The participants in this study included those in our previous studies (refer to Open Journal of Nursing, 2020, vol 10, issue 4 [5]). The following participant’s information is quoted from this issue. Eligible participants were nurses who are considered to have experienced terminal care in a general hospital that has an ER, HCU, and Palliative Care Ward (Hospice Ward) in Japan. In all, we recruited 144 participants who work in an ER, HCU, and Palliative Care Ward, and who worked in May 2018. Participants excluded from the study for the following reasons: those who were not assigned to the HCU, ER, or Palliative Care Ward for more than two months.

This study was an observational and cross-sectional study using an anonymous, self-completed questionnaire composed of the newly created Death Conference Nursing Self-Assessment Sheet. The method shown below is consistent with our previous research process (refer to Open Journal of Nursing, 2020, vol 10, issue 4 [5]). The following procedure’s information is quoted from this issue. The difference from the previous study is that the result is from analysis by using the Death Conference Nursing Self-Assessment Sheet.

This study was approved by the Ethics Review Board of St. Mary’s College, Chukyo Gakuin University, and the hospital where surveys were completed. The study was conducted following the Declaration of Helsinki. We distributed consent documents with the anonymous, self-completed questionnaire before the survey to all participants through the head nurse from the nursing department and asked them to fill out the questionnaire as having their consent by answering freely. The consent form stated that there would be no disadvantage, even if they did not participate in the research. The survey had a response time of 10 to 15 minutes. It was placed in an envelope, sealed, and collected by collaborators using a two-week retention method. All participants underwent an anonymous, self-completed survey composed of the Terminal Care and Death conference Nursing Self-Assessment Sheet. The participant characteristics were gender, affiliation, clinical experience, age, academic background, number of postmortem experiences, and with or without and the number of DC experiences [5]. The evaluation items in the Death Conference Nursing Self-Assessment sheet consist of four categories (Cooperation, Future direction of nursing, Specific measures for nursing, and Feeling of the nurse) and 14 questions.

A Death Conference Nursing Self-Assessment Sheet was created using a 5-step Likert scale of 1 to 5 for all items. In the beginning they are asked, “How often do you think about your nursing at the current terminal care and death conference, please circle the closest numbers respectively?” For this, the following steps were set. Here were scoring and answers for questions of all 14 items, “1) I never think about it, 2) I rarely think about it, 3) I sometimes think about it, 4) I often think about it, 5) I always think about it.”

Those categories and subjects are including the concept of the significance of DC (Open Journal of Nursing, 2019, 9, p. 527) [11] that was revealed in previous literature reviews [6] [9] [10] [12] [13] [14] [15] [16], and incorporated as a conceptual framework (Table 1). Three collaborators in previous studies reviewed the category of the significance of DC. This time, to ensure content validity, the 14 assessment items were initially considered and prepared by two co-authors of university teachers with clinical experience in terminal care as nurses. Next, we obtained advice from another co-author, a college faculty member conducting terminal care research, and two other co-authors, chief nurse managers who are in charge of the terminal care ward. The translation from Japanese to English and back of the 14 items in the Death Conference Nursing Self-Assessment Sheet was con-firmed by two bilingual native adults in English and Japanese, and a request, was also sent to an English proofreading company. They also verified the consistency of these 14 items with four categories and the meaning of DC. Participants’ characteristics question items are first identified by collaborators and then advised by the nursing department of the institution surveyed without the use of individual identification.

*Open Journal of Nursing, 2019, 9, p. 527 [13]. ^†No., Question No., T: Terminal Care Nursing Self-assessment items, D: Death Conference Nursing Self-assessment items. Concerning Terminal Care Nursing Self-assessment items, categories, significance of DC and those items are quoted from our previous studies (Refer to Open Journal of Nursing, 2020, vol. 10, issue 4 [5]).

Data were analyzed using JMP (ver. 14.2; SAS Institute Inc., Cary, NC, U.S.). Gender, affiliation, age, academic background, and the number of postmortem experiences are expressed as observation numbers and percentages. The Fisher’s exact test was used for categorical variables. The characteristics: clinical experience was evaluated by the Mann-Whitney U test to investigate the difference in the groups between nurses who participate in DC: High group and Low group frequency. The results presented are in the median and IQR (interquartile range). The affiliation variable is divided into HCU and others (ER and Palliative Care Ward). The academic background variable is divided into technical college, junior college, four-year university, and others (a particular course of junior college or university, five-year school, and graduate course).

