The Relationship Between Thanatophobia Levels and Attitudes Towards Caregiver Roles Among Nurses in the COVID-19 Period.

The current study aimed to determine the relationship between fear of death and their caregiver roles in nurses during the COVID-19. The research data were collected with the personal information form, the Thanatophobia scale, the Scale of Nurses' Attitudes to Their Caregiver Roles (SNACR), the Google Questionnaire Form. Of the nurses participating in the study, 16.1% were diagnosed with COVID-19. The current study found statistically significant differences among the thanatophobia mean scores of the groups composed according to the variables; age, gender, marital status, job position, voluntarily choosing the profession, satisfaction with the department, having had a COVID-19 diagnosis, personal assessments about their own COVID-19 knowledge, and evaluating the COVID-19 disease as fatal. In addition, there were statistically significant differences among the SNACR mean scores of the groups according to their evaluations about gender, income level, working experience as a nurse, being diagnosed with COVID-19, and their COVID-19 knowledge. The current study found no correlation between the nurses' Thanatophobia scale score and SNACR score.

Introduction

Following the emergence of a new form of coronavirus (SARS-CoV-2) in Wuhan in December 2019, since 9 March 2020, world countries have started to report cases of COVID-19, which has become a rapidly spreading global public health problem (Çelebi, 2020). Reportedly, the total number of COVID-19 cases worldwide was 332,617,707, and the updated total number of deaths was 5,551,314 on 19 January 2022 (WHO Coronavirus COVID-19 Dashboard).

Extreme COVID-19 prevalence, unpredictability, and severe contagiousness caused physical-distance and isolation measures in society, and also, high morbidity and mortality rates weakened conventional coping methods. While the emerging crisis required adaptation to the conditions and finding efficient solutions, it created an unprecedented burden on all healthcare professionals worldwide (Hiçdurmaz & Üzar-Özçetin, 2020). The Occupational Safety and Health Administration (OSHA) considers healthcare workers in the “severely high” and “high” risk groups in the COVID-19 infection (Sakaoğlu et al., 2020). WHO has stated that healthcare professionals, especially nurses, are very effective in managing this epidemic period. In this process, nurses have been at the forefront of the fight against COVID-19 and have proven that they are one of the main elements keeping the health system alive (Senol-Çelik et al., 2020). By constantly being around g hospitalized patients, nurses compose the most significant body of healthcare suppliers in COVID-19 combat, playing crucial roles in controlling the disease and healing patients, and facing the highest infection risks (Kiyat et al., 2020).

Since the emergence of modern nursing, nurses have assumed the roles of evaluating conditions, setting priorities, collaborating, and giving care in extraordinary situations (Senol-Çelik et al., 2020). Nurses who provide professional care have adapted to the pandemic-related conditions shortly and keep providing healthcare to patients safely and following their individual needs. The nurses provide physical and psychological care and support in the COVID-19 fight. During the pandemic, clinic nurses have been with patients until their last moments. They effectively continued the nursing process by providing proper medical procedures after the death of the patients and supporting their relatives during the sorrow. Nurses who are closely involved in the care of patients during the pandemic period have a high risk of exposure to COVID-19 (Lázaro-Pérez et al., 2020). Until 24 May 2021, 115,000 healthcare workers died due to Covid-19 (https://www.icn.ch/news/icn-says-115000-healthcare-worker-deaths-covid-19-exposes-collective-failure-leaders-protect). The high number of nurses who died globally will probably increase the thanatophobia level (fear of death) of the nurses still working in the clinic. A literature review shows so many studies revealing the majority of the nurses experience COVID-19 anxiety (Birimoğlu-Okuyan et al., 2020; Gavin et al., 2020; Hu et al., 2020), but no study showing COVID-19 related death fear

When new infectious diseases emerge, nurses in contact with patients may feel more fearful because of concerns about transmission and death. It is thought that the fear that nurses, who have important roles in the pandemic process, may experience may negatively affect the nursing caregiver role (Kaplan et al., 2021).

