The Open Nursing Journal




ISSN: 1874-4346 ― Volume 13, 2019

How Death Anxiety Impacts Nurses’ Caring for Patients at the End of Life: A Review of Literature



L. Peters1, R. Cant*, 1, S. Payne2, M. O’Connor1, F. McDermott1, K. Hood1, J. Morphet1, K. Shimoinaba1
1 Monash University, Faculty of Medicine, Nursing and Health Sciences, Melbourne, VIC 3168, Australia
2 Lancaster University, Faculty of Health & Medicine, Lancaster, UK

Abstract

Nurses are frequently exposed to dying patients and death in the course of their work. This experience makes individuals conscious of their own mortality, often giving rise to anxiety and unease. Nurses who have a strong anxiety about death may be less comfortable providing nursing care for patients at the end of their life. This paper explores the literature on death anxiety and nurses’ attitudes to determine whether fear of death impacts on nurses’ caring for dying patients. Fifteen quantitative studies published between 1990 and 2012 exploring nurses’ own attitudes towards death were critically reviewed. Three key themes identified were: i). nurses’ level of death anxiety; ii). death anxiety and attitudes towards caring for the dying, and iii). death education was necessary for such emotional work. Based on quantitative surveys using valid instruments, results suggested that the level of death anxiety of nurses working in hospitals in general, oncology, renal, hospice care or in community services was not high. Some studies showed an inverse association between nurses’ attitude towards death and their attitude towards caring for dying patients. Younger nurses consistently reported stronger fear of death and more negative attitudes towards end-of-life patient care. Nurses need to be aware of their own beliefs. Studies from several countries showed that a worksite death education program could reduce death anxiety. This offers potential for improving nurses’ caring for patients at the end of their life.

Keywords: Attitudes, death anxiety, end of life care, spirituality, thanatophobia.


Article Information


Identifiers and Pagination:

Year: 2013
Volume: 7
First Page: 14
Last Page: 21
Publisher Id: TONURSJ-7-14
DOI: 10.2174/1874434601307010014
PMID: 23400515
PMCID: PMC3565229

Article History:

Received Date: 8/10/2012
Revision Received Date: 26/11/2012
Acceptance Date: 27/11/2012
Electronic publication date: 24/01/2013
Collection year: 2013

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* Address correspondence to this author at the Monash University 100 Clyde Rd Berwick, VIC Aust 3806, Australia; Tel: +61 3 99047159; E-mailrobyn.cant@monash.edu




INTRODUCTION

Numerous studies over the last 30 years have explored death anxiety among individuals. This is a feeling of dread, anxiety or fear at the thought of death or anything to do with dying: a common fear or phobia [1Lehto R, Stein KF. Death anxiety: an analysis of an evolving concept Res Theory Nurs Pract 2009; 23: 23-41.
[http://dx.doi.org/10.1891/1541-6577.23.1.23] [PMID: 19418886]
]. Nurses, in the course of their clinical work are frequently exposed to the processes surrounding patient deaths. Nurses’ personal attitudes towards death and dying may, however, influence the quality of care they provide during the terminal stages of a person’s life. Faced with emotional issues such as the reality of deaths, nurses need skills and experience to manage such fears.

DEATH ANXIETY

Attitudes are formed as a result of a favorable or unfavorable evaluation of a person, object, or thing and are expected to change over time and with experience. The fear of death is a universal phobia experienced by humans [1Lehto R, Stein KF. Death anxiety: an analysis of an evolving concept Res Theory Nurs Pract 2009; 23: 23-41.
[http://dx.doi.org/10.1891/1541-6577.23.1.23] [PMID: 19418886]
], with societal preference strongly advocating the preservation of life in many fields, such as in medicine [2Meliones J. Saving money, saving lives Harvard Business Rev 2000; 00: 5-10.]. Individuals have their own attitudes towards death influenced by personal, cultural, social and philosophical belief systems that shape a person’s conscious or unconscious behaviors [3Rooda LA, Clements R, Jordan ML. Nurses' attitudes toward death and caring for dying patients Oncol Nurs Forum 1999; 26: 1683-7.
[PMID: 10573685]
]. These attitudes are attached to human emotions, which are in turn attached to actions taken towards the object of the emotions [4Braun M, Gordon D, Uziely B. Associations between oncology nurses' attitudes toward death and caring for dying patients Oncol Nurs Forum 2010; 37: E43-9.
[http://dx.doi.org/10.1188/10.ONF.E43-E49] [PMID: 20044331]
] in this case, death. Exposure to the processes accompanying the death of others makes individuals conscious of their own mortality, giving rise to anxiety and unease – although how these issues are related is complex [5Depaola SJ, Griffin M, Young JR, Neimeyer RA. Death anxiety and attitudes toward the elderly among older adults: the role of gender and ethnicity Death Stud 2003; 27: 335-54.
[http://dx.doi.org/10.1080/07481180302904] [PMID: 12749378]
]. Thus ‘death anxiety’ may be experienced, which is described as a ‘negative emotional reaction provoked by the anticipation of a state in which the self does not exist’ [6Tomer A, Eliason G. Toward a comprehensive model of death anxiety Death Stud 1996; 20: 343-65.
[http://dx.doi.org/10.1080/07481189608252787] [PMID: 10160570]
] accompanied by feelings of fear or dread [7Gomez J, Hidalgo MD, Tomas-Sabado J. Using polytomous item response models to assess death anxiety Nurs Res 2007; 56: 89-96.
[http://dx.doi.org/10.1097/01.NNR.0000263966.24125.92] [PMID: 17356439]
] (see Table 1). It is proposed that one reason for a degree of apprehension may be the ‘unknowable’- what really happens beyond death. These emotional factors experienced by nurses may influence how a nurse cares for a patient in the terminal stages of the patient’s life [8Brockopp DY, King DB, Hamilton JE. The dying patient: A comparative study of nurse caregiver characteristics Death Stud 1991; 15: 245-8.
[http://dx.doi.org/10.1080/07481189108252428] [PMID: 10111192]
].

