A pilot study of death competency amongst health workers in the Uthukela District in KwaZulu-Natal

Methodology: An exploratory survey was used to investigate the reg­ istered nurses’ death competencies before and after the scheduled workshops. Although these workshops were initially planned for registered nurses, a great variety of health workers (nurses, pharmacists, oral hygienists, physiotherapists and HIV community workers) ex­ pressed interest and were thus accommodated in the workshops. Data were collected from the Death Educa­ tion Workshops held at three sites, and fifty-one re­ spondents completed the questionnaire before the work­ shop and fifty-six on completion of the workshop. The tool that was used in this research was Bugen’s (19801981) Coping with Death Scale, cited in Neimeyer (1994). This scale consists of 30 items assessing the partici­ pant’s sense of competence in handling death and their concrete knowledge concerning preparation for death.


Introduction
Trauma in the province of KwaZulu-Natal is considered to be a large problem with violent deaths (that is non-natural deaths due to road traffic collisions, gunshots etc) account ing for a large number of the fatalities.These fatalities are usually young people in the prime of their lives (M eumann & Peden, 1997:3).Road traffic collisions result in approxi mately 11 deaths per 100 million kilometers travelled, which is about ten times that reported in developed countries (van der Spuy, 1998:1).Pedestrian road traffic collisions account for approximately 40% of the annual road mortality in South Africa (van der Spuy, 1998:2).During 1997atotal of 610 children (0 to 18 years old) were killed and another 5507 were non-fatally injured in traffic collisions involving pedestrians (Venter, 1998:8).The incidence of HIV/AIDS in South Africa is increasing at an alarming rate.It is esti mated that approximately two thirds o f the 34 million peo ple infected with HIV/AIDS worldwide, live in Sub-Saharan Africa (MRC, 2000:22).
Due to the large number of clients dying on a daily basis health workers are often expected to cope with the dying or dead clients and their families.This can be a challenging and stressful event for the health workers.Regular expo sure to this stress may lead to the development o f various stress disorders if the health workers are not given suffi cient support.The actions taken by the health workers play a large role in the bereavement outcomes for the families (Wright, 1996:1) and thus investigating their abilities to cope with death is essential.Workshops were initiated by the district administrators due to concerns raised by the Uthukela district management regarding the number o f deaths being experienced in the hospitals and clinics.Management was concerned that they were not addressing the needs or concerns o f the staff working with these clients.Originally these workshops were planned for registered nurses but due to the interest ex pressed by other health workers the workshops included other categories of nurses, physiotherapists, pharmacists, oral hygienists and HIV community workers.

Purpose
The purpose o f this research was to conduct a survey amongst health workers in the Uthukela District in KwaZulu-Natal in order to establish their ability to cope with the death of their clients.

Null hypothesis
Using the Coping with Death Scale by Bugen (1980Bugen ( -1981) ) cited in Neimeyer (1994), respondents' pre-test scores are equal to their post-test scores.

Objectives
The objectives of this research were to:

•
Investigate the health workers abilities to cope with the death o f clients.
• Determine whether the health workers' abilities to cope with death had altered in any way after attend ing the workshop.

Significance of the research
This research will establish whether there is a need to carry out death education workshops in this district.It will also establish whether the current workshops being offered are relevant to the needs of the workshop participants, that is, if they aid in improving the participants' death com peten cies or not.

Death competency
Death competency is "a construct that represents a range o f human skills and capabilities in dealing with death, as well as our beliefs and attitudes about these capabilities" (Robbins, 1994,161).

Health workers
Within this study this term was used to refer to the nurses (registered nurses, enrolled nurses, enrolled nursing as sistants), pharmacists, HIV community workers, oral hygi enists and physiotherapists involved as participants in the workshops.

Ethical considerations
Permission to carry out the research was obtained from the district's Research Committee and the district administra tion.One of the researchers explained the research project to the respondents, prior to handing out the questionnaire at the beginning and at the end of the one-and-a-half day workshop.The researchers ensured that the respondents were aware o f the right to refuse to participate, and of the right to withdraw from the research at any time.The hand ing back of completed questionnaires to the researchers was taken as consenting to participate.The questionnaires were completed anonymously and the data could not be traced back to the individuals.

