Learning from the Film “Mitorishi (Transition Doula)”—Application to Understanding the End-of-Life in a Gerontological Nursing Practice Course in Japan ()
1. Introduction
With the longest lifespans in the world [1] Japan is said to be in the era of increasing mortality [2] . Of all the deaths in Japan 71.3% occur in hospitals [3] , stressing that many older people are dying in hospitals. Education of nurses at universities in Japan is conducted on the basis of the Rules for Designation as Training Schools for Public Health Nurses, Midwives and Nurses prepared by the Ministry of Health, Labour and Welfare (designation rules) and the university establishment standards promulgated by the Ministry of Education, Culture, Sports, Science and Technology. Nursing education in Japan places more importance on practical training than on classroom lectures for the development of practical skills, and nursing students experience practical training in many aspects of nursing. However, the conditions of patients that nursing students without specific qualifications can be involved in are limited in number. It can be inferred that in gerontological nursing practice, where actual nursing care for older people is provided, students have few experiences of taking care of critically ill older patients or in actual end-of-life care. Further, the nursing curriculum was changed nationwide to be in accordance with the revision of the designation rules from the 2022 school year. With these changes, many educational institutions have shortened the length of the gerontological nursing practice component, the elements which focus on the care of older people that is unique to the gerontological nursing field. In addition, as face-to-face practice can be expected to remain restricted due to the COVID-19 pandemic, it may be anticipated that students will be less likely to be present at actual end-of-life care in the future than has been the case in the past. All geriatric nursing patients are already in the terminally-ill phase. How older people face their final stage in life is an important issue and in nursing training it is related to concerns about integration versus despair [4] , a matter that involves developmental issues in old age. For this reason, in studying gerontology, it is necessary for nursing students to learn about the experience and attitudes expected when attending the end of life of older people. Japan, with its increasingly aging and dying population, need to conduct a discussion of what educational materials are needed to help nursing students learn about end-of-life care other than just the presently available practical training experiences.
There are some previous studies that reported the experiences of nursing students who were in involved with terminally-ill cancer patients [5] [6] [7] [8] among these previous studies related to the nursing student education in end-of-life care and attending to the end of life of patients in Japan. However, we have located only one study reporting nursing student experiences of attending the end of life of older patients [9] . Further, studies of educational content related to end-of-life care and attending to the end of life of patients mainly focus on text materials and surveys drawn from the current educational content [10] [11] [12] [13] . There are also reports of specific educational efforts and the effects of audiovisual materials [14] , simulated death experiences [15] , and simulation scenarios [16] . However, due to the small number of reports of possible matters to include there appears to be a need for further discussion of what to include. A previous study has reported that simulations, lectures, films, and a humanistic approach all had a positive effect on student attitudes towards the care of dying persons, and that game like interventions in the education decreased student fears of death, while communication with dying patients and relatives became easier [17] . However, it is also reported that comparisons are limited by inconsistencies in instrumentation and the use of multiple teaching strategies in individual studies [18] , that most of the palliative care education was theoretical [19] , and that there is a lack of knowledge about palliative care in undergraduate nursing education curricula, including the uncertainties about extent of the education provided and the related pedagogical methods [19] . From these studies, it can be inferred that other countries, like Japan, are in a trial-and-error situation regarding end-of-life care education methodologies.
As a part of the present study, we used the film “Mitorishi (transition doulas)” as teaching material in a gerontological nursing practice course to help students acquire ideas and preparedness for end-of-life care when taking care of older people who are close to death. We think it necessary to analyze what the nursing students learned from this teaching element, and whether it helped in the acquisition of ideas and preparedness for end-of-life care. This study considered that if we know details of what nursing students learned by watching the film “Mitorishi” and are able to demonstrate the applicability of using the film as an element in the teaching, the findings from this study could lead to suggestions as a specific teaching experience for end-of-life nursing education in Japan, which is also still in a trial-and-error situation. This would contribute to the development of nurses with an intimate knowledge of life and death, contributing to a community where older people can live as they wish till the end of their lives.
This study aims to detail what nursing students learned from watching the film “Mitorishi”, which was used among the teaching materials in a gerontological nursing practice course in nursing education in Japan, and demonstrate the applicability of using the film as an element relevant to the teaching of end-of-life care in Japan.