This study aimed to reveal the relationship between nurses’ fear of death from COVID-19 and their caregiver roles. At the same time, it will be possible to determine the existing situation, improve the working conditions of nurses or support them with different approaches. Because it is important to support nurses in stress management, individual self-care and professional self-care in order to protect their mental health. In addition, it may be recommended to get support from colleagues, inform those responsible in the workplace, and get professional mental health support (Hiçdurmaz & Üzar-Özçetin, 2020).

Material and Method

Research Model

This study is a descriptive and cross-sectional study conducted to determine the relationship between fear of death and caregiver roles in nurses during the COVID-19 process and was conducted with participants who met the criteria (being a nurse, had no communication barriers, agreed to participate in the research, and to be over the age of 18.).

Population and Sample

The study population comprised 760 nurses working at the Fırat University Faculty of Medicine hospital. Before the study started, the sample size was calculated as 195 nurses using the statistical power analysis tool, G power 3.1.9.7 software, based on the correlation = 0.25, the α = 0.05, and the power (1-β) = 0.95. Data were collected from 230 nurses considering possible data losses. Since some collected data had missing or incorrect information, the study was completed with 211 nurses (Table 1).

Table 1.

Distribution of Nurses by Descriptive Characteristics.

	N	%
Age
20–29	115	54.5
30–39	65	30.8
40 +	31	14.7
Gender
Female	174	69.7
Male	64	30.3
Marital status
Married	99	46.9
Single	112	53.1
Income level
Income less than expenses	84	39.8
Income equal expenses	102	48.3
Income greater than expenses	25	11.8
Education level
Secondary education	21	10.0
Associate degree	26	12.3
Bachelor degree	131	62.1
Master’s degree	33	15.6
Professional working years?
0–5 years	119	56.4
6–11 years	55	26.1
12 years and over	37	17.5
Which service do you work in?
Internal services	129	61.1
Surgical services	82	38.9
What is your role title?
Clinic staff nurse	176	83.4
Clinic charge nurse	35	16.6
Working hours per week
40 h and under	111	52.6
41 h and over	100	47.4
Which shift do you work. Mostly?
Days	65	30.8
Nights/Days	146	69.2
Did you willingly choose to be a nurse?
Yes	141	66.8
No	70	33.2
Are you satisfied with the unit you work in?
Yes	167	79.1
No	44	20.9
Have you ever been diagnosed with COVID-19?
Yes	34	16.1
No	177	83.9
Have you had contact with someone diagnosed with COVID-19?
Yes	162	76.8
No	49	23.2
How would you rate your knowledge about COVID-19?
Good	121	57.3
Moderate	90	42.7
Do you think COVID-19 is a deadly disease?
Yes	145	82.9
No	36	17.1
Total	211	100

54.5% of the nurses participating in the current study were between 20 and 29 years old. Of the nurses, 69.7% were female, 53.1% were single, 48.3% had income equal to expenses, 62.1% were bachelor’s degree holders, 56.4% had 0–5 years of work experience, 61.1% worked in internal Medicine, 83.4% were clinical staff nurses, 52.6% worked 40 h or fewer per week, 69.2% worked in day/night shifts, 66.8% chose the nursing profession willingly, 79.1% were satisfied with the unit they worked, 83.9% were not diagnosed with COVID-19, 76.8% had contact with someone diagnosed with COVID-19, 57.3% had high-level knowledge about COVID-19, 82.9% accepted COVID-19 as a deadly disease.

Data Collection Tools

Personal Information Form

The Personal Information Form prepared by the researchers contains the introductory information of the nurses participating in the research. The personal information form includes the following questions: “age, gender, marittal status, income level, education level, professional working years, Which service do you work in?, What is your role title?, Working hours per week, Which shift do you work, mostly?, Did you willingly choose to be a nurse?, Are you satisfied with the unit you work in?, Have you ever been diagnosed with COVID-19?, Have you had contact with someone diagnosed with COVID-19?, How would you rate your knowledge about COVID-19?, Do you think COVID-19 is a deadly disease?”