Table 1

Some Definitions of Death Anxiety




This paper explores the literature on death anxiety and nurses’ attitudes to answer the question: Does fear of death impact on nurses’ caring for patients at the end of life and if so, what steps should be taken to improve the quality of care?

METHODS

Publications were sought using electronic databases in healthcare and global search engines Google and GoogleScholar. Few studies were identified using common healthcare databases- perhaps owing to the terms used in indexing. For example a search of Ovid Medline using key search terms was unproductive with regard to nursing studies. The search terms included death anxiety; attitude to death; anxiety or fear; hospice care, death; human; patient and stress- psychological.

The main sources were PubMed and the reference lists of identified studies. Studies conducted prior to 1990 were excluded in order to maintain the currency of data. The titles of papers and the abstracts were examined and where relevant the full papers were read to select articles for review. Owing to various designs, sampling methods, levels of evidence and outcomes the results are presented as a descriptive narrative report rather than in another format such as a meta-analysis.

Outcome of Search and Data Synthesis

Fifteen studies between 1990 and 2012 that explored nurses’ own attitudes towards death were included in the review. All were quantitative descriptive surveys of nurses, with three being repeated measure designs that evaluated nurses’ attitudes prior to and after an educational intervention. The included studies assessed general nurses [11Deffner JM, Bell SK. Nurses' death anxiety, comfort level during communication with patients and families regarding death, and exposure to communication education: a quantitative study J Nurses Staff Dev 2005; 21: 19-23.
[http://dx.doi.org/10.1097/00124645-200501000-00005] [PMID: 15731639]
-15Miyashita M, Nakai Y, Sasahara T. Nursing autonomy plays an important role in nurses' attitudes toward caring for dying patients Am J Hospice Palliat Med 2007; 24: 202-10.
[http://dx.doi.org/10.1177/1049909106298396] [PMID: 17601844]
], oncology nurses [4Braun M, Gordon D, Uziely B. Associations between oncology nurses' attitudes toward death and caring for dying patients Oncol Nurs Forum 2010; 37: E43-9.
[http://dx.doi.org/10.1188/10.ONF.E43-E49] [PMID: 20044331]
, 16Dunn KS, Otten C, Stephens E. Nursing experience and the care of dying patients Oncol Nurs Forum 2005; 32: 97-104.
[http://dx.doi.org/10.1188/05.ONF.97-104] [PMID: 15660148]
, 17Lange MB, Thom B, Kline NE. Assessing nurses' attitudes toward death and caring for dying patients in a comprehensive cancer center Oncol Nurs Forum 2008; 35: 955-.
[http://dx.doi.org/10.1188/08.ONF.955-959] [PMID: 18980927]
], emergency or critical care nurses [12Inci F. Effects of death education on nurses' death anxiety, depression regarding death, and attitudes towards the dying patient [not in English] Anadolu Psikiyatri Dergisi 2009; 10: 253-60., 18Beckstrand R, Smith MD, Heaston S, Bond AE. Emergency nurses' perceptions of size, frequency, and magnitude of obstacles and supportive behaviors in end-of-life care J Emerg Nurs 2008; 34: 290-300.
[http://dx.doi.org/10.1016/j.jen.2007.09.004] [PMID: 18640407]
], hospice or palliative care nurses [19Payne S, Dean S, Kalus C A. comparative study of death anxiety in hospice and emergency nurses J Adv Nurs 1998; 28: 700-6.
[http://dx.doi.org/10.1046/j.1365-2648.1998.00632.x] [PMID: 9829656]
, 20Santisteban-Etxeburu SI, Mier O. A descriptive study of death anxiety and stressors in the various practitioners of a palliative care unit [not in English] Unidad de Cuidados Paliativos 2006; 13: 18-24.], nephrology nurses [21Ho T, Barbero E, Hidalgo C, Camps C. Spanish nephrology nurses' views and attitudes towards caring for dying patients J Ren Care 2010; 36: 2-8.
[http://dx.doi.org/10.1111/j.1755-6686.2010.00141.x] [PMID: 20214702]
] and a study of multidisciplinary staff members including nurses [22Black K. Health care professionals' death attitudes, experiences, and advance directive communication behavior Death Stud 2007; 31: 563-72.]. In addition, one study of nursing students’ views [23Hutchison T, Sherman A. Didactic and experiential death and dying training: Impact upon death anxiety Death Stud 1992; 16: 317-0.] was included because it relates to antecedents of professional nurses’ views. The studies involve nurses from various continents and a broad range of countries: Canada, Iran, Israel, Japan, Spain, Turkey, UK, and USA. This suggests that evidence is now substantial across groups of registered nurses internationally.

Selection of Studies and Data Synthesis

All primary studies were included if they focused on death anxiety in the nursing profession. Data were synthesized in accordance with guidance from the Critical Skills Appraisal Programme for quantitative studies [24Waqqas s. Public Health Resource Unit Critical Appraisal Skills Programme: Making sense of evidence, 10 questions to help you make sense of reviews Available at: http://wwwcasp-uknet/wp-content/uploads/2011/11/CASP_Systematic_Review_Appraisal_Checklist_14oct10pdf [cited 2011 November 15] 2006.]. Study details were tabulated to report the design and instruments used, and to extract the results and study outcomes. Owing to variations in design and levels of evidence, no examination was made of the quality of the studies.

RESULTS

The reviewed studies and their outcomes are summarized in Table 2. The three major themes identified in the reviewed studies were: i). level of death anxiety; ii). death anxiety and attitudes towards caring for the dying, and iii). death education: necessary for emotional work.