2. Methods
2.1. Survey Period
Data were collected in September, 2022.
2.2. Details of the Gerontological Nursing Training Course of the Department of Nursing of University A
The gerontological nursing practice course at the Department of Nursing of University A is a 4 week/4 credit course, and students are divided into three groups between May and July. The study contents are shown in Table 1. The purpose of the training is to practice nursing activities with geriatric patients,
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Table 1. Details of the gerontological nursing practice course.
and to underpin the assistance they have provided, with existing theories, and scientific evidence. The goal of the training is to “become able to consider the meaning of protecting the dignity of older people”.
The students watched the film “Mitorishi” to “acquire ideas for end-of-life care”, learn “preparedness for end-of-life care”, and consider the end-of-life care that protects the dignity of patients until the very end of life of older patients. After watching the film, the students wrote a report on their learning from the movie in about 800 Japanese letters, and submitted the report to Google classroom as a data file.
The film “Mitorishi” used as the basis for the teaching was supervised and produced by the Japan End-of-Life Care Provider Agency (Nihon Mitorishi Kai), K. K., established in 2020 [20] . Kumiko Shibata, the president of the company, created a new profession, “transition doulas”, under the corporate philosophy of “creating a society where all people can spend their final days feeling loved and cared for”. The “transition doulas” is a professional who assists people to have a comfortable life from the time they are informed of their life expectancy to the time their ashes are placed in a tomb, which is a day everybody experiences, by creating a happy ending with the persons. The film “Mitorishi” was selected to be used in the teaching because it introduces several episodes in which people “staged” their final days for a positive view of life and death (death is an act to pass on the baton of life to the next generation). The film shows in detail how people die, how they reach the moment, how they are supported by themselves and their families, and the feelings of people who support the dying.
2.3. Participants
The participants were fourth-year nursing students at University A who had completed the gerontological nursing practice course, had watched the film “Mitorishi” during the course, and had written a report on their learning. The students were selected as participants because they had watched the film “Mitorishi” during the study and had written a report on their learning.
2.4. Data Collection
We used the learning reports submitted by the students as data.
2.5. Data Analysis
The data were analyzed qualitatively using the content analysis approach in the following manner: 1) Each participant was assigned an identification number (ID). 2) Numbering each context of the obtained data (context number). 3) Dividing each context into meaningful segments by sentence (segment number). 4) The segmented data were used as data to elucidate the responses to, “What did you learn from watching the film “Mitorishi”? 5) Coded the obtained data by assigning a name to represent the data unit. 6) Repeated the coding according to the semantic similarity of units, and the data were classified into categories of similarity. 7) Examined the contents of the learning from the categories and codes.
2.6. Ethics
2.6.1. Protection of Human Rights of Participants
We obtained consent to the study participation from the students by explaining that they would be handled anonymously at all stages of the study so that they could not be identified. We randomly assigned serial numbers to each participant to ensure that all data was handled anonymously, and made the dataset accessible only to the principal investigator.
2.6.2. Consideration for Potential Risks and Discomfort Caused by the Study
The data source for this study was a report that was being evaluated as student performance for a gerontological nursing training course. For this reason, there was a risk that students would fear that refusal would affect their performance evaluation. To avoid this, we asked the students to cooperate in the study after the evaluation of the course was finalized, and explained in writing and orally that there would be no advantages or disadvantages in their future learning and performance evaluation whether participating or not.
2.6.3. Methods to Explain the Study Outline and Obtain the Consent for Study Participation
Prior to obtaining the consent for study participation we explained the study outline and ethics to the students after the orientation for the second semester of 2022 school year. We carefully emphasized that participation in the study was voluntary, and that students can refuse or withdraw the consent without reason after they have expressed the consent. The students who were willing to participate in the study were asked to sign two consent forms and submit one by putting it in a collection box placed on a desk at the front of the classroom, and the faculty was kept at a distance. This study was approved by the ethics committee of the university the authors belong to (approval number: 04007).
3. Results
3.1. Demographics of Participants
We requested participation in the study from 86 students, and of these 82 expressed consent to the study participation, and were included in analysis. Table 2 shows the demographics of the 82 participants. For gender, 76 were female and 6 were male. All 82 were in the fourth year of the nursing university education, and enrolled in the “Gerontological Nursing Practice Course” in the first semester of their fourth year. During the fourth week of the training course, they watched the film “Mitorishi” in a group on campus.
