{'fraction_non_alphanumeric': 0.030501994680851064, 'fraction_numerical': 0.010804521276595746, 'mean_word_length': 5.173935351462289, 'pattern_counts': {'":': 0, '<': 0, '<?xml version=': 0, '>': 0, 'https://': 0, 'lorem ipsum': 0, 'www.': 0, 'xml': 0}, 'pii_count': 0, 'substrings_counts': 0, 'word_list_counts': {'cursed_substrings.json': 1, 'profanity_word_list.json': 0, 'sexual_word_list.json': 0, 'zh_pornsignals.json': 0}}
Nursing students’ relationships among resilience, life satisfaction, psychological well-being, and attitude to death

Purpose This study attempted to examine the influence of resilience, life satisfaction, and psychological well-being on attitude to death. Methods A predictive correlational design was used. The participants were 184 nursing students from three universities of Korea. They responded to a self-report questionnaire, with items on demographics, resilience, life satisfaction, psychological well-being, and attitude to death. Results The mean score for attitude to death was 2.77±0.39 (range, 1–4), and a significant difference was observed depending on age, grade, and death-related education. Attitude to death was positively correlated with death-related education, resilience, life satisfaction, and psychological well-being. Results of the hierarchical multiple regression analysis indicated that death-related education and psychological well-being were significant predictors of attitude to death, explaining 26.6% of the latter. The most important factor was psychological well-being. Conclusion Although death-related education and psychological well-being are two of the most influential factors among nursing students, no more than 30.4% of this study’s participants received death-related education. Death-related education is necessary to help nursing students so that they can cope positively with stressful situations by finding positive meaning. It is necessary to develop a systematic curriculum so that these students can establish a positive attitude to death.


Introduction
As the number of patients dying in medical institutions increases every year, more nursing students also experience death directly and indirectly during the course of study or clinical training [1,2]. According to Edo-Gual et al. [3], the most stressful event that nursing students experience during the course of nursing education is the distress for patients and patients' families who experience and face death situations. When nursing students experience death for the first time during clinical practice, they experience a feeling of helplessness, despondency, and a high level of anxiety [4], as well as fear or skepticism about recovery [2,5].
Nursing students are preliminary nurses who will nurse dying patients. As such, their attitude to death should be dealt with appropriately because this can motivate them to establish their attitude to their own lives and their identity in nursing, as well as improve the quality of nursing performance [6]. If nursing students nurse dying patients without having their thoughts and philosophy on death firmly established, they will have negative attitudes, such as anxiety and fear, to death [7,8].
End-of-life care requires comprehensive nursing care that helps patients end their lives with dignity as a human being at the last stage of life. Qualitative endof-life nursing should be preceded by nurses' proper attitudes to death. As attitude to death, however, is not formed in a short time but over a long one, the appropriate educational environment should be created so that nurses can have positive attitudes to death and end-of-life nursing during the course of nursing education [2,3,9].
The factors that affect the death anxiety of nursing students are diverse [2][3][4][5]8]. Among the factors that affect attitudes to death, life satisfaction is a cognitive element that is the core of subjective well-being [10]. In a recent report, a higher life satisfaction among college students indicates a more positive attitude to death [11].
A positive perception of the value and meaning of life promotes not only understanding of the meaning of death and a healthy perception of death but also positive acceptance of death [12].
Psychological well-being is the concept of how good one is at functioning as a member of society; it is also subjective well-being in relation to living [13]. Nursing students need a high level of psychological well-being to cope with such stressful situations as death, which they can face during the course of clinical training. Psychological well-being not only has a close relationship with life satisfaction [13,14] but also has a significant influence on reducing anxiety on and positively accepting death [14].
Resilience has been defined as the ability to recover and adapt when faced with adversity [15,16], and individuals tend to become stronger through experience and learning while overcoming adversity [17]. Such resilience is an important factor for nursing students in overcoming anxiety and the feeling of helplessness they feel when they care for dying patients and in establishing positive attitudes to death [17].
Resilience, life satisfaction, and psychological wellbeing make crucial contributions to nursing students' stance to death. In addition, an analysis of resilience and life satisfaction as variables significantly correlated with each other found that the better one's resilience is, the more satisfied one also is with life [18]. Psychological well-being is strongly correlated with resilience and life satisfaction [19]. For nursing students to establish positive attitudes to death, educational preparation is necessary so that students' life satisfaction, psychological well-being, and resilience can be improved, and students can accept death as a process of life. However, almost no research has been conducted among nursing students on the subject of resilience, life satisfaction, and psychological well-being in the context of terminal care and attitude to death.
Accordingly, this study aimed to explore the effects of the resilience, life satisfaction, and psychological wellbeing of nursing students on attitude to death. The study likewise aimed to provide data for the development of educational programs on death and the formation of positive attitudes to end-of-life care in the nursing curriculum.