Table 2

Summary of Death Anxiety Studies and their Outcomes




Level of Death Anxiety

The attitudinal components underlying fear of death have been examined using a number of valid assessment scales. The Death Attitude Profile-Revised (DAP-R) measures five subscales related to death anxiety. These were: Fear of death (7 items) includes fear of death and fear of the death of significant others; (ii) Neutral (or natural) acceptance (5 items) measuring the extent to which a person accepts the reality of death in a natural manner and neither fears it, nor welcomes it. (iii) Approach acceptance (10 items) is related to belief in an afterlife, and (iv) Escape acceptance (5 items) assesses the option of death as an alternative to a miserable life. Finally, Death avoidance (5 items) measures attempts to avoid thoughts about death as suggested by Wong, Reker, and Gesser in 1994 [10Wong TP, Reker GT, Gesser G, Neimeyer RA. Death Attitude Profile- Revised: A multidimensional measure of attitudes toward death Death Anxiety Handbook: Research, Instrumentation, and Application; Washington DC; Taylor & Francis: 2004; 00: 121-48.
[PMCID: PMC1904416]
]. The score for each sub-scale is the mean score of all its items. DAP-R had adequate validity and reliability according to Wong et al. and Braun et al. (2010) except for a low alpha for neutral acceptance recorded by Braun. The scale has accumulated a substantial body of reliability and validity data.

Payne et al. [19Payne S, Dean S, Kalus C A. comparative study of death anxiety in hospice and emergency nurses J Adv Nurs 1998; 28: 700-6.
[http://dx.doi.org/10.1046/j.1365-2648.1998.00632.x] [PMID: 9829656]
] used the DAP-R to assess the death anxiety of 60 hospice and emergency nurses and although limited differences were identified between groups, concluded that hospice nurses had lower death anxiety. Attitudes of 145 oncology nurses in Israel (all of whom frequently experienced patient deaths) revealed a moderate fear of death using the DAP-R [4Braun M, Gordon D, Uziely B. Associations between oncology nurses' attitudes toward death and caring for dying patients Oncol Nurs Forum 2010; 37: E43-9.
[http://dx.doi.org/10.1188/10.ONF.E43-E49] [PMID: 20044331]
]. Zyga et al. [25Zyga S, Malliarou M, Lavdaniti M. Greek renal nurses' attitudes towards death J Renal Care 2011; 37: 101-7.] examined 44 Greek renal nurses’ attitudes using DAP-R. They found nurses with specific palliative care education did not have a fear of death and had less difficulty talking about death and dying. Those in hospital palliative care or other teams had statistically significant different relationships with fear of death and neutral acceptance scores, with nursing experience and age the highest predictors of nurses' attitudes towards death [25Zyga S, Malliarou M, Lavdaniti M. Greek renal nurses' attitudes towards death J Renal Care 2011; 37: 101-7.]. Similarly, in a study of 355 inpatient and outpatient oncology nurses in USA, those with more work experience had more positive attitudes towards death [17Lange MB, Thom B, Kline NE. Assessing nurses' attitudes toward death and caring for dying patients in a comprehensive cancer center Oncol Nurs Forum 2008; 35: 955-.
[http://dx.doi.org/10.1188/08.ONF.955-959] [PMID: 18980927]
]. In addition to these reports, data from the comparative studies exploring death anxiety versus attitudes to patient caring (listed in Table 2) showed that almost always, the age of nurses (higher age) and length of work experience (longer time) were significantly positively related to less anxiety about death. Thus, as a corollary and as suggested in a number of the studies, there was a need for further education about death and dying for younger nurses to lessen their anxieties.

The Templer Death Anxiety Scale (DAS) is another self-report measure of death anxiety. The DAS consists of 15 true-false items measuring death anxiety at a conscious level. Thus scores range from 1 to 2 and the total score from 0 to 15, with higher scores indicating a greater degree of death anxiety. Santisteban-Etxeburu and Mier [20Santisteban-Etxeburu SI, Mier O. A descriptive study of death anxiety and stressors in the various practitioners of a palliative care unit [not in English] Unidad de Cuidados Paliativos 2006; 13: 18-24.] using the DAS, found that death anxiety level was moderately low (5.75; 38%) in a sample of 24 health professionals in a palliative care unit.

The use of various approaches to reporting the results in the studies and different assessment scales limits direct comparisons of death anxiety. However, results suggest that the level of death anxiety of nurses working in hospitals in general, oncology, renal and hospice care or in community services is not particularly high –generally at or below the 50th percentile on the scorecards. Nurses’ level of death anxiety appeared to be mediated by nurses’ older age and also length of nursing practice.

Death Anxiety and Attitudes Towards Caring for the Dying

Six studies of nurses’ death anxiety conducted comparative surveys about attitude to caring for dying patients [3Rooda LA, Clements R, Jordan ML. Nurses' attitudes toward death and caring for dying patients Oncol Nurs Forum 1999; 26: 1683-7.
[PMID: 10573685]
, 4Braun M, Gordon D, Uziely B. Associations between oncology nurses' attitudes toward death and caring for dying patients Oncol Nurs Forum 2010; 37: E43-9.
[http://dx.doi.org/10.1188/10.ONF.E43-E49] [PMID: 20044331]
, 13Iranmanesh SH, Dargahi H, Abbaszadeh A. Attitudes of Iranian nurses toward caring for dying patients Palliat Support Care 2008; 6: 363-9.
[http://dx.doi.org/10.1017/S1478951508000588] [PMID: 19006591]
, 14Matsui M, Braun K. Nurses' and care workers' attitudes toward death and caring for dying older adults in Japan Int J Palliat Nurs 2010; 16: 593-8.
[PMID: 21240103]
, 16Dunn KS, Otten C, Stephens E. Nursing experience and the care of dying patients Oncol Nurs Forum 2005; 32: 97-104.
[http://dx.doi.org/10.1188/05.ONF.97-104] [PMID: 15660148]
, 17Lange MB, Thom B, Kline NE. Assessing nurses' attitudes toward death and caring for dying patients in a comprehensive cancer center Oncol Nurs Forum 2008; 35: 955-.
[http://dx.doi.org/10.1188/08.ONF.955-959] [PMID: 18980927]
]. The Frommelt Attitude Towards Care of the Dying Scale (FATCOD) is a 30-item scale that measures nurses’ attitudes to caring for the dying and their families using an equal number of positive and negative items (Frommelt, 1991). Scores are based on a scale of 1-5 (maximum score 150). It has high reliability and validity according to Frommelt (1991) and had adequate reliability in a study of oncology nurses by Braun et al. in 2010 (Cronbach alpha: .89) [4Braun M, Gordon D, Uziely B. Associations between oncology nurses' attitudes toward death and caring for dying patients Oncol Nurs Forum 2010; 37: E43-9.
[http://dx.doi.org/10.1188/10.ONF.E43-E49] [PMID: 20044331]
].

