Multi-Generational Perspectives on the Competencies Required of First-Line Nurse Managers: A Phenomenological Study.

First-line nurse managers play an integral role in ensuring team and organizational effectiveness and quality of care. They are facing increasing challenges arising from the need to lead a generation-diverse workforce. Further research that examines multi-generational perspectives on the competencies of first-line nurse managers is warranted. This paper aimed to elucidate multi-generational perspectives on the competencies required of first-line nurse managers based on their lived experiences and perceptions, as well as those of frontline nurses. A descriptive phenomenological approach was adopted. A total of 48 informants were invited to individual semi-structured interviews to share their perspectives on the competencies required of first-line nurse managers. Findings were analyzed using Van Kaam's controlled explication method. Four themes that described four areas of competency were generated: (1) advocating for the interests of the staff, (2) allocating resources effectively, (3) building cohesive teams, and (4) embracing change and quality. The findings indicated that there were significant discrepancies among the different generations of informants in terms of their degree of commitment to work, preferred modes of team communication and collaboration, and perspectives on the role and function and preferred leadership styles of first-line nurse managers. This study fell short in examining the experiences of Generation Z nurses, and the findings are subject to further validation by larger samples. However, this study has implications for hospital administrators, nurse educators, and managers, encouraging them to rethink the notion of management competencies to develop effective strategies for leading a multi-generational workforce.

Competencies of Nurse Managers as Predictors of Staff Nurses' Job Satisfaction and Turnover Intention.

Nurse managers have played an integral role in stabilizing the nursing work environment and workforce in the face of the COVID-19 pandemic, yet the competencies required for such a feat are largely unknown. This study was conducted during the pandemic to identify the specific domains of nurse manager competencies that associate with nurse outcomes. A cross-sectional survey was conducted on a convenience sample of 698 staff nurses to measure the perceived competence of their nurse managers and their job satisfaction and turnover intention levels. The overall perceived nurse manager competency level in our sample was 3.15 out of 5 (SD = 0.859). The findings indicated that 34.3% of nurses were dissatisfied with their current jobs, and 36.3% of nurses were considering leaving their current workplace. Regression analyses identified "Team Communication and Collaboration" (ß = 0.289; p = 0.002), "Staff Advocacy and Development" (ß = 0.229; p = 0.019), and "Quality Monitoring and Pursuance" (ß = 0.213; p = 0.031) as significant predictors of staff nurses' job satisfaction and "Staff Advocacy and Development" (ß = -0.347; p < 0.000) and "Team Communication and Collaboration" (ß = -0.243; p = 0.012) as significant predictors of nurses' turnover intention. The findings of the study have implications for the future recruitment, training, and performance evaluation of nurse managers.

The Risk of Upper Urinary Tract Involvement in Patients With Ketamine-Associated Uropathy.

PURPOSE: The aims of this study were to investigate the prevalence of upper tract involvement in ketamine-associated uropathy, and to determine the predictors of hydronephrosis in patients with a history of ketamine abuse. METHODS: This was a cross-sectional study of a prospective cohort of patients with ketamine-associated uropathy. Data including demographics, pattern of ketamine abuse, pelvic pain and urgency or frequency (PUF) symptom score, uroflowmetry (UFM) parameters, serum renal function, and liver function tests were collected. Upon consultation, ultrasonography was performed to assess the function of the urinary system. RESULTS: From December 2011 to October 2015, we treated 572 patients with ketamine-associated uropathy. Of these patients, 207 (36.2%) had managed to achieve abstinence at the time of their first consultation. Ninety-six patients (16.8%) in the cohort were found to have hydronephrosis on ultrasonography. Univariate analysis identified age, duration of ketamine abuse, PUF symptom score, voided volume on UFM, serum creatinine levels >100 µmol/L, and an abnormal serum liver enzyme profile as factors associated with hydronephrosis. Logistic regression revealed the following parameters to be statistically related to hydronephrosis: age (adjusted odds ratio [OR], 1.090; 95% confidence interval [CI], 1.020-1.166; P=0.012), functional bladder capacity (adjusted OR, 0.997; 95% CI, 0.995-0.999; P=0.029), serum creatinine >100 µmol/L (adjusted OR, 3.107; 95% CI, 1.238-7.794; P=0.016, and an abnormal serum liver enzyme profile (adjusted OR, 1.967; 95% CI, 1.213-3.187; P=0.006). CONCLUSIONS: Ketamine-associated uropathy can involve the upper urinary tract. Patient demographics as well as investigations of UFM, renal function tests, and liver function tests may allow us to identify at-risk patients.