The workshops
A one-and-a-half day workshop was held on three separate occasions in three different areas of the Uthukela District in KwaZulu-Natal.The programme of the workshop broadly dealt with the following issues:

Research design
This pilot study, using an exploratory survey, was used to investigate the health workers death competencies before and after the scheduled workshops.

The sample and setting
Registered nurses working in three hospitals and in vari ous Primary Health Care clinics in the Uthukela District either volunteered to attend the workshop or were ap proached by their superiors.Three separate workshops took place at different time periods in three centres in the Uthukela District.The researchers had anticipated a sam ple of registered nurses but a number of respondents from a wide variety of fields expressed much interest in attend ing the workshops, after hearing about them informally, and were thus accommodated.The sample included the nurses (registered nurses, enrolled nurses, enrolled nurs ing assistants), pharmacists, HIV community workers, oral hygienists and physiotherapists.

The questionnaire
The tool that was used in this research was Bugen's (1980Bugen's ( -1981) ) Coping with Death Scale, cited in Neimeyer (1994).This scale consists of 30 items assessing the participant's sense o f competence in handling death and their concrete knowledge concerning preparation for death.The respond ents were asked to rate their agreement or disagreement on a five point Likert-type scale, with 1 representing 'do not agree at all", 3 being "neutral" and 5 "agree completely" .A sheet attached to the questionnaire also asked for biographi cal data from the respondents.

Validity and reliability
B ugen's C oping w ith Death Scale (1980)(1981) was found by Robbins (1994) to be both internally consist ent and reliable.N eim eyer (1997-1998:102) reported that this scale dis played internal consistency and testretest reliability as well as construct validity.

Data collection
Data were collected from the health workers attending the Death Educa tion Workshops at the three venues.
The respondents were asked to com plete the questionnaire on the day of the workshop, prior to starting, and then again at the end of the one and a half day workshop.Fifty-one respond ents completed the questionnaire be fore the workshop and fifty-six on com pletion of the workshop.The reason for the difference betw een the two groups is that some respondents ar rived late on the first day when the w orkshop had already com m enced and the q uestionnaire had already been administered.

Data analysis
Data analysis was carried out using the Statistical Package for Social Sci ences (SPSS) version 11.The data were summarized using descriptive statis tics, and the significance of the work shop resu lts w ere an aly sed using paired samples T-test.

Discussion of findings
Applying the two sampled T-Test to compare the scores of the two related groups (that is the pre-workshop and post-workshop variables), the results yielded were t = 0.00,95% confidence level.Thus there was a significant dif ference with the two groups, and the null hypothesis is therefore rejected.

Neutral responses
The findings after the workshop generally showed a move to have a more definite opinion.This usually was towards from a neutral stance to one where the respondents tended agreeing with the statement in the questionnaire.It is interesting to note that in the case of item 8 (/ fe e l prepared to fa ce my own death), this number had increased after the workshop and that both of these items above refer to the respondents' own death.

Death competency in dealing with self
The objective of the workshop was to encour age the health workers to spend some time thinking about what death meant to them and how they felt about facing their own dying process.The death competency of the health workers in coping with themselves is reflected in Table 1.The nine items shown in this table dealt with the health workers' own death re lated issues and fears, and this table shows the items reflecting a marked change in the number of health workers who agreed with the statements before and after the workshop.
The subject o f death is one that is usually avoided and health workers "being part o f a society that fears, avoids, and denies death, share the same fears and attitudes about death as those they are called on to serve" (Jacik, 1989:257).Unless the health workers are able to work through their own issues about death and dying, they will not be able to efficiently help their clients, and "the counsellor may become the counselled" (Whittle, 1999:1).It has been men- tioned that nurses who are specifically educated to meet the needs of a dying client and their family are likely to reflect a positive attitude towards coping with death (Corr & Doka, 1994:551).

Education and preparation of nurses for coping with death
There is a lack of relevant death education for nurses, which was demonstrated in a study by Cooke, Cooke & Glucksman (1992:1207).These authors found in their survey of 78 Emer gency Departments in England & Wales that 44 of these departments indicated that increased training was needed in order to improve the care of the bereaved relatives.Flam (1999:97) supported this finding in a study carried out in Brussels, Belgium where the physicians and the nurses involved in the study commented that they had not been taught how to notify people of bad news in their basic training.In a phenom enological study carried out by Brysiewicz (2000:89) amongst emergency nurses in South Africa, it was highlighted that death education is missing from the basic nursing curriculum.Death education, for example the proper identification of the stages of grief and the knowledge of appropriate inter personal skills, will help the health workers in dealing effec tively with the death of a client.This would lead to a reduc tion in death anxiety and lessen the developm ent o f stress disorders amongst these professionals (Wheeler, 1996:30).Tye (1993:955) suggests that training should be provided which focuses on psychosocial and interpersonal skills as well as exploring ones own experiences and attitudes about death and dying -and that doctors as well as nurses need to be involved.