In Israel, Braun [4Braun M, Gordon D, Uziely B. Associations between oncology nurses' attitudes toward death and caring for dying patients Oncol Nurs Forum 2010; 37: E43-9.
[http://dx.doi.org/10.1188/10.ONF.E43-E49] [PMID: 20044331]
] investigated the attitudes of 145 oncology nurses using the FATCOD and DAP-R scales. The nurses (all of whom frequently experienced patient deaths) had positive attitudes towards caring for the dying (FATCOD mean: 125.7)(84%), and their attitudes’ towards death were significantly associated with their attitudes to caring for dying patients. Similarly, in Iran [13Iranmanesh SH, Dargahi H, Abbaszadeh A. Attitudes of Iranian nurses toward caring for dying patients Palliat Support Care 2008; 6: 363-9.
[http://dx.doi.org/10.1017/S1478951508000588] [PMID: 19006591]
], attitudes of 114 hospital general and oncology nurses were found to be neutral to moderately positive toward giving care to the dying (mean FATCOD score 3.55/5; 71%). Although Fear of Death was negatively correlated (r -.199) with attitude toward caring for the dying, most nurses were likely to give care and emotional support to persons at the end of life, with religion a strong mediator. For example, ‘most nurses’ accepted death as a natural part of life and as a ‘gateway’ to the afterlife.

In Japan, Miyashita et al. [15Miyashita M, Nakai Y, Sasahara T. Nursing autonomy plays an important role in nurses' attitudes toward caring for dying patients Am J Hospice Palliat Med 2007; 24: 202-10.
[http://dx.doi.org/10.1177/1049909106298396] [PMID: 17601844]
] surveyed 178 hospital nurses (who had all cared for a terminal patient) using FATCOD- form B (Japanese version) and the Death Attitude Inventory (DAI). Nurses showed positive attitudes towards caring for the dying and had a mean score of 16/28 (57%) on the death anxiety subscale of DAI. Also in Japan, Matsui and Braun [14Matsui M, Braun K. Nurses' and care workers' attitudes toward death and caring for dying older adults in Japan Int J Palliat Nurs 2010; 16: 593-8.
[PMID: 21240103]
] surveyed 190 RNs and 177 care workers in convalescent homes and aged care homes and found the FATCOD score (mean 107; 71%) was negatively associated with fear of death and escape acceptance (i.e., those with better attitudes to end of life care had less fear of death and were less accepting of death as a means of escape) on the DAP Japanese version. Of note, care workers had less experience of death and dying than RNs in the sample.

Earlier, Rooda [3Rooda LA, Clements R, Jordan ML. Nurses' attitudes toward death and caring for dying patients Oncol Nurs Forum 1999; 26: 1683-7.
[PMID: 10573685]
] surveyed 403 hospital and community nurses in USA and found FATCOD scores (e.g., showing acceptance of death) were positively related to current contact with dying patients and with two DAP-R subscales (Approach Acceptance and Neutral Acceptance), and negatively correlated with two DAP-R subscales (Fear of Death and Death Avoidance). Also in USA, Dunn surveyed 58 oncology and medical-surgical nurses, finding that the nurses had positive attitudes towards caring for dying patients (FATCOD mean; 130.7/150: 87%), were not hesitant in developing relationships with dying patients and felt that educating and preparing patients for death were important. Of note, there was no difference in attitudes between oncology and other nurses. Deffner and Bell [11Deffner JM, Bell SK. Nurses' death anxiety, comfort level during communication with patients and families regarding death, and exposure to communication education: a quantitative study J Nurses Staff Dev 2005; 21: 19-23.
[http://dx.doi.org/10.1097/00124645-200501000-00005] [PMID: 15731639]
] also in USA investigated the comfort level (attitude) of 190 registered nurses about communicating with patients about death. They reported a statistically significant inverse relationship of comfort level of the nurse when communicating with patients and families regarding death (p = .000). They concluded that individuals who are generally more anxious about life (or death) events find it less comfortable to talk with patients and families about death than others who are less anxious.

In summary (and as shown in Table 2, column 5) most of the comparative studies identified significant associations between FATCOD and some of the subscales that measured death anxiety (whether these were negative or positive). Whilst all studies were based on convenience samples and all were self-reported surveys, the use of sufficiently large cohorts (most N= >100; range 28 to 403) and validated instruments leant weight to the reliability of the findings. Some evidence showed an inverse association between nurses’ attitude towards death and their attitude towards caring for dying patients, showing that nurses who were more anxious about death had a less positive attitude towards caring for the dying. This appears to be a complex relationship mediated by factors such as nurses’ age, length of nursing work experience, level of education in death and dying, their culture and also religion. Some factors noted to be absent were assessment of cross-cultural beliefs and the views of male nurses (who were under-represented in studies).