Extended use of Prostate Health Index and percentage of [-2]pro-prostate-specific antigen in Chinese men with prostate specific antigen 10-20 ng/mL and normal digital rectal examination.

PURPOSE: We investigated the extended use of Prostate Health Index (PHI) and percentage of [-2]pro-prostate-specific antigen (%p2PSA) in Chinese men with prostate-specific antigen (PSA) 10-20 ng/mL and normal digital rectal examination (DRE). MATERIALS AND METHODS: All consecutive Chinese men with PSA 10-20 ng/mL and normal DRE who agreed for transrectal ultrasound (TRUS)-guided 10-core prostate biopsy were recruited. Blood samples were taken immediately before TRUS-guided prostate biopsy. The performances of total PSA (tPSA), %free-to-total PSA (%fPSA), %p2PSA, and PHI were compared using logistic regression, receiver operating characteristic, and decision curve analyses (DCA). RESULTS: From 2008 to 2015, 312 consecutive Chinese men were included. Among them, 53 out of 312 (17.0%) men were diagnosed to have prostate cancer on biopsy. The proportions of men with positive biopsies were 6.7% in PHI<35, 22.8% in PHI 35-55, and 54.5% in PHI>55 (chi-square test, p<0.001). The area under curves (AUC) of the base model including age, tPSA and status of initial/repeated biopsy was 0.64. Adding %p2PSA and PHI to the base model improved the AUC to 0.79 (p<0.001) and 0.78 (p<0.001), respectively, and provided net clinical benefit in DCA. The positive biopsy rates of Gleason 7 or above prostate cancers were 2.2% for PHI<35, 7.9% for PHI 35-55, and 36.4% for PHI>55 (chi-square test, p<0.001). By utilizing the PHI cutoff of 35 to men with PSA 10-20 ng/mL and normal DRE, 57.1% (178 of 312) biopsies could be avoided. CONCLUSIONS: Both PHI and %p2PSA performed well in predicting prostate cancer and high grade prostate cancer. The use of PHI and %p2PSA should be extended to Chinese men with PSA 10-20 ng/mL and normal DRE.

Prostate health index (PHI) and prostate-specific antigen (PSA) predictive models for prostate cancer in the Chinese population and the role of digital rectal examination-estimated prostate volume.

PURPOSE: To investigate PSA- and PHI (prostate health index)-based models for prediction of prostate cancer (PCa) and the feasibility of using DRE-estimated prostate volume (DRE-PV) in the models. METHODS: This study included 569 Chinese men with PSA 4-10 ng/mL and non-suspicious DRE with transrectal ultrasound (TRUS) 10-core prostate biopsies performed between April 2008 and July 2015. DRE-PV was estimated using 3 pre-defined classes: 25, 40, or 60 ml. The performance of PSA-based and PHI-based predictive models including age, DRE-PV, and TRUS prostate volume (TRUS-PV) was analyzed using logistic regression and area under the receiver operating curves (AUC), in both the whole cohort and the screening age group of 55-75. RESULTS: PCa and high-grade PCa (HGPCa) was diagnosed in 10.9 % (62/569) and 2.8 % (16/569) men, respectively. The performance of DRE-PV-based models was similar to TRUS-PV-based models. In the age group 55-75, the AUCs for PCa of PSA alone, PSA with DRE-PV and age, PHI alone, PHI with DRE-PV and age, and PHI with TRUS-PV and age were 0.54, 0.71, 0.76, 0.78, and 0.78, respectively. The corresponding AUCs for HGPCa were higher (0.60, 0.70, 0.85, 0.83, and 0.83). At 10 and 20 % risk threshold for PCa, 38.4 and 55.4 % biopsies could be avoided in the PHI-based model, respectively. CONCLUSIONS: PHI had better performance over PSA-based models and could reduce unnecessary biopsies. A DRE-assessed PV can replace TRUS-assessed PV in multivariate prediction models to facilitate clinical use.

Prostate Health Index and %p2PSA Predict Aggressive Prostate Cancer Pathology in Chinese Patients Undergoing Radical Prostatectomy.