Thanatophobia Scale

The Thanatophobia scale developed by Merrill et al. (1998) evaluates the fear of death of healthcare workers. Çiftçioğlu (2019) has tested its validity and reliability in Turkey. The scale is a 7-item Likert type containing seven questions scored between “1-strongly disagree” and “7-strongly agree.” An increased scale mean score indicates an increased fear of death in persons. The Cronbach’s Alpha reliability coefficient of the Turkish version was 0.85 (Çiftçioğlu, 2019). In the current study, the Cronbach’s Alpha reliability coefficient of the Thanatophobia scale was found as 0.83.

The Scale of Nurses’ Attitudes to Their Caregiver Roles

The scale developed by Koçak et al. (2014) in Turkey determines nurses’ attitudes towards their caregiver roles. The 5-point Likert type scale consists of 16 items. The items of the scale are evaluated between 1 and 5 points with the answers: “1 = Strongly Disagree,” “2 = Disagree,” “3 = Partially Agree,” “4 = Agree,” and “5 = Strongly Agree.” The scale can produce points between 16 and 80. The scale has three sub-dimensions: “Attitude subscale regarding the nurse’s role in patient’s care needs and counseling” (second, sixth, 10th, 11th, 14th, 15th, 16th items) can produce between 7 and 35 points; “Nurses’ attitudes towards their role in protecting individuals and respecting their rights” sub-dimension (third, fifth, 12th, 13th items) can give between 4–20 points; “Nurses’ attitudes towards their role in the treatment process” sub-dimension (first, fourth, seventh, eighth, ninth items) give between 5 and 25 points. Higher sub-dimension and total scores on the scale indicate nurses’ positive attitudes towards their caregiver roles, and lower scores denote negative approaches. Cronbach’s Alpha value was found as 0.91 for all items of the Scale of Nurses’ Attitudes to Their Caregiver Roles (Koçak et al., 2014). In the current study, the scale’s Cronbach’s Alpha reliability coefficient was determined as 0.84.

Data Collection

The research permission was obtained from Fırat University Social and Human Sciences Research Ethics Committee (protocol number: E-97132852-302.14.01-3515). Following approval, research data were collected within subsequent 30 days with Google Form Questionnaires sent to the study participants via the mobile/internet network system. All participants had the opportunity to charge their own devices without changing their location. Thus, the risk of contamination during the pandemic process has been eliminated by using the online form. The survey consisted of four stages. The first part: the Informed Voluntary Consent Form to inform the participants about the research and get their consent; the second part: the Personal Information Form developed by the researchers; the third part: the Thanatophobia scale; the fourth part: the Scale of Nurses’ Attitudes to Their Caregiver Roles. Data collection took approximately 10–15 min for each participant.

Data Analysis

SPSS 22 package program was employed to perform statistical analysis of the data collected by the Google Forms survey method and the Kolmogorov-Smirnov test to verify the normal distribution of the data. One Way ANOVA was used to compare the differences between the groups, and the Bonferroni Post Hoc t-test to determine the significance of the difference. Independent Samples t-Test was utilized to compare the difference between the two groups, and a Pearson correlation test to investigate the relationship between the scores obtained from the two scales. Statistical significance was accepted as p < .05.

Findings

Table 2 shows the mean scores of the Thanatophobia Scale and The Scale of Nurse Attitudes to Caregiver Role (SNACR) according to the descriptive characteristics of nurses. There were statistically significant differences between the Thanatophobia scale mean scores based on the variables of age, gender, marital status, working role, willingly (or not) choosing the profession, satisfaction with the workplace, being diagnosed with COVID-19, COVID-19 knowledge levels of the nurses from their own perspectives, and nurses' perspectives about the fatality of the COVID-19 disease. Thanatophobia scale mean scores of nurses aged 40 and over were statistically higher than those under 40. In addition, the Thanatophobia scale mean scores of female nurses were statistically significantly higher than males and married nurses than singles. The mean score of the Thanatophobia Scale of the clinical staff nurses was statistically high compared to the charge nurses. The Thanatophobia Scale mean scores of the nurses who chose their profession unwillingly were statistically significantly higher than those who willingly chose the profession. The Thanatophobia Scale mean scores of the nurses who were not satisfied with the unit they worked in were statistically significantly higher than those being pleased. The Thanatophobia Scale mean scores of the nurses who were not diagnosed with COVID-19 were statistically higher than those diagnosed with COVID-19. The Thanatophobia Scale mean score of the nurses who stated their knowledge about COVID-19 at a moderate level was statistically significantly higher than those who expressed a satisfactory level. The Thanatophobia Scale mean scores of the nurses who evaluated COVID-19 as a fatal disease were statistically significantly higher than those who did not consider COVID-19 a lethal disease.