Death Education: Necessary for Emotional Work

Nursing is emotional work because nurses’ own emotions become involved when they experience feelings towards their patient [26Erickson R, Grove W. Why emotions matter: age, agitation, and burnout among registered nurses Online J Issues Nursing 2007; 13]. Furthermore, in addition to clinical nursing skills, end of life care involves skills in dealing with both the patient and a grieving family. It demands emotional maturity from nurses [27Peters L, McDermott F, O'Connor M, Lee S, Aranda S. Surviving and thriving: the nurse-patient relationship in palliative care. Palliative Care Nursing: A Guide to Practice [e-book] Melbourne: AusMed Publications 2011.]. Some nurses in this role use strategies to avoid discussing with patients their emotional issues or concerns, thus maintaining an emotional distance [28Skilbeck J, Payne S. Emotional support and the role of clinical nurse specialists in palliative care J Adv Nurs 2003; 43: 521-30.]. For example, Iranian nurses were likely to give nursing care and emotional support to dying patients, but were not likely to discuss death and would not tell patients the honest truth about their condition [13Iranmanesh SH, Dargahi H, Abbaszadeh A. Attitudes of Iranian nurses toward caring for dying patients Palliat Support Care 2008; 6: 363-9.
[http://dx.doi.org/10.1017/S1478951508000588] [PMID: 19006591]
]. The studies above showed this could be attributed to the nurses’ personal death anxiety as a limiting factor in their comportment or way in which they conducted care. Deffner and Bell [11Deffner JM, Bell SK. Nurses' death anxiety, comfort level during communication with patients and families regarding death, and exposure to communication education: a quantitative study J Nurses Staff Dev 2005; 21: 19-23.
[http://dx.doi.org/10.1097/00124645-200501000-00005] [PMID: 15731639]
] related this to emergency nurses’ level of ‘comfort’ in caring for the dying; when in discomfort, nurses may avoid such contact. For example, a nurse may request not to be allocated to care for a dying child, which was regarded as one of the most stressful situations nurses may have to cope with [29Fernández P. Anxiety of nursing staff in the face of death in critical care units and its relationship with the patients' age [not in English] Ansiedad del personal de enfermera 2011; 22: 96-103.]. These examples fit with the notion that anxiety caused by an anticipated threat to wellbeing initiates avoidance behavior as a technique that humans employ to reduce an impending threat [30Marks I. Fears, phobias and rituals: Panic, anxiety, and their disorders Oxford; Oxford University Press 1987.]. Escape (the ‘flight’ response) or avoidance (pre-flight response) allows individuals to distance themselves from the perceived threat [31Marks I, Nesse R. Fear and fitness: An evolutionary analysis of anxiety disorders Ethol Sociobiol 1994; 15: 247-61.]. Whether nurses are aware of it or not, these emotional factors may ultimately negatively influence a nurses’ clinical skills performance.

Reviewed studies advanced the idea that nurses should receive death and dying education based on evidence that younger nurses reported higher levels of anxiety about death and held more negative attitudes towards caring for the dying [17Lange MB, Thom B, Kline NE. Assessing nurses' attitudes toward death and caring for dying patients in a comprehensive cancer center Oncol Nurs Forum 2008; 35: 955-.
[http://dx.doi.org/10.1188/08.ONF.955-959] [PMID: 18980927]
, 25Zyga S, Malliarou M, Lavdaniti M. Greek renal nurses' attitudes towards death J Renal Care 2011; 37: 101-7.]. Three studies explored such teaching programs regarding death education [12Inci F. Effects of death education on nurses' death anxiety, depression regarding death, and attitudes towards the dying patient [not in English] Anadolu Psikiyatri Dergisi 2009; 10: 253-60., 14Matsui M, Braun K. Nurses' and care workers' attitudes toward death and caring for dying older adults in Japan Int J Palliat Nurs 2010; 16: 593-8.
[PMID: 21240103]
, 23Hutchison T, Sherman A. Didactic and experiential death and dying training: Impact upon death anxiety Death Stud 1992; 16: 317-0.].

In Turkey, Inci [12Inci F. Effects of death education on nurses' death anxiety, depression regarding death, and attitudes towards the dying patient [not in English] Anadolu Psikiyatri Dergisi 2009; 10: 253-60.] conducted repeated surveys prior to and after 90-minute teaching sessions for nurses over 7 weeks for staff of an oncology and children’s hospital. At the end of the education, death anxiety and death depression decreased significantly (p<0.05) according to DAS. However, it should be noted there was no impact of nurses’ age, years working or how they reported being affected.

In Japan, Matsui and Braun [14Matsui M, Braun K. Nurses' and care workers' attitudes toward death and caring for dying older adults in Japan Int J Palliat Nurs 2010; 16: 593-8.
[PMID: 21240103]
] applied multiple regression analysis to demonstrate that more positive attitudes of 190 RNs and 177 care workers in aged care homes were positively associated with seminar attendance on end of life care and negatively associated with fear of death. Similarly, renal nurses in Greece who had specific education on palliative care had less difficulty talking about death and dying and did not have a fear of death [25Zyga S, Malliarou M, Lavdaniti M. Greek renal nurses' attitudes towards death J Renal Care 2011; 37: 101-7.].

Nursing students are the registered nurses of the future and therefore their beliefs are informative. Hutchison and Sherman [23Hutchison T, Sherman A. Didactic and experiential death and dying training: Impact upon death anxiety Death Stud 1992; 16: 317-0.] showed that 83 North American nursing students’ fear of death was significantly less after participation in a 6-hour workshop on death and dying (DAS mean initial: 6.79, post: 5.82: P=<.05) with results that were maintained after 8 weeks. The above results indicate that education on death and dying has potential to remediate nursing student and RN fears about death. Such interventions may ultimately translate into better quality of nursing care for patients at the end of life.

DISSCUSSION

The care of dying patients presents ethical challenges for nurses, contradicting the medical mandate which is strongly focused on restoring patients to health [2Meliones J. Saving money, saving lives Harvard Business Rev 2000; 00: 5-10.]. In particular, the primary work of critical care, intensive care and emergency doctors and nurses is to rescue patients from medical crises. It is also complicated by the clinical environments in these areas that are designed to allow for intervention and observation, are rarely private for the patient or their family and are always in high demand. Thus, time for caring is limited. There is also a real conflict for nurses who have the competing demands of caring for a dying patient along with an acute or “rescuable” patient group. This conundrum was also a conflict for cancer nurses [32Leung D, Esplen MJ, Peter E. How haematological cancer nurses experience the threat of patients’ mortality J Adv Nurs 2012; 68: 2175-84.].