3.2. Extracted Categories
The descriptions in the reports the participants submitted were organized using the content analysis method. As a result, 690 meaningful descriptions were obtained.
In total 658 descriptions that were extracted in light of the question, What did you learn from watching the film “Mitorish”? were used as the data. Categories are indicated in bold (number of codes), and subcategories with single angular brackets (< >), (number of the segments). Analysis identified the following five categories: Characteristics of life during the final days (9), Importance of views on life and death (3), Importance of end-of-life care (3), Assistance in preparation for the final days of life (13), and Understanding the profession of transition doulas (9) (Table 3).
3.2.1. Characteristics of Life during the Final Days
Characteristics of life during the final days (9) is comprised of the following nine codes:
,
,
,
,
,
,
,
, and
.
was extracted based on descriptions such as “I felt that not everyone thinks the same way about death at first because patients in the terminal phase have various feelings depending on differences in age, roles, and developmental issues of patients”.
was extracted based on “I think that the number of people who wish to die at home will increase in the future as the population ages”.
was based on a “Preferable end-of-life care differs depending on the individual and there is no right answer to end-of-life care”.
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Table 2. Demographics of participants n = 82.
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Table 3. Learning from the film “Mitorishi”.
(15)> was based on “I was convinced that it is a very difficult problem for families to decide what is the happiest choice for them”.
was based on “I learned how difficult it is for dying persons and their families to face death”.
was based on “I was very impressed by the words ‘death’ is a part of daily life”.
3.2.2. Importance of Views on Life and Death
Importance of views on life and death (3) was comprised of the following three codes:
,
, and
.
was extracted based on descriptions such as “I know that people will die someday, and that this is a fate that nobody can reverse”.
was based on “I think that the dying people can convey and connect their thoughts and feelings to their family”.
was based on “It was a good opportunity for me to think about my view of life and death once again”.
3.2.3. Importance of End-of-Life Care
Importance of end-of-life care (3) was comprised of the following three codes:
,
, and
.
was extracted based on descriptions such as “I think that it is necessary to learn nursing skills such as end-of-life care skills to meet the needs in future community”.
was based on “I felt it was very difficult to respect the opinions of the patients and their families because they have various wishes about who they want to spend their final days with”.
3.2.4. Assistance in Preparation for the Final Days of Life
Assistance in preparation for the final days of life (13) was comprised of the following thirteen codes:
,
,
,
,
,
,
,
,
,
,
,
, and
.
was based on “I want to become a nurse who can respect the wishes of patients and their families and what is important to them”.
was based on “I learned that it is very important to be involved in a manner that enables patients to pass away at peace, although death is inevitable for all”.
was based on “I was reminded of the importance of staying close to patients”.
was based on “I learned that it is important to stay close to the end-of-life patients so that they will not have feelings of regrets”.
was based on “I think that how much the dying persons and their family face death is important for them to be able to spend the final days of life peacefully”.
was based on “I was reminded of the importance of care for bereaved families”.
was based on “It is most important for us to perceive the distress and pain that the patients, who had been diagnosed and treated in the hospital, struggled with alone, and to listen to their thoughts sincerely”.
was based on “It is important to listen to the patient thoughts, especially at the end of life, and to be involved attentively”.
3.2.5. Understanding the Profession of Transition Doulas
Understanding the profession of transition doulas (9) was comprised of the following nine codes:
,
,
,
,
,
,
,
, and
.
was based on “I learned that transition doula is a profession who place importance on the mental and physical conditions of patients to help them spend the final days in natural and happy ways while protecting the dignity of the patients”.
was based on “I think that it is an important role for the bereaved family members and transition doulas to act toward the realization of the last moment as the dying patients wish to live”.
was based on “I learned that transition doulas help patients to have a warm and peaceful end of life and to pass away at peace”.
was based on “The role of transition doulas is to ensure that older people who have no families/relatives also have final days with a warm feeling, feeling ‘There are people who love me’”.
was based on “I felt that being close to people as a profession is common to both nurses and transition doulas”.
was based on “I learned that there are transition doulas who do not perform medical care but provide care for daily life”.
was based on “Transition doula can obtain certification after undergoing training”.