PURPOSE: To investigate the performance of prostate health index (PHI) and percentage prostate-specific antigen (PSA) isoform [-2]proPSA (%p2PSA) in predicting pathologic outcomes at radical prostatectomy (RP) in a Chinese population. METHODS: We performed a prospective study of 135 prostate cancer patients with RP. The accuracy of preoperative %p2PSA (= p2PSA/free PSA) and PHI [= (p2PSA/free PSA) × âˆšPSA] in predicting pathologic outcomes of RP including pT3 disease, pathologic Gleason score (pGS) ≥7, Gleason score (GS) upgrade at RP, tumor volume >0.5 ml, and Epstein criteria for significant tumor were calculated using multivariate analyses and area under the curve. The base model in multivariate analysis included age, PSA, abnormal digital rectal examination, and biopsy GS. RESULTS: PHI was significantly higher in patients with pT3 or pGS ≥ 7 (p < 0.001), pT3 disease (p = 0.001), pGS ≥ 7 (p < 0.001), GS upgrade (p < 0.001), tumor volume >0.5 ml (p < 0.001), and Epstein criteria for significant tumor (p = 0.001). %p2PSA was also significantly higher in all the above outcomes. The risk of pT3 or pGS ≥ 7 was 16.1 % for PHI < 35 and 60.8 % for PHI > 35 (sensitivity 84.2 %, specificity of 60.3 %), and the risk of tumor volume >0.5 ml was 25.5 % for PHI < 35 and 72.6 % for PHI > 35 (sensitivity 79.1 %, specificity 67.2 %). In multivariate analysis, adding %p2PSA or PHI to the base model significantly improved the accuracy (area under the curve) in predicting pT3 or pGS ≥ 7 (by 7.2-7.9 %), tumor volume >0.5 ml (by 10.3-12.8 %), and Epstein criteria for significant tumor (by 13.9-15.9 %). Net clinical benefit was observed in decision curve analyses for prediction of both tumor volume >0.5 ml, and pT3 or pGS ≥ 7. CONCLUSIONS: Both PHI and %p2PSA predict aggressive and significant pathologies in RP in Chinese men. This enabled identification of nonaggressive cancers for better counseling on active surveillance or treatment.

Clinical Outcome of a Prospective Case Series of Patients With Ketamine Cystitis Who Underwent Standardized Treatment Protocol.

OBJECTIVE: To assess the outcome of a prospective cohort of patients with ketamine-associated uropathy after standardized treatment. METHODS: This is a prospective case series of patients with ketamine-related urologic problems. Management for the patients includes a 4-tier approach, namely anti-inflammatory or anti-cholinergic drugs, opioid analgesics or pregabalin, intravesical hyaluronic acid, and finally, surgical intervention including hydrodistension and augmentation cystoplasty. Outcome was assessed with functional bladder capacity, pelvic pain and urgency or frequency (PUF) symptom scale, and the EuroQol visual analog scale. RESULTS: Between December 2011 and June 2014, 463 patients presented with ketamine-associated uropathy. All were managed by the same standardized protocol. Among these patients, 319 patients came back for follow-up assessment. Overall mean follow-up duration was 10.7 ± 8.5 months. For those patients who received first-line treatment (290 patients), there was a significant improvement in PUF scores, the EuroQol visual analog scale, and functional bladder capacity. Both abstinence from ketamine usage and the amount of ketamine consumed were factors predicting the improvement of PUF scores. For those patients who required second-line oral therapy (62 patients), 42 patients (67.7%) reported improvement in symptoms. Eight patients have completed intravesical therapy. There was a significant improvement in voided volume for the patients after treatment. CONCLUSION: The study demonstrated the efficacy of managing ketamine-associated uropathy using a 4-tier approach. Both anti-inflammatory drugs and analgesics could effectively alleviate symptoms. Being abstinent from ketamine abuse and the amount of ketamine consumed have bearings on treatment response.

Short-stay transurethral prostate surgery: A randomized controlled trial comparing transurethral resection in saline bipolar transurethral vaporization of the prostate with monopolar transurethral resection.