Table 2.

The Mean Scores of the Thanatophobia Scale and the Scale of Nurse Attitudes to Caregiver Role According to Nurses’ Descriptive Characteristics.

	Thanatophobia scale	SNACR
Age[a]
20–29 a	33.30 ± 9.48	65.12 ± 10.79
30–39 b	32.46 ± 8.92	63.30 ± 8.37
40 + c	38.27 ± 8.09	61.03 ± 7.79
Test statistic	4.567	2.380
p	.011	.095
Significant difference	c>a.b
Gender[b]
Female	35.72 ± 8.05	65.42 ± 8.59
Male	29.29 ± 10.36	60.60 ± 11.42
Test statistic	8.859	1.987
p	.000	.001
Marital status[b]
Married	35.31 ± 8.97	64.02 ± 7.88
Single	32.41 ± 9.37	63.91 ± 11.21
Test statistic	.660	8.658
p	.023	.934
Income level[a]
Income greater than expenses a	31.68 ± 10.02	66.04 ± 14.21
Income equal to expenses b	34.79 ± 7.69	65.38 ± 8.21
Income less than expenses c	33.15 ± 10.66	61.61 ± 9.57
Test statistic	1.446	4.180
p	.238	.017
Significant difference		b>c
Education[a]
Secondary education	34.28 ± 10.90	62.71 ± 9.20
Associate degree	35.11 ± 10.98	62.53 ± 10.12
Bachelor degree	34.06 ± 8.87	64.06 ± 9.45
Master’s degree	31.21 ± 8.24	65.48 ± 11.20
Test statistic	1.064	.566
p	.365	.638
Work experience[a]
0–5 years a	33.43 ± 9.08	65.52 ± 10.18
6–11 years b	32.72 ± 9.56	61.16 ± 9.46
12 years and over c	36.40 ± 9.22	63.08 ± 6.89
Test statistic	1.933	4.051
p	.147	.019
Significant difference		a>b
Which service do you work in?[b]
Internal medicine	34.78 ± 8.23	64.13 ± 8.68
Surgical services	32.18 ± 10.57	63.68 ± 11.32
Test statistic	4.294	2.020
p	.061	.756
What is your role title[b]
Clinic staff nurse	34.82 ± 8.60	63.97 ± 9.68
Clinic charge nurse	28.48 ± 10.79	63.91 ± 10.34
Test statistic	2.072	.105
p	.002	.976
Your weekly working hours[b]
40 h and below	33.63 ± 9.01	62.79 ± 9.67
41 h and over	33.92 ± 9.60	65.26 ± 9.76
Test statistic	.122	.080
p	.828	.067
Which shift do you work. Mostly?[b]
Days	34.20 ± 8.83	64.23 ± 7.74
Nights/Days	33.58 ± 9.49	63.84 ± 10.57
Test statistic	.012	5.441
p	.648	.766
Did you willingly choose to be a nurse[b]
Yes	32.62 ± 9.44	63.53 ± 9.22
No	36.08 ± 8.54	64.81 ± 9.68
Test statistic	.447	.674
p	.008	.372
Are you satisfied with the unit you work in?[b]
Yes	33.05 ± 8.74	63.67 ± 9.83
No	36.50 ± 10.71	65.06 ± 9.55
Test statistic	1.538	0.011
p	.047	.394
Have you ever been diagnosed with COVID-19?[b]
Yes	30.08 ± 11.15	60.02 ± 12.37
No	34.48 ± 8.47	64.71 ± 8.46
Test statistic	7.715	13.248
p	.048	.043
Have you ever had contact with someone diagnosed with COVID-19?[b]
Yes	33.50 ± 9.51	64.03 ± 10.14
No	34.65 ± 8.49	63.73 ± 8.49
Test statistic	.218	.512
p	.423	.839
How would you rate your level of knowledge about COVID-19?[b]
Good	32.61 ± 9.34	65.10 ± 9.87
Moderate	35.33 ± 9.01	62.42 ± 9.47
Test statistic	.369	.002
p	.034	.047
Do you think COVID-19 is a deadly disease?[b]
Yes	34.38 ± 9.11	63.95 ± 9.74
No	30.80 ± 9.62	64.00 ± 10.03
Test statistic	.303	3.560
p	.046	.980

