±7.01 and after=51.41±8.35; t=–2.808, P=0.006).
Table 3 . Clinical Outcomes of Baseline and Follow-Up Examination in Groups A and B (N=71)..
| Variable | Group | Examination | Changes | t | P | |
|---|---|---|---|---|---|---|
| Baseline | Follow-up | |||||
| M±SD | M±SD | |||||
| Motivation | A (n=34) | 75.17±13.15 | 83.88±8.76 | 8.11±2.81 | 2.341 | 0.022 |
| B (n=37) | 76.16±13.36 | 76.48±10.50 | 0.47±2.89 | |||
| Death anxiety | A (n=34) | 44.41±7.13 | 41.21±3.65 | -3.20±1.37 | -2.166 | 0.034 |
| B (n=37) | 43.48±5.04 | 43.39±5.42 | -0.91±1.27 | |||
| CAD | A (n=34) | 56.82±7.01 | 51.41±8.35 | -6.50±1.97 | -2.808 | 0.006 |
| B (n=37) | 55.89±7.86 | 56.92±8.12 | 0.43±1.99 | |||
CAD: Communication apprehension with the dying.
This study was conducted in order to identify the effects of PCEP on the hospice volunteers’ motivation, death anxiety, and communication apprehension with the dying.
The result of this study showed that the mean motivation score of the Korean volunteers, who received a 6-session PCEP for 2 weeks, increased. Since there was no study that investigated the change of motivation after providing a program to the hospice volunteers, a direct comparison is difficult to achieve. However, these results confirmed those of previous study. Kim et al. (13) showed that a 15-hour hospice volunteer education, which was composed of overview and ethics of hospice, family management, physical management, psychological management, bereavement management, spiritual management, and role of the volunteers, significantly increased the volunteers’ awareness of hospice and value of life. Yeun et al. (22) reported that a hospice palliative medicine education program, which consisted of a total of 5 sessions (3 sessions per week), increased the nurses’ awareness of hospice. According to a study that was conducted on 351 hospice volunteers, the major factor that enabled them to continue to participate in volunteer activities was the positive experience with the hospice organization (27). It means that continuous support and supervision are important for motivating them to continue their hospice volunteer services. Therefore, it is necessary to constantly develop program to enhance the motivation of hospice volunteers in the future.
PCEP was effective on reducing the death anxiety of the volunteers. This is similar to the result of a study, in which a 6-session death education was provided to the junior year nursing students and resulted in a reduced death anxiety (28). It is also similar to the study result of Lee et al. (21), in which a 7-session hospice palliative care education program was provided to the nursing students and resulted in an improved attitude toward death. In addition, Yoon (29) reported that after a 5-day death preparation education program for the hospice volunteers 6 hours every day, death anxiety was significantly lowered, thereby supporting the result of this study. The education program of this study includes the content to help in the overall understanding of death, and it is believed that anxiety about death was reduced by discovering the positive feeling and meaning of death through various activities.
PCEP was also effective on improving the volunteers’ communication apprehension with the dying. It is difficult to direct compare the results of this study with previous studies because there is no study that verifies the effect of volunteers’ communication apprehension with the dying after intervention. Compared with similar studies, Wittenberg et al. (30) found that a training that used the Communication, Orientation and options, Mindful communication, Family, Openings, Relating, and Team (COMFORT) communication for the palliative care teams’ curriculum enhanced the communication ability of nurses, social workers, doctors, military chaplains, and psychologists with the dying. Brown et al. (31) reported that simulation-based palliative care communication skill workshops improved the hospice communication skills of the internal medicine residents, medicine subspecialty fellows, nurse practitioner students, and community-based advanced practice nurses. According to a previous study, the communication ability with the dying was correlated with the volunteers’ intention to continue participating in volunteer activities (32). Therefore, it is believed that education programs should be developed continuously in order to improve the volunteers’ communication ability.
The study had several strengths. For example, it was the first study to investigate the effects of hospice palliative care education on the volunteers’ motivation, death anxiety, and communication apprehension with the dying of the Korean hospice volunteers. In addition, the program could be used as an effective method for the volunteers to promote their participation in the community. Based on the above results, suggestions for further studies are as follows. First, the mean volunteer motivation score of this study subjects was higher than those of the volunteers in France (16), and the United Kingdom (33). We suggest a study exploring the factors associated with motivation enhancement through comparison of the motivation levels by country or culture. Second, this study measured the changes in variables only at baseline and 2-week follow-up. It is necessary to carry out a study that measures the variable changes over time in order to identify the lasting effects of education and determine the re-education schedule in the future.