OBJECTIVES: The aim of the present study was to establish the safety and efficacy profile of transurethral resection in saline (TURis) bipolar vaporization of the prostate relative to monopolar transurethral resection of prostate (TURP) and to test the hospital stay efficiency after TURis vaporization. MATERIALS AND METHODS: in this multicenter, double-blinded, prospective, randomized controlled trial, men aged 50-75 years old were randomized into two arms: TURis bipolar vaporization and monopolar TURP. Intraoperative details, perioperative parameters, and postoperative functional outcomes were assessed after intervention. Follow-up with symptom score assessment, prostate volume measurement, and uroflowmetry were performed at 3 and 6 months. RESULTS: Eighty-four patients (mean age, 65.0 ± 5.6 years) were randomized into each study arm. TURis bipolar vaporization had a longer operative time than monopolar TURP (51.6 ± 24.5 vs 38.5 ± 20.3 min, P < 0.001). Postoperatively, the TURis group had a shorter catheter time (33.6 ± 23.7 vs 40.8 ± 29.4 h, P = 0.013) and a shorter length of hospital stay (43.14 ± 18.79 vs 52.33 ± 30.58 h, P = 0.013). The postoperative dysuria score was higher in the TURis vaporization arm. There was no statistically significant difference between the two arms in terms of hemoglobin change and postoperative complication. No significant difference was observed in quality of life score at 3 and 6 months. CONCLUSIONS: TURis bipolar vaporization of the prostate is a safe and comparable alternative to monopolar TURP. It leads to a reduction in both catheter time and length of hospital stay.

Prognostic significance of time to prostate-specific antigen (PSA) nadir and its relationship to survival beyond time to PSA nadir for prostate cancer patients with bone metastases after primary androgen deprivation therapy.

BACKGROUND: This study investigated the prognostic significance of time to the prostate-specific antigen nadir (TTPN) and its relationship to survival beyond TTPN in metastatic prostate cancer after primary androgen-deprivation therapy (ADT). METHODS: All metastatic prostate cancer patients treated with primary ADT from 2000 to 2009 were reviewed. The prognostic significance of TTPN in predicting progression-free survival (PFS) beyond TTPN and overall survival (OS) beyond TTPN was analyzed using the Cox regression model. The median PFS and OS were plotted against TTPN on a monthly interval. The PFS beyond TTPN and the OS beyond TTPN with reference to TTPN were calculated and presented. RESULTS: The study enrolled 419 patients with a median follow-up period of 38 months. The findings showed that TTPN was a significant prognostic indicator for both PFS beyond TTPN (hazard ratio [HR] 0.72, 95 % confidence interval [CI] 0.52-0.99, p = 0.04) and OS beyond TTPN (HR 0.65, 95 % CI 0.47-0.90, p = 0.01) according to Cox regression analyses. The relationship between TTPN and survival beyond TTPN consisted of three phases. In the first phase (<3 months for PFS and <6 months for OS), the survival beyond TTPN increased with TTPN. In the second phase (3-17 months for PFS and 6-20 months for OS), the survival beyond TTPN remained relatively static. In the third phase (>17 months for PFS and >20 months for OS), the survival beyond TTPN increased exponentially with TTPN. CONCLUSIONS: In this study, TTPN was a good prognostic indicator for PFS beyond TTPN and OS beyond TTPN in metastatic prostate cancer cases after primary ADT. Different TTPNs had different implications for predicting survival beyond TTPN.

What accounts for hospital readmission?

AIMS: This study was launched to address the knowledge gap regarding factors leading to readmission to hospital. BACKGROUND: Repeated hospital admission is an issue of concern for health care service providers. Research findings reveal that multiple factors can contribute to the phenomenon, but no study has examined the direct and indirect effects of these variables on hospital readmission. DESIGN: A survey conducted during the period from 2003-2005 in three hospitals in Hong Kong. METHODS: Patients who were readmitted to the same hospital within 28 days during the study periods were included. Data were collected using structured interviews. A structural equation model was employed to examine what factors will contribute to hospital readmission. RESULTS: The final model showed that subjective health outcome was the only significant variable that had a direct effect on readmission, and it had indirect effects on readmission mediating through the variables of age, income and satisfaction with care. CONCLUSIONS: A literature review reveals that none of the studies has recognised patients' subjective appraisal of their health condition as a significant variable to predict hospital readmission. Results did not find an association between evaluated and perceived need. In other words, patients who felt a higher need for hospital care were not necessarily sicker. It is possible that if patients can be empowered to manage their own health condition and make a fair appraisal of their well-being, unnecessary use of hospital services can be reduced. RELEVANCE TO CLINICAL PRACTICE: This study provides evidence to support the notion that an effective transitional care programme needs to incorporate patients' own subjective assessment of health in the intervention and measurement of the outcome. We cannot solely use providers' judgment to measure health outcomes, for patients are active agents in seeking health care, and the use of services is to an extent self-selective.