It was unsurprising, then, that some nurses facing the prospect of a patient dying felt anxious and were uncertain how to cope with the procedures that surround death. A number of studies reported inverse statistically significant correlations between staff attitudes to death and intention to discuss death and dying. Depending on a nurses’ orientation to fear of death, nurses who held higher anxiety scores on fear of death were less likely to have a positive attitude towards caring for a patient at the end of life. There was evidence that short courses in death education could reduce the death anxiety of registered nurses [14Matsui M, Braun K. Nurses' and care workers' attitudes toward death and caring for dying older adults in Japan Int J Palliat Nurs 2010; 16: 593-8.
[PMID: 21240103]
, 25Zyga S, Malliarou M, Lavdaniti M. Greek renal nurses' attitudes towards death J Renal Care 2011; 37: 101-7.] with likely subsequent improvement in nurses’ coping with death and dying. Hutchison and Shermans’ work [23Hutchison T, Sherman A. Didactic and experiential death and dying training: Impact upon death anxiety Death Stud 1992; 16: 317-0.] with student nurses also showed positive results after participation in a 6 hour workshop on death and dying. Thus, there are opportunities to improve education for nurses at both undergraduate level and post-registration, through continuing education. It would also be important to evaluate the depth of death education provided at undergraduate level. A planned system of mentoring for younger, inexperienced nurses in the workplace could provide further support for nurses.

The emotional work of nurses is especially important in forming a therapeutic relationship with a patient, but this carries the risk of stress and burnout [33McQueen A. Emotional intelligence in nursing work J Adv Nurs 2004; 47: 101-8.]. In end of life care, palliative and hospice nurses rated stress induced by the workplace environment and work pressures more highly than experiences of frequent deaths [34Peters L, Cant R, Sellick K. Is work stress in palliative care nurses a cause for concern? - A review of literature Int J Pall Nurs 2012; 11: 561-7.]. In this field nurses also need to deal with the expectation that the nurse-patient relationship is about to be severed [27Peters L, McDermott F, O'Connor M, Lee S, Aranda S. Surviving and thriving: the nurse-patient relationship in palliative care. Palliative Care Nursing: A Guide to Practice [e-book] Melbourne: AusMed Publications 2011.]. Nurses in Spain viewed caring for patients at the end of life as emotionally demanding work [21Ho T, Barbero E, Hidalgo C, Camps C. Spanish nephrology nurses' views and attitudes towards caring for dying patients J Ren Care 2010; 36: 2-8.
[http://dx.doi.org/10.1111/j.1755-6686.2010.00141.x] [PMID: 20214702]
]. Given any nurses’ strong beliefs and attitudes to dying, nurses may have developed negative attitudes towards caring and might apply protective coping mechanisms by distancing themselves from death or practising death avoidance behaviors. However, an additional study of intensive care nurses showed positive attitudes towards caring for the dying characterized as ‘doing one’s utmost’ to provide dignified end of life care, the main relationships being with the patient’s relatives [35Fridh I, Forsberg A, Bergbom I. Doing one's utmost: Nurses' descriptions of caring for dying patients in an intensive care environment Intensive Crit Care Nurs 2009; 25: 233-41.]. McClement [36McClement SE, Degner LF. Expert nursing behaviors in care of the dying adult in the intensive care unit Heart Lung 1995; 24: 408-19.] when reporting on experienced intensive care nurses described the care of the dying as enhancing nurses’ personal growth.

That younger nurses in the reviewed studies consistently reported stronger fear of death and more negative attitudes towards caring at end of life in the current review concurred with the findings of other studies [7Gomez J, Hidalgo MD, Tomas-Sabado J. Using polytomous item response models to assess death anxiety Nurs Res 2007; 56: 89-96.
[http://dx.doi.org/10.1097/01.NNR.0000263966.24125.92] [PMID: 17356439]
, 37Cabrera MM, Gutiérrez MZ, Escobar JMM. Professional nurse attitudes towards the death of patients [not in English] Ciencia y Enfermeria 2009; 15: 39-48.]. Younger nurses may not be experienced nurses and may not be well skilled in dealing with emotional work [26Erickson R, Grove W. Why emotions matter: age, agitation, and burnout among registered nurses Online J Issues Nursing 2007; 13]. Erikson and Grove [26Erickson R, Grove W. Why emotions matter: age, agitation, and burnout among registered nurses Online J Issues Nursing 2007; 13] described why nurses’ emotions matter and constructed how this is manifested:

‘When emotion management is part of what it takes to perform a job effectively (as it is in nursing), the task is referred to as “emotional labor”. Nurses may use ‘surface acting’ or ‘deep acting’ to manage emotion. ‘For example, nurses may manage their emotions in interactions with others by covering up (surface acting), pretending to have unfelt emotions (surface acting), and making an effort to actually feel emotions that were expected at work (deep acting). Successfully suppressing and evoking emotions can be experienced as stressful.’ (p: conclusion)

These authors reported a study of stress in 829 urban acute care nurses’ in USA using valid assessment scales [26Erickson R, Grove W. Why emotions matter: age, agitation, and burnout among registered nurses Online J Issues Nursing 2007; 13]. Nurses <30 years of age were significantly more likely to experience higher rates of intense feelings of frustration, anger and irritation (agitation) than those over 30. Nurses aged <30 reported a mean level of agitation of 11.22 compared to a mean of 8.80 for nurses over 30 (t= -4.16, df= 827, p< .001). No significant differences were found between the age groups for positive emotional experiences (such as happiness or pride), although these were experienced by all nurses. Stressful environments and the experience of unpredictable circumstances were among the antecedents of death anxiety according to Lehto [1Lehto R, Stein KF. Death anxiety: an analysis of an evolving concept Res Theory Nurs Pract 2009; 23: 23-41.
[http://dx.doi.org/10.1891/1541-6577.23.1.23] [PMID: 19418886]
]. Overall, these results suggest that younger nurses are more at risk of negative attitudes to end of life care.