Table 1 Program Contents.
| Session | Objectives | Contents items | Detailed contents | Methods |
|---|---|---|---|---|
| 1 | Hospice and palliative care | • Understanding life and death | • Life toward death | L&D |
| • The dying process | ||||
| • Bioethics and preparation for a dignified life | • Ethics related to terminal patients | L&D | ||
| • Preparation for death | ||||
| • Attitudes and roles of the volunteers, and stress management | • Origin of palliative care | L&D | ||
| • Purpose of palliative care | ||||
| • Stress management strategies | ||||
| 2 | Physical care | • Physical symptoms of palliative care recipients | • Signs of near death | L&D |
| • End of care | ||||
| • Cancerous disease and nursing care | • Kinds of cancer | L&D | ||
| • Pain evaluation and management | ||||
| • Physical care for palliative care recipients | • Physical needs of terminal patients | L&D | ||
| • Physical care for terminal patients | ||||
| • Nutrition management for palliative care recipients | • Needs of nutrition | L&D | ||
| • Guidance of nutrition management | ||||
| 3 | Psychological and spiritual care | • Psychological needs of palliative care recipients and provision of care | • Psychological needs of terminal patients | L&D |
| • Good death | ||||
| • Psychological care for terminal patients | ||||
| • Spiritual needs of palliative care recipients and provision of care | • Spiritual l needs of terminal patients | L&D | ||
| • Spiritual care for terminal patients | ||||
| 4 | Communication methods | • Communication process with palliative care recipients | • Communication with terminal patients | L&P |
| • Communication with terminal patients’ family | ||||
| • Bereaved family management | • Stages of bereavement or grief | L&D | ||
| • Feelings of grief | ||||
| • Coping with grief | ||||
| 5 | Complementary and alternative medicine | • Foot massage lecture and practice | • Effects & method of foot massage | L&P |
| • Foot massage practicum | ||||
| • Laughter therapy lecture and practice | • Effects & method of Laughter therapy | L&P | ||
| • Laughter therapy practicum | ||||
| 6 | Field trip and curriculum evaluation | • Field trip to the hospice center | • Visiting to hospice center | FT |
| • Curriculum evaluation | • Discussion and evaluation of the program | Conf. |
L&D: Lecture and discussion, L&P: Lecture and practice, FT: Field trip, COnf.: Conference.
Table 2 Subjects’ General and Clinical Characteristics at Baseline (N=71).
| Characteristics | Categories | Group A (n=34) | Group B (n=37) | P |
|---|---|---|---|---|
| n (%) or M±SD | n (%) or M±SD | |||
| Gender | 0.464 | |||
| Male | 11 (32.4) | 16 (43.2) | ||
| Female | 23 (67.6) | 21 (56.8) | ||
| Age (yrs) | 0.928 | |||
| 20~29 | 2 (5.9) | 3 (8.1) | ||
| 30~39 | 1 (2.9) | 1 (2.7) | ||
| 40~49 | 7 (20.6) | 5 (13.5) | ||
| 50~59 | 15 (44.1) | 19 (51.4) | ||
| ≥60 | 9 (26.5) | 9 (24.3) | ||
| Religion | 0.547 | |||
| Yes | 27 (79.4) | 25 (67.6) | ||
| No | 7 (20.6) | 12 (32.4) | ||
| Educational level | 0.319 | |||
| Middle school | 4 (11.8) | 1 (2.7) | ||
| High school | 7 (20.6) | 11 (29.7) | ||
| College | 8 (23.5) | 12 (32.4) | ||
| ≥University | 15 (44.1) | 13 (35.2) | ||
| Economic status | 0.590 | |||
| Good | 5 (14.7) | 6 (16.2) | ||
| Fair | 21 (61.8) | 27 (73.0) | ||
| Poor | 8 (23.5) | 4 (10.8) | ||
| Health status | 0.113 | |||
| Good | 8 (23.5) | 6 (16.2) | ||
| Fair | 25 (73.6) | 31 (83.8) | ||
| Poor | 1 (2.9) | 0 (0.0) | ||
| Motivation | 75.17±13.15 | 76.16±13.36 | 0.679 | |
| Death anxiety | 44.41±7.13 | 43.48 ±5.04 | 0.528 | |
| CAD | 56.82±7.01 | 55.89±7.86 | 0.601 |
CAD: Communication apprehension with the dying.
Table 3 Clinical Outcomes of Baseline and Follow-Up Examination in Groups A and B (N=71).
| Variable | Group | Examination | Changes | t | P | |
|---|---|---|---|---|---|---|
| Baseline | Follow-up | |||||
| M±SD | M±SD | |||||
| Motivation | A (n=34) | 75.17±13.15 | 83.88±8.76 | 8.11±2.81 | 2.341 | 0.022 |
| B (n=37) | 76.16±13.36 | 76.48±10.50 | 0.47±2.89 | |||
| Death anxiety | A (n=34) | 44.41±7.13 | 41.21±3.65 | -3.20±1.37 | -2.166 | 0.034 |
| B (n=37) | 43.48±5.04 | 43.39±5.42 | -0.91±1.27 | |||
| CAD | A (n=34) | 56.82±7.01 | 51.41±8.35 | -6.50±1.97 | -2.808 | 0.006 |
| B (n=37) | 55.89±7.86 | 56.92±8.12 | 0.43±1.99 | |||
CAD: Communication apprehension with the dying
2015; 18(2): 112-119
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