Identifying patient readmission subtypes from unplanned readmissions to hospitals in Hong Kong: a cluster analysis.

It has been conjectured with regard to patient readmission patterns that there might be significant differences in patient characteristics, need factors, enabling resources, and health behavior. The aim of this study was to identify the profiles of readmitted patients in Hong Kong (n = 120) based on their predisposing characteristics, needs, health behavior, and enabling resources. All the readmitted patients were recruited to the study in three hospitals from 2003 to 2005. A cluster analysis yielded three clusters: Clusters 1, 2, and 3 constituted 27.5% (n = 33), 27.5% (n = 33), and 45.0% (n = 54) of the total sample, respectively. The study results show that community nurse services do affect the rate at which patients are admitted to hospital for a second time. The findings might help by providing important information that will enable health-care policy-makers to identify strategies to target a specific group of patients in the hope of reducing its readmission rate.

Can home visits help reduce hospital readmissions? Randomized controlled trial.

AIM: This paper is a report of a study to determine whether home visits can reduce hospital readmissions. Background. The phenomenon of hospital readmission raises concerns about the quality of care and appropriate use of resources. Home visits after hospital discharge have been introduced to help reduce hospital readmission rates, but the results have not been conclusive. METHOD: A randomized controlled trial was carried out from 2003 to 2005 . The control group (n = 166) received routine care and the study group (n = 166) received home visits from community nurses within 30 days of hospital discharge. Data were collected at baseline before discharge and 30 days after discharge. FINDINGS: Patients in the study group were statistically significantly more satisfied with their care. There were no statistically significant differences in other outcomes, including readmission rate, ADL score, self-perceived life satisfaction and self-perceived health. Regression analysis revealed that self-perceived life satisfaction, self-perceived health and disease category other than general symptoms were three statistically significant variables predicting hospital readmissions. CONCLUSION: Preventive home visits were not effective in reducing hospital readmissions, but satisfaction with care was enhanced. Subjective well-being is a key variable that warrants attention in the planning and evaluation of postdischarge home care.

A study on investigating unplanned readmission patterns.

AIM: To explain frequent hospital readmissions, this study aimed to determine whether definable subtypes exist within a cohort of subjects with chronic illness with regard to factors associated with a patient's readmission patterns and to compare whether these factors vary between subjects in groups with different profiles. RESEARCH METHOD: A descriptive correlational survey was conducted and data were collected by using a structured questionnaire. Seventy-four readmitted subjects were recruited in three general hospitals in Hong Kong. OUTCOME MEASURES: Five outcome variables were employed in the study: predisposing characteristic, need factors, health behaviour, health status or outcomes and enabling resources. RESULTS: A cluster analysis yielded two clusters. Each cluster represented a different profile of the sample on patient use of healthcare services. Cluster A consisted of 41.9% (n = 31) and Cluster B consisted of 58.1% (n = 43) of the patients. Cluster A patients, more of whom were male, were younger, more educated, had higher activities of daily living scores and fewer of them had received community nurse services than patients of Cluster B. Cluster A patients (32.3%) had more than one readmission record within 28 days than Cluster B patients (9.3%, p = 0.017). CONCLUSION: Our study shows that community nurse services can reduce the rate at which they are readmitted a second time. However, such services may have a positive effect only on a group of patients whose profile is similar to the patients in Cluster B and not for patients such as those in Cluster A. A clear profile may help healthcare policy makers make appropriate strategies to target a specific group of patients to reduce their readmission rates. RELEVANCE TO CLINICAL PRACTICE: The identification of risk for future healthcare use could enable better targeting of interventional strategies within these groups. The results of this study might provide hospital managers with a model to design specified interventions to reduce unplanned hospital readmissions for each profile group.

The validity and reliability of the World Health Organization Mental Disorders Checklist for use in a telehealth clinic in Hong Kong.