4. Discussion
This section discusses the five categories of end-of-life care identified in this study: Characteristics of life during the final days (9), Importance of views on life and death (3), Importance of end-of-life care (3), Assistance in preparation for the final days of life (13), and Understanding the profession of transition doulas (9).
4.1. Characteristics of Life during the Final Days, Views on Life and Death, and the Importance of End-of-Life Care
Characteristics of life during the final days (9) included
. Kübler-Ross [21] introduced the five stages of the process of acceptance of death: “denial and loneliness”, “anger”, “bargaining”, “depression”, and “acceptance”. These show that people who are dying have a variety of emotions at different time points, and that it is important to accept and support the diversity of the emotions of the dying in the end-of-life care. This importance may be related to
in Characteristics of life during the final days (9). About this, the film “
Mitorishi” shows a variety of death scenes that do not follow one pattern, and this may have helped the participant nursing students become aware of the diversity of emotions of people dying and the various ways of accepting death. Even if the students understand that there is a
and are aware of a
, they learned that it is difficult for those dying and their families who support them to choose how they should live their final days, because of the
extracted as Characteristics of life during the final days (9). In the present study, the code
was extracted. According to the White Paper on older people [22] , 4238 people living alone and aged 65 or older passed away at home (solitary deaths) in Japan in 2020. This number was 1.5 times higher than that of a decade earlier. The percentage of deaths at home in Japan was low at 13.9%, compared with 31% in the Netherlands, 24.2% in France, and 20% in Sweden [23] . This suggests that end-of-life care at home is difficult in Japan. This means that understanding the
is an important perspective when considering end-of-life care in Japan, and the students may have been able to learn that it is important to give consideration to
in providing end-of-life care that is agreeable for the dying people and their families. In this way, we believe that understanding Characteristics of life during the final days (9) will lead to an appropriate understanding of patients when providing care.
One notable result was that
in Characteristics of life during the final days (9) was extracted. People are destined to die. In Japan, however, there is a custom of scattering salt to purify those attending during death-related ceremonies for keeping vigil over the dead and funerals. Kashiwagi [24] reported that, with the advance of medical science, previously incurable diseases can now be cured with appropriate treatment, and that this has created an idea of death as something that should not happen, something ominous, something to be avoided, something not to be thought about, and something to be kept under wraps. In other words, the Japanese think of death as an extraordinary thing. However, in the Roper-Logan-Tierney nursing model [25] , the “dying activity” is included among the 12 activities of daily living. This indicates that death is a part of the daily activities, and treated as an everyday affair. Shibata [26] stated that when dying people are properly cared for and their souls are departing the earthly abode, the death is not recalled as a sad and painful memory, but is felt as if the soul (life) of the dead person is residing within us, and that therefore “end-of-life care” is a powerfully important act. This suggests that death is not an abhorrent thing, but a positive thing. Shimazono [27] stated that it is common for people today to have diverse and complex views of life and death. This means that it is important to accept the ideas of death as something positive and everyday rather than something abhorrent, and to accept a diversity of views on life and death. In this way, it is necessary to be able to think of death as a part of daily life in order to respond to various views of life and death although the number of segments of
has been small.
In relation to the identified code
, when providing end-of-life care, it is very important to understand the patient views of life and death. For this reason, the result that the
,
, and the
as extracted shows that the students have learned important lessons. Shimazono [27] compared the Japanese views of life and death during and after World War II, and stated that a brave view of life and death during the war seems to be the intrinsic Japanese view of life and death, but that the views of life and death of modern people are usually diverse and complex, as described earlier. Tomimatsu
et al. [28] reported that the views of life and death in each period may be different depending on the characteristics of that period. This suggests that views of life and death change with time, age, and experience, and it is necessary to examine these views for each time period and occasion. We believe that becoming aware of the
was an important learning experience for nursing students to develop their views on nursing as nurses in the future.
Importance of end-of-life care (3) includes the Importance of end-of-life care (3),
, and
. Because these codes are necessary perspectives for improving the quality of end-of-life care, suggesting that the students can learn important lessons for their own personal growth when working as nurses in the future.
4.2. Assistance in Preparation for the Final Days of Life
in Assistance in preparation for the final days of life (13) is the code derived from most of the number of segmented phrases. As mentioned earlier,
and
in Characteristics of life during the final days (9) were identified. It can be inferred that these are important perspectives because learning these will lead to support that takes individuality into consideration.
