Death Anxiety among Nurses and Health Care Professionals: A Review Article.

Death anxiety, a negative affective state that is incited by mortality salience, may be experienced by nurses and other health care workers who are exposed to sickness, trauma, and violence. This paper examines death anxiety and management strategies among health providers in different health settings across cultures. A literature review of the research published since 2000 in the English language was conducted using PubMed, Science direct, CINAHL, and PsychInfo databases. Death anxiety is commonly experienced and is associated with more negative attitudes about caring for dying patients and their families. Performing educational and psychological interventions to help nurses build strong coping strategies for managing death anxiety are recommended to offset negative consequences such as leaving positions, poor communication, and decrements in personal health and quality of life.

INTRODUCTION

Confronting death is a formidable human concern that is influenced by personal experiences and socio-cultural beliefs.[1,2] Death anxiety, a negative affective state that is incited by mortality salience, may be experienced by nurses and other health care workers who are exposed to sickness, trauma, violence, and death factors that may influence the experience and level of death anxiety in health providers include age, ego integrity, physical problems, psychiatric conditions, religiosity[3] ethnicity, occupational stressors, personal death experiences, and media influences.[4] While there is an increasing focus on burnout and compassion fatigue among nurses who care for patients at the end of life, there has been limited research that has examined the role of death anxiety in contributing to these occupational stressors.[5-9] Furthermore, there is less focus on death anxiety among nurses who care for patients in a variety of environments including intensive care units, psychiatric wards, emergency rooms, and inpatient and outpatient settings.[10] Nursing staff have also perceived educational gaps relative to their preparation to provide effective care for dying patients.[11] The purpose of this review is to examine death anxiety and management strategies among health providers in different health settings across cultures. A better understanding of the experience of death anxiety in nurses globally may ultimately lead to interventions that can offset serious consequences such as leaving positions, poor patient care, and decrements in personal health.

Death Anxiety

While health care environments throughout the developed world have expanded the use of technology and advanced sophisticated treatments to manage serious conditions, many patients facing trauma and life-threatening conditions experience death in institutional settings.[2] Nurses play critical roles globally in preventing death, and also they help patients and their family members with advanced directives, and end of life decision-making. Nurses may become anxious and feel overwhelmed with the work stressors associated with death and dying.[12] Furthermore, nurses may feel unprepared to communicate effectively with patients who are dying and their family members.[8,11] In some work environments such as the emergency room setting, workload demands may compromise the nurses’ ability to facilitate dignified end of life care.[10] Death anxiety is a multidimensional construct[13] with emotional, cognitive, and experiential attributes.[14] Although there is a somewhat exploratory ambience pervasive to the death anxiety concept given divergent philosophical and scientific perspectives, there is a host of rigorous research that has focused on elements of this important phenomenon. Researchers have examined the concept differently and have progressed empirically guided by particular theoretical orientations.

In Lehto and Stein’s review of the death anxiety literature, it was noted that developmental and sociocultural factors such as age, gender, and religiosity influence its expression. Life experiences with death may also impact attitudes about death and contribute to lower levels of death anxiety.[15] While the fear of death is pervasive in humans, personal death and the experience of death anxiety may be denied and/or avoided. Importantly, it is recognized that death anxiety brings about important behavioral and emotional consequences.

Moreover, the attitude of nurses towards death may affect their empathic concern,[16] the quality of care they provide,[17] and the way they cope with work-related stressors such as patients’ death.[18] While nurses and other health care professionals may have positive intentions to provide the highest quality care for patients facing death, they may have fears related to death that may negatively influence their attitudes about providing care.[19,20] Furthermore, caring for dying patients may lead to grief and perceptions of failure, which also evoke heightened anxiety about managing death situations in the work environment.[8] Therefore, the purpose of this paper was to examine what is known about death anxiety in nurses and identify strategies that may reduce deleterious consequences of death anxiety related work stress.

MATERIALS AND METHODS

Search Strategy and Study Selection

A literature review limited to the health sciences of multiple databases and search engines was undertaken using the keywords death anxiety, fear of death, nursing, health care, and thanatophobia. To maintain the currency of the findings, inclusion criteria incorporated only research articles that were published since 2000 in the English language. Exclusion criteria included commentary and theory papers, non-research studies, and non-English language articles. Data sources included PubMed, Science direct, CINAHL, and PsychInfo. Titles and abstracts were first examined to determine their relevancy for review.

After the articles were retrieved, two reviewers conducted an analysis of each study using quality criteria for qualitative and quantitative studies. Following this rigorous process, we were left with 38 articles that met the review inclusion criteria. Three of the papers were qualitative studies.