This research aimed to test the validity and reliability of the 'World Health Organization Mental Disorders Checklist' for use in a telehealth clinic in Hong Kong. The Checklist adopted four subscales: (i) depression; (ii) anxiety; (iii) alcohol use disorders; and (vi) functioning and disablement, and was translated from English into Chinese. It was validated by a panel of five experts to confirm its content validity (content validity index = 0.98) and cultural appropriateness in Hong Kong. The reliability of the checklist was supported by the findings of a test-retest procedure (Pearson correlation = 0.66-0.88, P < 0.01), internal consistency reliability (Cronbach's alpha = 0.54-0.83), and interrater reliability (Kendall's coefficient of concordance = 0.58-1.00, P < 0.01) involving a sample of 197 subjects from one telehealth clinic in Hong Kong.

Problem-based learning: ancient Chinese educational philosophy reflected in a modern educational methodology.

Problem-based learning (PBL) has been widely adopted as a strategy by nurse educators all over the world. Many studies have been carried out to examine its process and outcomes. There are few studies discussing the relevance of PBL to students with different cultural background. This study reports the experiences of Chinese students in Hong Kong using PBL and explores if their experiences were compatible with the educational philosophy documented in traditional Chinese literature. The phenomenological approach was used in the treatment of data. The informants were students enrolled in the post-registration nursing degree programme at a university in Hong Kong during 1997-1998. A total of 94 journals were included in the analysis. Seven main themes emerged from the phenomenological analysis. They were the integration of knowing and doing, critical reflection and debate, individuality of learning, self-motivated learning, critical inquiry and independent thinking, timeliness of instruction and cooperative learning. This study provides evidence to show that PBL is an approach that is compatible with the Chinese way of learning. The result of this study shows that aspects of the modern PBL process harken back to an ancient Chinese learning philosophy that underpins Chinese learning today.

Evaluating the use of developmental action inquiry in constructing a problem-based learning curriculum for pre-registration nursing education in Hong Kong: a student perspective.

BACKGROUND: Developmental action inquiry (DAI) was chosen as the change strategy for introducing problem-based learning (PBL) in a pre-registration nursing programme. The central task was to transform the tutor and student participants to become collaborators in this curriculum reconstruction project. AIM: This paper expounds the way in which the action inquiry was constructed and in light of students' feedback analysis, the way in which PBL has made a difference in student learning was evaluated. DESIGN: Taking into consideration the change context and different group characteristics, the DAI was conducted in terms of two dynamically interlinked circles that formed partnerships between PBL core group members and tutors, and between tutors and students in coconstructing knowledge useful for PBL curriculum development. FINDINGS: The findings of the student evaluation questionnaire reveal that the majority of students felt PBL made a difference to their expectations of self, the student group and the teacher role in creating a facilitative environment to enhance learning. However, there was a significant difference among individual student group responses. The students' positive and negative PBL experience in self-learning, tutor-student interaction, and group-learning were identified as crucial factors contributing to these group variations. CONCLUSION: The evaluation findings show that a paradigm shift from teacher-centred to student-centred learning, from valuing self-learning to co-operative group-learning, and from theory-based to practice-based learning occurred among the students. DAI was found to be an effective change strategy for transforming participants to become collaborators in searching for useful knowledge and coconstructing the PBL learning context.

The issue of death and dying: employing problem-based learning in nursing education.

Caring for dying patients can be an emotionally painful, distressing and sometimes threatening experience for nurses as the illness is incurable and death is imminent. The avoidance of discussion of dying in the presence of patients in Chinese culture further increases nurses' anxiety. The purpose of this article is to provide an example of how nurses can be helped when caring for dying patients by using a problem-based learning (PBL) approach in Hong Kong. The process and value of using PBL is discussed from the students' perspective. Students went through the PBL process and documented their learning throughout the course in journals. A total of 96 sets of journals were collected and analysed. The case analysis explored the perception of learning in the process of PBL. Three themes, related to nurses' attitudes and caring behaviours towards death and dying, have been derived from the findings. They were (a) increased self-awareness (b) positive attitudes towards death (c) providing culturally sensitive care. Problem-based learning as a pedagogical strategy for achieving learning in death and dying was well received. Problem-based learning was found to be a highly satisfactory method for enabling nurses to reflect on their own attitudes towards death and understanding of the emotional aspects of death and dying. Independent finding of information not only prompted nurses to find information from books and journals, but nurses also interviewed experts and patients for updated and experiential knowledge. Tutorials serve as a safe environment for discussion and sharing of feelings and information. The results definitely support PBL as an effective teaching strategy for nursing educators in the area of death education.