The results of the median and IQR are presented as follows. In the univariate analysis for items in the Death Conference Nursing Self-Assessment Sheet by DC experiences, which are categorized by participating in DC: High group and Low group frequency, the P values from the Mann-Whitney tests are analyzed. Univariate and multivariate logistic regression analysis was used for variables in the Death Conference Nursing Self-Assessment Sheet predicting DC experiences which are categorized by participating in DC: High group and Low group frequency. In the multivariate analysis, two models are presented with the variables used for adjustment. Model 1 was adjusted for gender, age. Model 2 was adjusted for academic background. P-Values for the Whole Model Test of all variables predicting DC experience in model 1 and model 2 are by specific likelihood ratio Chi-square tests that evaluate how well the categorical model fits the data.

P values < 0.05 were considered significant. The sample size calculation used the EPI-INFO 7.0 statistical package. A sample size of at least 132 participants of the population size of 1000 nurses included public health nurses, midwives, associate nurses defined as sufficient for an 85% incidence rate with the statistical power of 80%, an acceptable margin of error of 5% and a confidence level of 95%.

During the study period, 144 nurses are expected to have experienced terminal care at the department of ER, HCU, and Palliative Care Ward in a general hospital. Responses were received from all 144 participants who distributed the survey. The participants of this study are included in the analyzed 139 participants (97%) in the final analysis of our previous studies [5]. Participants included in final analysis of this study were 34 participants (23.6%) who answered the number of DC experiences.

Characteristics of the study participants are listed in Table 2. Each eligible nurse in the study group is classified according to DC experiences; High group (50%, n = 17), or Low group (50%, n = 17), and comparisons were made between the groups. Gender distribution was as follows: in the High group, there were no men and 17 women participants; in the Low group, there were a man and 16 women participants. The affiliation of nurses was nineteen participants for HCU, one for ER, and fourteen for Palliative Care Ward, fifteen (88%) of 17 nurses in the Low group of DC experiences belong to HCU, as were twelve (71%) in the High group. The median (interquartile range, IQR) clinical experience of all participants was 7 (3 - 14.8) years. The median (interquartile range) clinical experience in the High group and the No group were 20 (11.5 - 25) years and 4 (3 - 10) years, respectively. Therefore, the clinical experience was much longer in the High group of DC experiences. Twelve of all participants (41%) were age < 30. There was a larger proportion of nurses in the Low group 12 (71%) than in the High group Two (12%) in the age group < 30 years. Thirteen nurses among the entire group (38%) had a technical college academic background, and there was a larger proportion of nurses in the High group 9 than in the Low group 4 in the technical college group. Twenty-one (62%) nurses had experienced more than 20 postmortem treatments, none said that they had not experienced postmortem treatment. The number distribution of postmortem experiences was as follows: in the High group, 0, 1, and 16 nurses in number of postmortem experiences 1 - 9, 10 - 19, and ≥ 20, respectively; in the Low group, 10, 2, and 5 nurses, respectively. There was, therefore, a higher proportion of the number of postmortem experiences ≥ 20 in the High group (P < 0.001) (Table 2).

IQR, interquartile range. DC, Death Conference. DC experiences were categorized by participating in DC: High or Low. *P values are from Fisher’s exact test analyzed on nonparametric comparisons between nurses who participate in DC: High group and Low group frequency. ^†Others included ER and Palliative Care Ward. ^‡P values are from the Mann-Whitney U test analyzed on nonparametric comparisons between nurses who participate in DC: High group and Low group frequency. ^§Others included who graduated a particular course of junior college or university, five-year school, and graduate course.

No significant differences in characteristics were observed in gender or academic background.