aOne-Way ANOVA.

bIndenpendent Samples t-test.

There were statistically significant differences between the mean scores of SNACR according to the variables of gender, income level, work experience, being diagnosed with COVID-19, and the level of knowledge about COVID-19. Accordingly, female nurses’ mean SNACR scores were statistically higher than male nurses. The mean SNACR score of nurses whose income was equal to expenditure was statistically higher than nurses whose income was less than expenditure. The mean SNACR score of nurses with 0–5 years of work experience was statistically higher than the nurses with 6–11 years of experience. The mean SNACR scores of nurses diagnosed with COVID-19 were statistically higher than nurses not diagnosed. In addition, the mean SNACR score of nurses with better COVID-19 knowledge was statistically higher than nurses with moderate COVID-19 knowledge.

Table 3 shows nurses' Thanatophobia scale mean scores.

Table 3.

Nurses’ Thanatophobia scale mean scores.

	Min	Max	Mean	Standard deviation
Thanatophobia scale	7.00	49.00	33.77	9.27

Table 4 shows the SNACR and its sub-dimensions mean scores.

Table 4.

Mean Scores of The Scale of Nurse Attitudes To Caregiver Role.

	Min	Max	Mean	Standard deviation
Attitude subscale regarding the nurse’s role in patient’s care needs and counseling	7.00	35.00	27.47	5.06
Attitude subscale regarding the nurse’s role in protecting the individual and respecting their rights	4.00	20.00	17.08	2.41
Attitude subscale regarding the nurse’s role in the treatment process	5.00	25.00	19.39	3.26
SNACR	16.00	80.00	63.96	9.77

Pearson Correlation

Table 5 shows the correlation between the scores of the nurses on the Thanatophobia scale and SNACR. No correlation was found between the scores of the two scales.

Table 5.

Relationship between Thanatophobia Scale and SNACR scores.

		SNACR
Thanatophobia scale	r	.129
	p	.62

Discussion

Although all society segments are at risk in the COVID-19 pandemic, healthcare workers are the riskiest occupational group for catching the infection. People over 50 and those with comorbidities are the most vulnerable groups for COVID-19. According to the WHO’s COVID-19 report, death cases are generally seen in the elderly or individuals with concomitant systemic disease(https://covid19.saglik.gov.tr/TR-66116/yayinlar.html). Parallel to this, the current study has observed that the thanatophobia levels of nurses aged 40 and over are higher than those between 20 and 39 years old (Table 2).

The current study has observed that female nurses have higher thanatophobia levels than males (Table 2). Similarly, a study conducted on Indian youth has found that the thanatophobia levels of women during COVID-19 are 3.38 times higher than that of men (Gaur et al., 2021). Again, a study on COVID-19 in Kuwait has determined that the thanatophobia levels of women are significantly higher than men (Al-Ma'seb & Al-Sejari, 2021). The study by Karaköse et al., conducted on school administrators, has revealed that women experience more COVID-19 phobia than men (Karaköse et al., 2021). The study by Cihan and Gökgöz Durmaz (2021) conducted on the geriatrics unit has determined that the psychological sub-dimension scores of the COVID-19 phobia scale are higher in women than in men. The literature supports the current study findings.

