Chinese Nursing Students’ Perceptions of a Good Death

A recent study titled “Nursing students’ perceptions of a good death: A mixed method study,” authored by Yan Wang, Xiaoyan Jin, and Ming Liu from the Peking University Health Science Center – Macao Polytechnic University Nursing Academy, Macao Polytechnic University, Macao, offers critical insights into how future nursing professionals in China understand end-of-life care. Published in Nurse Education Today in 2024, this research contributes significantly to the growing discourse on the “good death” concept, especially within the unique Chinese cultural context.

Background and Rationale: The increasing global population aging and the rising burden of chronic diseases have underscored the urgent need for nurses equipped with professional palliative care competencies and positive attitudes toward death. The concept of a “good death” emerged from the hospice movement, reflecting a collective desire to improve the quality of unavoidable death. While there is no universally accepted definition, consensus suggests it encompasses physical, psychological, social, and spiritual dimensions. Previous research on this topic has largely focused on the perceptions of older adults, social workers, patients, dying individuals, family caregivers, and medical staff, often revealing significant differences across groups. However, research specifically investigating the perceptions of nursing students, who are poised to become primary caregivers in hospice settings, has been scarce, particularly within the Chinese context. This study addresses this gap, emphasizing that a profound understanding of students’ perceptions is crucial for designing effective educational interventions.

Study Objectives and Methodology: The primary objective of this study was to investigate how Chinese nursing students perceive a good death. Additionally, it aimed to compare these perceptions between students from mainland China and Macao SAR. The researchers employed a mixed quantitative and qualitative design, combining a descriptive cross-sectional investigation with descriptive qualitative research.

• Participants and Setting: The study involved 493 nursing students from one university in mainland China (X University in China’s capital) and one in Macao SAR (Y University). Quantitative data was collected from 472 participants, while 21 participants were interviewed for qualitative data, reaching saturation.
• Instruments: Quantitative data was collected using the Good Death Inventory (Chinese version) (GDI-C), an 18-domain scale with a 5-Likert system, developed in Japan (a neighbor with a similar Eastern Asian background). The GDI-C measures the perceived importance of various domains, with higher scores indicating a more positive perception of a good death. Qualitative data was gathered through semi-structured interviews, utilizing two open-ended questions: “What is a ‘good death’?” and “What are the characteristics of a good death?”.
• Data Analysis: Quantitative data was analyzed using SPSS Statistics 23.0, employing descriptive statistics, independent t-tests, and ANOVA. Qualitative data underwent reflexive thematic analysis, as developed by Braun and Clarke (2021).

Key Findings: The study yielded comprehensive insights into Chinese nursing students’ perceptions of a good death, integrating both quantitative and qualitative results:

• Overall Perception: Chinese nursing students demonstrated a moderate degree of good death perception, with an average GDI-C score of 3.76 ± 0.39.
• Influence of Sociodemographic Factors:
  • Mainland China students scored higher (3.83 ± 0.36) than Macao students (3.70 ± 0.41) (p < 0.05). However, both groups showed high consistency in their ranking of good death dimensions, indicating a similar structural concept of a good death within the Chinese context.
  • Female students and those in senior grades scored higher in the GDI-C (p < 0.05). The positive perception among senior students is attributed to their increased professional knowledge and internship experiences.
  • Interestingly, no significant differences were found based on religious beliefs, family structure (one-child family or not), experiences caring for the dying or the dead, or household income per capita.
• Prioritized Good Death Dimensions (Quantitative Rankings): The top five most important dimensions were:
  1. Being respected as an individual.
  2. Dying in a favorite place.
  3. Preparation for death.
  4. Good relationships with family/medical staff.
  5. Environmental comfort. Conversely, the last five rankings, indicating less importance, were religious and spiritual comfort, independence, unawareness of death, pride and beauty, and not being a burden to others.
• Qualitative Themes (Comprehensive Perception): The qualitative analysis revealed four overarching themes characterizing students’ perceptions:
  1. Positive psychological status.
  2. No physical suffering.
  3. Open and supportive social surroundings.
  4. Spiritual/religious perfection.
• Unique Framework of Chinese Nursing Students:
  • Deep Understanding of Respect/Dignity: Students prioritized “being respected as an individual” as the top domain. They differentiated “being respected” (how others treat you) from “maintaining dignity” (inner desire for self-care, autonomy). This emphasis reflects Chinese traditional culture, which regards keeping dignity as a characteristic of an honorable person.
  • Emphasis on Social Components: Chinese nursing students placed greater importance on social aspects, such as dying in a favorite place (often home) and good relationships with family. This is attributed to the collectivistic and family-oriented nature of Chinese culture.
  • Importance of Preparation and Open Communication: Students highly valued preparation for death and consequently placed less importance on “unawareness of death”. They advocated for open communication about death, stating that individuals should define their good death and express it to family members. This contrasts with the traditional Chinese death-denial cultural context.
  • Less Emphasis on Appearance and Not Being a Burden: Domains like “pride and beauty” and “not being a burden to others” were ranked low. Students indicated that preoccupation with sick appearance conflicted with death acceptance and that accepting care was a granted right for the dying, reflecting cultural interpretations of filial piety and dependency. Physical and psychological comfort also ranked lower than social components, possibly due to students’ limited clinical experience and their own healthy, young status.

Conclusion and Implications: The study concludes that Chinese nursing students possess a moderate perception of a good death, characterized by a strong emphasis on social domains. The findings underscore the shared perceptions between students from mainland China and Macao SAR within the broader Chinese context. To enhance students’ empathy and prepare them for hospice care, the researchers recommend providing more hospice care opportunities. Furthermore, educators should guide students to apply principles of respect, dignity, and open communication in their nursing practice.

Limitations: The study acknowledges limitations, including the reliance on self-reported data, the use of only one top Chinese university for mainland students, and the use of convenience sampling, which may limit the generalizability of the results to all Chinese nursing students.

APA Reference for the article: Wang, Y., Jin, X., & Liu, M. (2024). Nursing students’ perceptions of a good death: A mixed method study. Nurse Education Today, 142, 106343. https://doi.org/10.1016/j.nedt.2024.106343