Assistance in preparation for the final days of life (13) include
,
,
, and
. Oka [29] conducted a literature review on the maters included in the nursing practice that shows considerations of the feelings of others, and reported that patients in terminal stages and palliative care were the most common in the reviewed articles. Based on this, Oka suggested that nurses should be provided with nursing practice training that shows considerations of the feelings of others for patients with mental distress, such as anxiety and loneliness including the families in these concerns and activities. The cases introduced in the film “
Mitorishi” were people in this kind of situations. These codes suggest that having these attitudes will lead to
,
, and
.
In end-of-life care,
is also important. The codes
and
in Characteristics of life during the final days (9) show that the death of a loved one is a heavy burden on the family, suggesting that this burden leads to grieving, influencing the subsequent life of the family member(s) negatively. Shibata [26] stated that if families take care of their beloved dying family member without any regrets, the bereaved families will not suffer a terrible sense of loss, and they will feel it as if the soul of the dead is still alive in the bereaved families. This was depicted in the film “
Mitorishi” as a family who showed warm concern, and passed on the baton of life to the next generation with a positive attitude even though it would be a painful separation. This depiction may have enabled the students to understand the importance of grief care.
4.3. Understanding the Profession of Transition Doulas
Most of the participating students became aware of the profession of transition doulas for the first time by watching the film “Mitorishi” in the Gerontological Nursing Practice Course. The result of this was that these participants learned the
and interpreted the profession as
,
,
and
in the category Understanding the profession of transition doulas (9). Seeing the scenes of a peaceful death in the film with an awareness of the profession of transition doulas may have motivated the students to think about the importance of end-of-life care more deeply and with a better understanding and concern than before. Further, the students clarified the position of nurses by understanding
and
. Nurses have the role of working in interprofessional collaboration. For this reason, we believe that understanding the professionalism of nurses is an important learning experience so that the students can demonstrate the uniqueness of nursing when they become nurses.
4.4. Usefulness as Learning Material
In nursing education in Japan, nursing students rarely have opportunities to be present at end-of-life care, and this makes it difficult for them to have a well-developed idea of what the final scenes in the life of older patients would be like. For this reason, we determined to have students watch the film “Mitorishi” as a part of the curriculum in the teaching materials to help students “visualize end-of-life care” and learn about the “preparedness for end-of-life care”. The film “Mitorishi” introduced episodes of professionals who organized the final days of the life of dying people under a positive view of life and death (death meaning the passing on the baton of life to the next generation). The film visualized in detail the processes of dying, how people at the end-of-life reach that moment, how professionals (transition doulas) support the dying people and their families, with the emotions of the transition doulas as depicted in detail. We think that the participating students gained an “idea of end-of-life care” by understanding Characteristics of life during the final days (9), and deliberating on Assistance in preparation for the final days of life (13). It can be inferred that the students also understood about the need for the preparedness for end-of-life care and roles of transition doulas. In this process the students may get to understand the uniqueness of transition doulas and the commonalities between the transition doulas and nurses, and clarify the position of nurses from the Understanding of the profession of transition doulas (9).
As described above, the students have learned the “role of nurses at the time of end-of-life care” while “visualizing end-of-life care” and learning “preparedness for end-of-life care”. These findings suggest that using the film “Mitorishi” in the teaching curriculum is effective for learning about end-of-life care for older people.
5. Conclusions
The findings of this study clarified the following:
· Students who watched the film “Mitorishi” learned from the Characteristics of life during the final days (9), Importance of views on life and death (3), Importance of end-of-life care (3), Assistance in preparation for the final days of life (13), and Understanding the profession of transition doulas (9).
· Using the film “Mitorishi” in the teaching curriculum is effective for learning about end-of-life care for older people because the students learned about the “role of nurses at the time of end-of-life care” while “visualizing end-of-life care” and learning “preparedness for end-of-life care”.
Acknowledgements
We wish to express our gratitude to the participants for their kind cooperation in conducting this research. This research is funded by research funds allocated to the researcher (head author) by Hokkaido Bunkyo University, and the funds are properly managed and disbursed through the Accounting Division of Hokkaido Bunkyo University. The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.