In line with previous research [5Depaola SJ, Griffin M, Young JR, Neimeyer RA. Death anxiety and attitudes toward the elderly among older adults: the role of gender and ethnicity Death Stud 2003; 27: 335-54.
[http://dx.doi.org/10.1080/07481180302904] [PMID: 12749378]
] both cultural background and the depth of a nurses’ belief in a higher being (a God) appeared to influence beliefs about death and dying. There were differences in fear of death attitude scores between nurses in western countries such as USA and Middle Eastern or Asian studies, with nurses in USA and in Israel reporting low anxiety on fear of death and higher attitude towards caring for the dying (87% and 84% positive scores on FATCOD respectively). This was in contrast to nurses in Japan whose mean score was 57%. Nurses in Turkey and in Iran rated their attitudes in between these scores. Nurses with high scores on intention to care for dying patients in Israel were mostly of the Jewish religion, with religiosity perhaps impacting on their approach to caring for the dying should they believe in a higher order being. Supporting this were findings from Iran where most nurses were positive about caring for the dying (FATCOD mean 71%) and showed commitment to religious beliefs, with 80% reporting daily prayer and 82% reported they always experienced God in their daily life [13Iranmanesh SH, Dargahi H, Abbaszadeh A. Attitudes of Iranian nurses toward caring for dying patients Palliat Support Care 2008; 6: 363-9.
[http://dx.doi.org/10.1017/S1478951508000588] [PMID: 19006591]
]. Those who viewed death as a gateway to the afterlife or who viewed death as a ‘natural part of life’ had higher scores on caring. The authors stated that Iranians were very familiar with death owing to recent war and natural disasters in that country. The above results suggest particular cultural environments and religiosity influence nurses’ attitudes to death, such that each nursing culture needs to be understood independently. Irish [38Irish D, Irish D, Lundquist KF, Jenkins- Nelson V. Ethnic variations in dying death and grief Diversity in universality: Philadelphia: Taylor & Francis 1993.] described the differences between ethnic cultures owing to the various meanings given to death and perceptions of death and mourning, such that within their therapeutic relationship nurses should be aware of their patients’ culture and when death is said to occur.

Some limitations to this review are recognized. Attitudes to death are complex human phenomena and not all the factors that influence these beliefs may be captured by the measurement instruments that were used. As the DAP-R measure was developed in USA, it might not function well cross-culturally. Further, self- reports such as in these studies have potential for bias: social desirability was a possible confounder, as suggested by Martin [39Martin T. Death anxiety and social desirability among nurses Omega 1982; 13: 51-8.] saying that for hospital nurses, the admission of anxiety concerning death is more socially acceptable than denial. The studies were quasi-experimental with non-random samples and most comprised >80% of females. The larger cohorts were likely to be adequately powered to detect differences between groups. However the current review identifies further issues and raises important questions that should be answered about nurses’ skill levels.

CONCLUSION

Nursing care of the dying is a particularly demanding role that requires nursing skill and also necessitates nurses to have insight into their personal beliefs about death and dying. Nurses who had a more positive attitude towards death were more likely to have a positive attitude towards providing end of life care for patients. Nurses need to consider their own race and spiritual beliefs (as well as those of the dying patient) because these may affect their objectivity in caring for a patient and the end of their life. Regardless of the cultural settings in which nurses work (or their continent) younger nurses under age 30, with less ability to cope with negative attitudes and the demands of emotional work would benefit from death education in the workplace.

CONFLICT OF INTEREST

The authors confirm that this article content has no conflicts of interest.

ACKNOWLEDGEMENT

Declared none.