Avoiding death
Emergency nurses have been shown in a study done by Payne, Dean & Kalus (1998:705) to be more likely to avoid thinking about death and showed greater fear and less ac ceptance o f death than hospice nurses.One reason for this may be that the emergency nurses are unprepared for death and the handling of the client and their family.Health work ers with a high level of death anxiety are more likely to use "avoiding" coping strategies (Payne et al, 1998:705).These health workers cope with the situation by avoiding it (ei ther physically or emotionally), thus not having to come face to face with death and deal with their emotions.Many health workers are left with feelings of failure if despite all their interventions the client dies (Jacik, 1989:262).

Dealing with children and death
Item 23 of the questionnaire (see Table 2) refers to the re spondent's ability to speak to children about death.Less than half the respondents agreed that they were able to speak to children about death before the workshop, as com pared with 7 1.4% who agreed after the workshop.It is diffi cult for adults to talk to children about death as there is the urge to protect the child, that "they are too young to un derstand" or "they don't need to know about that, not yet" .It is however important to remember that children are very perceptive and will know that something is wrong and will then be frightened by a lack of knowledge (Wright, 1996:64).When speaking to children about death, it is very important to be honest and to explain in such a way that they can understand.Questions need to be answered and opportunities made to allow children to express their feel ings (Iserson, 1999: 137-138).

Death competency in dealing with significant others
Table 2 shows the responses of the workshop participants with regards to death competency in coping with the sig nificant others, that is, the client's family and friends.The items shown in this table illustrate how after the workshop the respondents felt more able to cope with the significant others, thus suggesting that the workshop had provided them with the necessary information.This table shows the items reflecting a marked change in the number o f health workers who agreed with the statements before and after the workshop.Dealing with the family of a client who has died is very difficult, emotionally draining and overwhelm ing.There is no time to prepare the family for the loss and they seldom have past experiences upon which to draw to enable them to cope.The death of their loved one is often their first experience with death.The family needs to have health professionals who are able to empathise with them as this will make a lasting impression that will help towards emotional healing (Waters, 1987:46).
Helping the families who have lost a loved one can be chal lenging although by understanding their needs and keep ing ones death skills up to date, it can be extremely reward ing both personally and professionally (Wheeler, 1996:30).

Limitations of the study
A limitation to the study was that the workshops were origi nally developed for registered nurses to attend although due to the interest expressed by other health workers the sample then included health workers from diverse fields.This then posed a problem with the questionnaire as there were a variety of educational qualifications amongst the workshop participants and for some the language in the questionnaire was difficult to understand.For this reason some of the respondents chose not to complete the ques tionnaire a second time as they found it time consuming on the first occasion.Due to the small sample size the results o f this study cannot be generalised.

Recommendations
For future research the questionnaire should be modified to ensure easy interpretation of the language used, and possibly translated into Zulu.The sample size could be increased and the research carried out in another district in KwaZulu-Natal.Recommendations for practice are that ef forts be made to get health workers to explore their own thoughts and feelings concerning death and to educate them about best ways of coping with bereaved families and themselves.

Conclusion
Given the frequency with which health workers are expected to cope with death and the bereaved families, it is essential that management is sensitive to their needs.This sensitiv ity is necessary for the health and well being of the worker as well as for the care o f the dying and the bereaved.These short workshops demonstrated the benefits to health work ers in addressing their needs.M anagement and educators need to take cognisance of the words of Coolican (1994,611) who states that "patients die only once, we need to make it the best death it can b e ..... for the patient, the family and the caregiver".

References
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TABLE 1 : Death competency i n coping with self TABLE 2: Death competency i n coping with significant others the
workshop there was a total of 328 neutral responses to the 30 items in the question naire.This means an average of 6 neutral re sponses per respondent.The highest number of neutral responses were to items;