Study design
This descriptive survey investigated nursing students' resilience, life satisfaction, psychological well-being, and attitude to death, and the factors that influence nursing students' attitude to death.

Participants
The participants were nursing undergraduates from three universities located in Daejeon, South Korea. The final participants were selected using G*Power 3.

1) Resilience
The Interpersonal Reactivity Index, which was developed by Shin et al. [17], was used to measure

3) Psychological well-being
The psychological well-being scale, which was developed by Ryff [13] and adapted by Kim and Yoo [19], was used to measure psychological well-being. It has 24 items, each scored on a 5-point Likert scale, with higher scores indicating greater levels of psychological well-being. The possible scores range from 24 to 120.
The reliability (Cronbach's α) of the adapted scale was 0.83, and it was 0.89 in the present study.

4) Attitude to death
The attitude to death scale, which was developed by Thorson and Powell [21] and adapted by Kim and Lee [22], was used to measure attitude to death. This scale is  The factors that influenced attitude to death were analyzed using hierarchical multiple regression analysis.     Thus, a positive correlation was observed among all the variables in this study (Table 4).

Factors influencing attitude to death
A hierarchical multiple regression analysis was con-  Table 5).

Discussion
This study aimed to explore the effects of the resilience, life satisfaction, and psychological well-being of nursing students on attitude to death. The participants' score on attitudes to death was 2.77 out of a total of 4 points. This result matched that in Park and Kim [7], whose participants scored 2.75 points. The level of attitude to death of nursing students in the present study was average. The juniors and seniors had more positive attitudes toward death than the freshmen or sophomores.
This result is consistent with the finding of Park and Kim [7] and of Lee et al. [23] which recorded experienced nurses having more positive attitudes to death than inexperienced novice. This result implies that lower graders can regard a patient's death as an event of unfamiliarity and anxiety, instead of reality, and consequently, carry a relatively less positive attitude toward death. As their grade level moves up, they develop a more positive attitude toward death after experiencing end-of-life care or death-related education through major-related learning and clinical training. The present study found that the attitude of students who participated in death-related education was more positive compared with those who did not. The positive changes in the attitudes to death observed in the present study when nursing students were systematically provided with death education for a certain time are similar to the findings of Shin [24]. Similarly, Mallory [25] reported that nursing students who have had death education hold a positive attitude to death. As discussed above, the systematic acquisition of knowledge on death allows students to have positive attitudes to death and helps establish healthy attitudes to death. However, despite its importance, death-related education is rarely included in curriculums. In this study, no more than 30.4% of the respondents received death-related education. Park and Kim [7] reported that 86.2% of nursing students who well-being is closely related to individuals' educational experiences [15,27]. It is supported by the findings in previous studies that those receiving death-related education have a higher level of psychological wellbeing and have more positive attitudes to death [28]. Resilience develops through learning and can be improved by external circumstances or conditions [17].
This study also found that the students receiving education about death had better resilience. It is therefore essential to improve nursing students' resilience by helping them convert their negative feelings concerning death into mature experiences and assisting them to cope positively with any situation related to death. It is also necessary to apply systematic education and programs with the objective of helping nursing students improve their resilience.
In conclusion, this study found that death-related educational experience and the level of psychological well-being are major influencing factors in establishing attitudes toward death among nursing students. Previous studies have found that death-related education contributed to a positive change in attitude towards death.
However, many previous studies have established the importance of death-related education for elderly people and patients who were preparing for their own death [28][29][30]. On the other hand, this study found that deathrelated education for nursing students and medical professionals, who are supposed to accept the deaths of others and assist with end-of-life care, was also an important part of education. Through this study, we found that death-related education could help nursing students to accept death as a course of life, to establish their attitude toward death, and contribute to enhancing their psychological well-being. Therefore, the inclusion of systematic death-related education in the relevant curriculum is needed, through which nursing students' attitude toward death should be established and their preparation for end-of-life care should be made.
But it has the following limitations. First, the results could not be generalized because the participants were from a specific region. As such, it is necessary to expand the number of participants and areas covered. Second, considering the relatively small proportion of male students, the effects of sex need to be determined in a follow-up study with a sufficient number of male participants.
Funding: This paper was supported by Daejeon University Research Grant of 2018.

Conflicts of interest:
No potential conflict of interest relevant to this article was reported.
Author contributions: All work was done by Jihyun Kim.