In the univariate analysis for items in the Death Conference Nursing Self-Assessment Sheet by DC experiences; High group and Low group frequency listed in Table 3. Nurses who had experience in DC showed significant results (Question No., Category—Items of the Death Conference Nursing Self-Assessment Sheet) on the following questions. D4. Specific measures for nursing—understanding

*No., Question No., D, Items of Death Conference Nursing Self-Assessment Sheet. Data are Median (IQR; interquartile range). ^†Variables, Items of Death Conference Nursing Self-Assessment Sheet. DC, Death Conference, DC experiences were categorized by participating in DC: High or Low. ^‡P values are from the Mann-Whitney U test analyzed on nonparametric comparisons between nurses who participate in DC: High group and Low group frequency.

patients and their family’s intentions and reflect on their care (P = 0.047), D5. Future direction of nursing—having a proposal to connect the solutions obtained for the next time (P < 0.001), D6. Cooperation—DC helps me improve my teamwork (P = 0.011), D7. Future direction of nursing—sharing values with people who have the same thoughts (P = 0.004), D8. Feeling of the nurse—talking at DC will calm my mind (P = 0.027), D12. Feeling of the nurse—looking back at care and deepen my thoughts on end-of-life patient care at the DC (P = 0.025), D13. Feeling of the nurse—can increase my self-efficacy at DC (P = 0.019).

However, items that did not show a significant relationship with DC experiences; High group and Low group frequency were as follows: D1. Specific measures for nursing—feeling DC are an opportunity to learn about end-of-life patient care (P = 0.267), D2. Future direction of nursing— sharing the purpose and direction of care (P = 0.074), D3. Future direction of nursing—clarifying nursing problems and get solutions (P = 0.070), D9. Feeling of the nurse—being always remorseful and sometimes denied and accused at DC (P = 0.529), D10. Feeling of the nurse—having an increased interest of palliative care after DC (P = 0.074), D11. Feeling of the nurse—can improve the quality of care by participating in DC (P = 0.090), D14. Feeling of the nurse—feeling catharsis at DC (P = 0.089) (Table 3).

Univariate and multivariate logistic regression analysis for items of the Death Conference Nursing Self-Assessment Sheet predicting DC experiences; High group and Low group frequency are shown in Table 4. In univariate logistic regression analysis, all variables, the original concept, which is the significance of DC included items of the Death Conference Nursing Self-Assessment Sheet

DC, Death Conference, OR, odds ratio. CI, confidence interval. No., question no. Variable, the original concept of items of Death Conference Nursing Self-Assessment Sheet (refer Table 2). *Adjusted for gender, age. (Model 1), ^†Adjusted for academic background. (Model 2). DC experiences were categorized by participating in DC: High or Low. OR reviled High/Low. P-Values for the Whole Model Test of all variables predicting DC experience in model 1 and model 2 are all less than 0.05, which are by specific likelihood ratio Chi-square tests that evaluate how well the categorical model fits the data. Participation experience in Death Conference was categorized by the participation experience High or Low.

(Refer Table 3), are shown to be independent risk factors for DC experiences as follow (Question No., Category). D6. Cooperation (OR 2.54, 95% CI, 1.20, 5.37, P < 0.007), D5. Future direction of nursing (OR 6.12, 95% CI, 1.76, 21.22, P < 0.001), D7. Future direction of nursing (OR 4.30, 95% CI, 1.45, 12.81, P = 0.002), D4. Specific measures for nursing (OR 2.35, 95% CI, 1.00, 5.53, P = 0.035), D8. Feeling of the nurse (OR 2.70, 95% CI, 1.14, 6.40, P = 0.011), D12. Feeling of the nurse (OR 2.55, 95% CI, 1.02, 6.34, P < 0.028), D13. Feeling of the nurse (OR 2.59, 95% CI, 1.14, 5.87, P < 0.013).

In model 1 of the multivariate logistic regression analysis adjusted for gender, age, variables; the original concept, which is the significance of DC of items of the Death Conference Nursing Self-Assessment Sheet, are shown to be independent risk factors for DC experiences. High group and Low group frequency are as follows (Question No., Category). D5. Future direction of nursing (OR 5.99, 95% CI, 1.32, 27.32, P = 0.004), D7. Future direction of nursing (OR 3.20, 95% CI, 0.82, 12.50, P = 0.007) and D13. Feeling of the nurse (OR 3.18, 95% CI, 0.92, 10.98, P = 0.033). However, in the following questions of D6, D4, D8, and D12, no significant difference was seen using model 1.