RESULTS

Measurement of Death Anxiety in Nursing Studies

Studies that have examined death anxiety in nurses have primarily used self-report instruments. The Collett-Lester Fear of Death and Dying Scale (CFDS) and the revised version (RCFDS) are Likert scale instruments that examine feelings about personal death, dying, and death experience with others (Lester, 1994). The CFDS[21-23] and the RCFDS[24,25] were used in several studies examining death anxiety among nurses and other health professionals. Similar to the RCFDS, the Multidimensional Fear of Death Scale (MFODS), a 42-item scale that includes death fears related to the unknown, has also been incorporated.[26-29] Other instruments used in these studies include Templer’s 15-item Death Anxiety Scale (TDAS), an instrument that has been used in multiple studies over the past 3 decades;[21,30-32] the Revised Death Anxiety Scale (RDAS), a 25-item multi-dimensional scale;[33-35] and the Death Attitude Profile-Revised (DAP-R) that measures fear of death, avoidance, and acceptance parameters.[16,20,36-41] Another frequently used scale, the Frommelt Attitude Towards Care of the Dying (FATCOD), has 30 items that examine attitudes of caregivers towards the death of patients.[16,19,20,37,38,42-44] Although the tools that have been used to measure death anxiety in health professionals have been validated and translated into the languages where the research originated, comparisons of the findings across the studies becomes challenging. Also, the self-report approach is not able to capture death anxiety that is not consciously experienced or that is denied or avoided.

Experience of Death Anxiety among Nurses

High levels of death anxiety were found among Egyptian female nursing students compared with Spanish students who were slightly older and more experienced.[45] One study conducted in Turkey found moderate anxiety levels among pediatric intensive care unit nurses when experiencing the death of a patient.[46] These same nurses were found to carry low levels of trait anxiety through normal work conditions. In a cross-sectional study conducted on Japanese nurses and health workers, fear of death was associated with less positive attitudes about caring for dying patients.[20] Similarly, an Iranian cross-sectional study also found that nurses with higher death fears had more negative attitude toward providing care to dying patients.[38] Another cross-sectional descriptive study conducted on 147 Israeli nurses found that fear of death was associated with death avoidance and lowered experience with exposure to dying patients.[37] In a sample of 355 American cancer nurses, those with less work experience were significantly more likely to have higher death fears and avoidance as compared to more experienced oncology nurses.[19] Another research has found that working on cancer units, depression, and using coping strategies such as humor predicted distress and burnout in health care workers.[5]

A correlational study that examined death anxiety factors among 243 Spanish nursing students with varying years of experience found that students with more experience had lower fears related to death. Emotional clarity, a component of emotional intelligence needed to effectively monitor personal feelings and emotions to guide thinking and actions, was associated with lower fear of death.[21] Another study, however, conducted among American nursing students found that the students with more experience had higher levels of death anxiety as compared to general non-nursing students and less experienced nursing students.[47] In this study, social desirability was significantly and negatively correlated with death anxiety parameters.[47]

Early experiences with patient death play a significant role in how distressing nurses find management of dying patients. Kent et al (2012) investigated the nurses’ death experiences using a convenience sample of 174 New Zealander nurses. Their findings indicated that some nurses reported experiences that promoted learning and were rewarding, whereas other nurses identified high levels of distress. Given the powerful nature of early death encounters for nurses, the authors recommend that more understanding of the nurses’ reactions to death is needed to reduce negative factors such as perceptions of inadequacy, unexpectedness, and other conflicts.[12] Similarly, Halliday and Boughton (2008) found that palliative care nurses who had rich experiences with patient death reported lower death anxiety using the RDAS than similar participants in young, middle-age, and older age ranges. In the same study, females and older participants had higher comparative death anxiety.[33] In Zyga et al.’s (2011) study conducted in Greece, renal nurses with more experience and training in palliative care had lowered death fear and more positive attitudes about caring for dying patients.[41]

Two qualitative studies[8,9] examined the nurses’ personal concerns about caring for the dying and resources available to manage them. Some factors that increased worry included providing comfort for an event that they had not personally experienced, getting too involved, saying the wrong thing, and acting as intermediaries between the family and the patient. Some nurses tried to limit their involvement with dying patients and create professional distancing. Ulla and colleagues[18] from Spain found that personal and situational factors modulate the nurses’ perceptions about death-related phenomenon in the work setting. Nurses vary in their impressions about death, suggesting the importance of tailoring related to psychological factors in training and educational programs.[18]

In a study conducted on 176 helping professionals, the participants provided feedback about building competence in death work. Findings demonstrated that building competence to provide optimal care of patients facing death included self, practice, knowledge, and work-environment competence. Self-competence, the most important component, included use of personal resources, existential coping, and emotional coping.[48] Personal resources entailed qualities such as maturity, calmness, patience, and sense of humor. Existential coping included the role that religion, spirituality, hope, and faith played. Emotional coping referred to the maintenance of self-care and strong mental health.[49,50]

Consequences of Death Anxiety

Social workers with higher death anxiety were less likely to disclose information about advance directives with patients.[25] A study conducted on 343 Indian nurses found that death anxiety was not associated with related attitudes about euthanasia.[31] Another descriptive correlational study performed on 190 nurses found that nurses with higher death anxiety reported discomfort with communication with patients and their family members about death. Nurses who reported having received death communication training indicated more positive perceptions about such difficult subjects.[30] In another study carried out on 135 health care professionals who were primarily nurses, it was found that death anxiety attributes were associated with lowered collaboration with colleagues about advance directives for patients. Furthermore, professionals who accepted death more were more willing to discuss advance directives with patients.[36]