REFERENCES

[1] Lehto R, Stein KF. Death anxiety: an analysis of an evolving concept Res Theory Nurs Pract 2009; 23: 23-41.
[http://dx.doi.org/10.1891/1541-6577.23.1.23] [PMID: 19418886]
[2] Meliones J. Saving money, saving lives Harvard Business Rev 2000; 00: 5-10.
[3] Rooda LA, Clements R, Jordan ML. Nurses' attitudes toward death and caring for dying patients Oncol Nurs Forum 1999; 26: 1683-7.
[PMID: 10573685]
[4] Braun M, Gordon D, Uziely B. Associations between oncology nurses' attitudes toward death and caring for dying patients Oncol Nurs Forum 2010; 37: E43-9.
[http://dx.doi.org/10.1188/10.ONF.E43-E49] [PMID: 20044331]
[5] Depaola SJ, Griffin M, Young JR, Neimeyer RA. Death anxiety and attitudes toward the elderly among older adults: the role of gender and ethnicity Death Stud 2003; 27: 335-54.
[http://dx.doi.org/10.1080/07481180302904] [PMID: 12749378]
[6] Tomer A, Eliason G. Toward a comprehensive model of death anxiety Death Stud 1996; 20: 343-65.
[http://dx.doi.org/10.1080/07481189608252787] [PMID: 10160570]
[7] Gomez J, Hidalgo MD, Tomas-Sabado J. Using polytomous item response models to assess death anxiety Nurs Res 2007; 56: 89-96.
[http://dx.doi.org/10.1097/01.NNR.0000263966.24125.92] [PMID: 17356439]
[8] Brockopp DY, King DB, Hamilton JE. The dying patient: A comparative study of nurse caregiver characteristics Death Stud 1991; 15: 245-8.
[http://dx.doi.org/10.1080/07481189108252428] [PMID: 10111192]
[9] Farley G. Death anxiety. National Health Service UK. Available at: www.palliativecare.bradford.nhs.uk/.../ ... [[cited 2012 May 15]];
[10] Wong TP, Reker GT, Gesser G, Neimeyer RA. Death Attitude Profile- Revised: A multidimensional measure of attitudes toward death Death Anxiety Handbook: Research, Instrumentation, and Application; Washington DC; Taylor & Francis: 2004; 00: 121-48.
[PMCID: PMC1904416]
[11] Deffner JM, Bell SK. Nurses' death anxiety, comfort level during communication with patients and families regarding death, and exposure to communication education: a quantitative study J Nurses Staff Dev 2005; 21: 19-23.
[http://dx.doi.org/10.1097/00124645-200501000-00005] [PMID: 15731639]
[12] Inci F. Effects of death education on nurses' death anxiety, depression regarding death, and attitudes towards the dying patient [not in English] Anadolu Psikiyatri Dergisi 2009; 10: 253-60.
[13] Iranmanesh SH, Dargahi H, Abbaszadeh A. Attitudes of Iranian nurses toward caring for dying patients Palliat Support Care 2008; 6: 363-9.
[http://dx.doi.org/10.1017/S1478951508000588] [PMID: 19006591]
[14] Matsui M, Braun K. Nurses' and care workers' attitudes toward death and caring for dying older adults in Japan Int J Palliat Nurs 2010; 16: 593-8.
[PMID: 21240103]
[15] Miyashita M, Nakai Y, Sasahara T. Nursing autonomy plays an important role in nurses' attitudes toward caring for dying patients Am J Hospice Palliat Med 2007; 24: 202-10.
[http://dx.doi.org/10.1177/1049909106298396] [PMID: 17601844]
[16] Dunn KS, Otten C, Stephens E. Nursing experience and the care of dying patients Oncol Nurs Forum 2005; 32: 97-104.
[http://dx.doi.org/10.1188/05.ONF.97-104] [PMID: 15660148]
[17] Lange MB, Thom B, Kline NE. Assessing nurses' attitudes toward death and caring for dying patients in a comprehensive cancer center Oncol Nurs Forum 2008; 35: 955-.
[http://dx.doi.org/10.1188/08.ONF.955-959] [PMID: 18980927]
[18] Beckstrand R, Smith MD, Heaston S, Bond AE. Emergency nurses' perceptions of size, frequency, and magnitude of obstacles and supportive behaviors in end-of-life care J Emerg Nurs 2008; 34: 290-300.
[http://dx.doi.org/10.1016/j.jen.2007.09.004] [PMID: 18640407]
[19] Payne S, Dean S, Kalus C A. comparative study of death anxiety in hospice and emergency nurses J Adv Nurs 1998; 28: 700-6.
[http://dx.doi.org/10.1046/j.1365-2648.1998.00632.x] [PMID: 9829656]
[20] Santisteban-Etxeburu SI, Mier O. A descriptive study of death anxiety and stressors in the various practitioners of a palliative care unit [not in English] Unidad de Cuidados Paliativos 2006; 13: 18-24.
[21] Ho T, Barbero E, Hidalgo C, Camps C. Spanish nephrology nurses' views and attitudes towards caring for dying patients J Ren Care 2010; 36: 2-8.
[http://dx.doi.org/10.1111/j.1755-6686.2010.00141.x] [PMID: 20214702]
[22] Black K. Health care professionals' death attitudes, experiences, and advance directive communication behavior Death Stud 2007; 31: 563-72.
[23] Hutchison T, Sherman A. Didactic and experiential death and dying training: Impact upon death anxiety Death Stud 1992; 16: 317-0.
[24] Waqqas s. Public Health Resource Unit Critical Appraisal Skills Programme: Making sense of evidence, 10 questions to help you make sense of reviews Available at: http://wwwcasp-uknet/wp-content/uploads/2011/11/CASP_Systematic_Review_Appraisal_Checklist_14oct10pdf [cited 2011 November 15] 2006.
[25] Zyga S, Malliarou M, Lavdaniti M. Greek renal nurses' attitudes towards death J Renal Care 2011; 37: 101-7.
[26] Erickson R, Grove W. Why emotions matter: age, agitation, and burnout among registered nurses Online J Issues Nursing 2007; 13
[27] Peters L, McDermott F, O'Connor M, Lee S, Aranda S. Surviving and thriving: the nurse-patient relationship in palliative care. Palliative Care Nursing: A Guide to Practice [e-book] Melbourne: AusMed Publications 2011.
[28] Skilbeck J, Payne S. Emotional support and the role of clinical nurse specialists in palliative care J Adv Nurs 2003; 43: 521-30.
[29] Fernández P. Anxiety of nursing staff in the face of death in critical care units and its relationship with the patients' age [not in English] Ansiedad del personal de enfermera 2011; 22: 96-103.
[30] Marks I. Fears, phobias and rituals: Panic, anxiety, and their disorders Oxford; Oxford University Press 1987.
[31] Marks I, Nesse R. Fear and fitness: An evolutionary analysis of anxiety disorders Ethol Sociobiol 1994; 15: 247-61.
[32] Leung D, Esplen MJ, Peter E. How haematological cancer nurses experience the threat of patients’ mortality J Adv Nurs 2012; 68: 2175-84.
[33] McQueen A. Emotional intelligence in nursing work J Adv Nurs 2004; 47: 101-8.
[34] Peters L, Cant R, Sellick K. Is work stress in palliative care nurses a cause for concern? - A review of literature Int J Pall Nurs 2012; 11: 561-7.
[35] Fridh I, Forsberg A, Bergbom I. Doing one's utmost: Nurses' descriptions of caring for dying patients in an intensive care environment Intensive Crit Care Nurs 2009; 25: 233-41.
[36] McClement SE, Degner LF. Expert nursing behaviors in care of the dying adult in the intensive care unit Heart Lung 1995; 24: 408-19.
[37] Cabrera MM, Gutiérrez MZ, Escobar JMM. Professional nurse attitudes towards the death of patients [not in English] Ciencia y Enfermeria 2009; 15: 39-48.
[38] Irish D, Irish D, Lundquist KF, Jenkins- Nelson V. Ethnic variations in dying death and grief Diversity in universality: Philadelphia: Taylor & Francis 1993.
[39] Martin T. Death anxiety and social desirability among nurses Omega 1982; 13: 51-8.

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