The present study has found that female nurses have a higher attitude towards their caregiver roles (Table 2). The literature review has shown that some studies find no relationship between gender and attitudes towards caregiver roles, unlike the current study finding (Altınbaş & Derya-İster, 2020; Bakır, 2019; Dimen, 2019; Kul, 2021; Yılmaz et al., 2017). The difference is thought to stem from the number of male nurses in the study -approximately one-third of the female nurses- because this ratio is higher than other research findings.

The current study has found that less-experienced nurses have a higher attitude towards their caregiver roles (Table 2). Contrary to our finding, some literature studies have stated no significant relationship between professional experience and attitudes towards caregiver roles (Bakır, 2019; Kul, 2021; Solak, 2021; Yılmaz et al., 2017). This difference probably stems from more than half of the nurses participating in the study were within the first 5 years of professional experience.

The present study has determined that nurses diagnosed with COVID 19 have a higher attitude towards their caregiver roles than those not diagnosed with COVID-19 (Table 2). No research has been found in the literature that has examined the relationship between the diagnosis of COVID-19 and SNACR. However, it should be recalled that empathy develops among people who experience similar situations (Özbek, 2010). Clinical empathy enables a nurse to understand the patient’s current situation, perspective, feelings, as well as to determine his needs and to make reasonable clinical decisions (Ağaçdiken & Aydoğan, 2017). The reason nurses who have been diagnosed with COVID-19 score higher on attitudes towards their caregiver roles may stem from their higher levels of empathy. The current study finding is almost identical to the literature.

Research has determined that having high knowledge about COVID-19 increases attitudes towards caregiver roles (Table 2). Professionalism in nursing care depends on proficient knowledge, skills, attitude, as well as occupational knowledge based on research (Gül, 2019). An increased level of occupational knowledge likely increases attitude towards care. The current research finding is similar to the literature.

The present study calculated the SNACR mean score of nurses as 63.29 ± 9.77 (Table 4). Considering the highest score on the scale is 80, nurse attitudes towards their caregiver roles can be assessed as high. Studies in the literature have reported that the mean score of nurses from SNACR varies between 60.74 ± 9.06–67.24 ± 9.04 (Altınbaş & Derya-İster, 2020; Bakır, 2019; Dimen, 2019; Ocak, 2021; Solak, 2021; Yılmaz et al., 2017). The current research finding shows parallelism with the literature.

The current study found no relationship between nurses' thanatophobia levels and SNACR (Table 5). Nurses are the health workers who have the most interaction with patients, especially in palliative care and intensive care services. Nurses spend more time with patients than other healthcare professionals do; they are closely intertwined with death (Alıcılar et al., 2021). In terminally ill patients, treatment ceases to be the main goal and care comes to the fore. Therefore, both physical care and spiritual care become primary in nursing functions (Isik et al., 2009). Therefore, being constantly intertwined with death may cause nurses to normalize the dying process and death fear and maintain their traditional attitudes towards caregiving.

Conclusion

Of the nurses participating in the study, 69.7% were female, 53.1% were single, 48.3% had income equal to expenses, 62.1% were bachelor’s degree holders, 56.4% had 0–5 years of work experience, 16.1% were diagnosed with COVID-19. The current study found statistically significant differences among the thanatophobia mean scores of the groups composed according to the variables; age, gender, marital status, job position, voluntarily choosing the profession, satisfaction with the department, having had a COVID-19 diagnosis, personal assessments about their own COVID-19 knowledge, and evaluating the COVID-19 disease as fatal. In addition, there were statistically significant differences among the SNACR mean scores of the groups according to their evaluations about gender, income level, working experience as a nurse, being diagnosed with COVID-19, and their COVID-19 knowledge. The current study found no correlation between the nurses’ Thanatophobia scale score and SNACR score.

Strategies should be developed to help nurses cope with compassion fatigue, by providing necessary support to nurses, especially in the pandemic, where nurse workforce is needed significantly, and relevant guides should be created. However, it is thought that it is important that nurses are supported by the management, strengthened with health policies and provided with psychosupport.

This study examined the relationship between fear of death and caregiver roles in nurses during the COVID-19 process. The limitation of the study is that the study was conducted with nurses working in only one hospital. Conducting the research in only one province in Turkey constitutes another limitation of the study in terms of the generalizability of the findings.