Death Education Interventions to Reduce Death Anxiety

More research has been conducted on incorporating death education in undergraduate nursing programs. One study examined the impact on death anxiety of a 13 week program of instruction which incorporated training lectures, discussion, and activities to help undergraduate students better understand life and death issues pertinent to health care. Using the CFDS, the study found reductions in death anxiety among the intervention group who received training over the course of semester as compared to a comparison group.[23]

Using a pre-post-test design, 17 participants who were oriental as palliative care volunteers received 27 hours of training that incorporated death, grief, and bereavement concepts. While the participants felt more prepared to care for dying patients, there was no change in death anxiety scores as a result of the class they attended.[22] A Hungarian study that utilized pre- and post-testing examined whether a semester long thanatology and palliative care course for medical students and a 40 hour palliative care course offered to health professionals had effects on the participants’ death anxiety and attitudes. Findings demonstrated that overall death anxiety was reduced as a result of the courses in both groups. The training program incorporated communication, psychology of bereavement, support, societal viewpoints on death and dying, and symptom management.[27]

Lee and King (2014) examined the impact of an educational program on reduction of death anxiety and burnout among hemodialysis nurses. Using a pre-post design, 15 nurses were recruited to participate in a series of four 2-hour classes that covered topics such as death anxiety, burnout, grieving, effective coping and self-care, end of life legislation, and preferences. Although the sample size was small and the findings were not statistically significant, CFDS subscale scores were lower following the training.[24]

A quasi-experimental study conducted on end of life health care workers enrolled 69 participants in a 6-week, 18-hour art-based therapy supervision course and 132 individuals in a 3-day 18 hour standard supervision to compares the effects on death anxiety and burnout. Findings demonstrated that art based participants had significantly lower death anxiety, exhaustion, and increased emotional awareness as compared to the standard skills group. The researchers argued that the arts-based approach enhanced emotion regulation, fostered reflectiveness and meaning-making, contributing to the decreased death anxiety and burnout.[40]

Melo and Oliver (2011) sought to determine if a 36-hour group training program consisting of two modules resulted in lowered death anxiety and burnout among health care workers who cared for terminally ill patients in Portugal. The first module of care facilitated by a psychologist provided a person-centered approach to finding the meaning of life, relationships, coping, suffering, aging, and death. The second module provided theory and skill building exercises to advance communication with and understanding of the spiritual and psychological needs of those facing death. Findings from the mixed methods study demonstrated that the course reduced death anxiety and burnout and improved well-being, quality of patient relationships, and professional satisfaction. Melo’s study is one of the few studies that have examined death anxiety in relation to burnout.

Evaluation and Limitations

A limitation of this study was that a part of the questions used to evaluate the outcomes were developed for the purposes of the study.[6]

The studies that have tested interventions to manage death anxiety in health care professionals identify common themes that appear to be beneficial. Emphasizing personal growth and building capacities to regulate emotions appear necessary for auxiliary nurses to manage the stressors associated with caring for dying patients. Strengthening adaptive and individualized coping strategies for nurses and teaching the important self-care qualities during nursing training is recommended to offset burnout.[5] While the interventional studies have identified important information that can be used to expand psycho-education programs related to death and dying content, these studies have primarily used the pre-posttest design, which is a limitation. While research examining death anxiety and its implications for nursing is growing, most studies have used cross-sectional descriptive approaches. Furthermore, the reliance on self-report measures increases the possibility of social desirability bias. The studies have largely used convenience samples that limit generalizability of the findings. Also, convenience sampling may lead to samples that are more comfortable with engagement relative to thanatology content. While extensive research has examined the role of culture and religiosity as factors that impact death anxiety, there is yet only limited research in nursing that has examined these factors along with cross-cultural comparative approaches.

CONCLUSION

There are few practice areas where nurses are not inclined to be faced with death, e.g. life-threatening illnesses, accidents, code situations, post-operative compromise, long term care, psychiatric nursing with post-traumatic stress disorder victims, to name a few. There has been an increasing recognition of the importance of death education for nursing and allied health professionals. Coincident with the need for heightened training in optimizing death and dying care are curriculum that addresses emotion awareness and regulation for providers.

Given the tendencies for the modern health care enterprise to focus on prolonging life, it is not surprising that death and dying curriculum exposure have not been prioritized or uniformly applied in educational programs. Globally a large number of patients continue to die in hospital or nursing home settings despite preferences to die in home environments. It is recommended that programs on death education be expanded, with a focus on the multi-faceted experience of death anxiety as a normative occurrence for health care workers. These programs need to occur not only in the formative educational process, but also as a part of orientation for new staff members, and as refreshers for more experienced nurses. Such an emphasis may reduce the culture of death as a taboo topic for health care workers, and may increase quality of communications and thus perceptions of care between health care professionals and their patients and family members. If death discussions are not evaded, patients at the end of life may have increasing options as to how and where they experience death.