In model 2 of the multivariate logistic regression analysis was adjusted for academic background, variables; the original concept, which is the significance of DC of items of the Death Conference Nursing Self-Assessment Sheet, are shown to be independent risk factors for DC experiences. High group and Low group frequency are as follows (Question No., Category). D6. Cooperation (OR 2.41, 95% CI, 1.10, 5.25, P = 0.016), D5. Future direction of nursing (OR 6.00, 95% CI, 1.59, 22.63, P = 0.001), D7. Future direction of nursing (OR 4.10, 95% CI, 1.26, 13.35, P = 0.006), D4. Specific measures for nursing (OR 2.73, 95% CI, 1.02, 7.30, P = 0.029), D8. Feeling of the nurse (OR 2.69, 95% CI, 1.00, 7.22, P = 0.027), D12. Feeling of the nurse (OR 2.47, 95% CI, 0.94, 6.54, P = 0.049), D13. Feeling of the nurse (OR 2.87, 95% CI, 1.15, 7.15, P = 0.011).

Under the hypothesis that increasing the number of DC participation, nurses were expected to improve the quality of nurses’ terminal care and developing nursing minds. Therefore, there was a need for further evidence on the impact of repeated DC participation on nurses’ terminal care. Hence, continuing from our previous study clarify [5], we analyzed that the impact of repeated DC participation on nurses’ terminal care and nursing in DC using the prepared Death conference Nursing Self-Assessment Sheet. There were significant differences in four categories (Cooperation, Future direction of nursing, Specific measures for nursing, and Feeling of the nurse). The current results show that repeated DC participation concerns about the impacted on nurses’ terminal care and nursing in DC.

For the assessment items of the categories that were significant in the univariate analysis described above, a significant association with the experience of participating in DC; High group and Low group frequency was confirmed by univariate and multivariate logistic regression using adjustment factor of an academic background. The verification of the reliability and validity of the questionnaire are the challenge in the future. More evidence of the way of terminal concerns by raising the quality of DC developing nursing minds will be needed using the Terminal Care and Death Conference Nursing Self-Assessment Sheet. Moreover, research to see the relationship between items of the Terminal Care Nursing Self-Assessment Sheet and items of the Death Conference Nursing Self-Assessment Sheet will also be needed. Nurses should resolve the stress associated with terminal care by participating in DC [5], and consider how to operate DC so that nurses can grow not only in nursing but also as a whole.

There was no significant association between the experience of participating in DC and the following category (the significance of DC) corresponding to items in the Death Conference Nursing Self-Assessment Sheet. They are the following category (the significance of DC) that Specific measures for nursing (learning patient care at the end of life), Future direction of nursing (share the purpose and direction of care, clarification and resolution of nursing problems), Feeling of the nurse (be rebuked or accused of being penitentiary, growing interest in palliative care, improvement in the quality of care and nurse’s catharsis).

Concerning specific measures for nursing (learning patient care at the end of life), it is necessary to acquire knowledge and skills through training. In hospitals, it is necessary to examine the contents of nursing standards and procedures related to postmortem treatment, dealing with family members at that time, and regarding DC. Regular training needs to be held throughout the hospital or in each ward department to acquire knowledge and skills in terminal care.

About future direction of nursing (share the purpose and direction of care, clarification and resolution of nursing problems), it is necessary to have a time to hold DC regularly and to analyze the content and quality of DC to reduce the stress of nurses performing terminal care even in busy to respond to patients and their families. It is necessary to hold DC regularly, analyze the content and quality of DC using the assessment sheet used this time, and make improvements as appropriate. Nurses and health care professionals should share the development of the nursing process of patients and their families, classify and resolve problems that have arisen in dealing with patients and their families, and build evidence.

According to feeling of the nurse (be rebuked or accused of being penitentiary, growing interest in palliative care, improvement in the quality of care and nurse’s catharsis), at the conference, nurses and healthcare professionals should never blame each other’s nurses or impose their responsibilities on particular nurses, as indicated in the definition of DC. Nurses and healthcare professionals should maintain DC as a place where they can find directions for using in the next nursing, and the aim is to improve nursing. With the participation of DC, the team can support nurses to share their own problems, feel catharsis by solving them, and take a new interest in terminal care.

This study has several limitations. The generalizability may be limited because the number of participants was very small. To generalize these results, we need to add many more participants. The future task is to verify the reliability and validity of the Terminal Care and Death Conference Nursing Self-Assessment Sheet.