Nurses are exposed to dying patients in the course of their clinical work, and the personal attitudes of nurses about death and dying will probably affect the quality of care that they provide during the terminal stages of a patient's life. There are different reasons to fear of death, and the aim of the present study was to examine the reasons why Iranian nurses fear death and to compare these reasons with those of other women. The subjects were 112 women (56 nurses and 56 comparison women). Nurses were selected from a general hospital, and the control group was matched for age, education, marital status, employment status and years of work experience. On the Reasons for Death Fear Scale (RDFS), the nurses had significantly higher scores than the control group on only two items: grieving over what they would leave behind (wealth, valuables, etc.) and over the loss of self or identity. Since nurses experience emotional issues related to death, they need skills to manage their fear of death, and death education program in the workplace might reduce their fear of death. The generalizability of the present results to male nurses and other health professionals merits further investigation.
Keywords: Fear of death, Nurses, Women, Iran
Death is a common phenomenon, and it can be conscious and unconscious (Lester, Templer, & Abdel-Khalek, 2007). Nurses facing the dying patients. and death in their patients every day, and the care of dying patients, giving comfort and solace to the patients' family, whether in the case of sudden death or during a long incurable illness, are difficult experiences for nurses. Nurses who have fear about death may be less comfortable providing nursing care for dying patients. The fear of death can influence their communication with and quality of care delivery for dying patients and can also affect their own mental health. The death of their patients has an impact on nurses. This can affect them both in their work environment and outside of work (Masoudzadeh, Setareh, Mohammadpour Tahamtan, et al, 2008, Bagherian, Iranmanesh, Dargahi, et al, 2010, Wilson & Kirshbaum, 2011).
2. Literature review
Peters, Cant, Payne, et al (2013) reported that younger nurses reported more fear of death and more negative attitudes to end-of-life patient care. Chen, Del Ben, Fortson, et al (2006) reported that nursing students who had experienced the death of other people reported significantly more fear of the dying process than nursing students who had not. Both experienced and inexperienced nursing students had more fear of the unknown than controls. Findings of Iranmanesh, S??venstedt and Abbaszadeh (2008) showed that nursing students from Bam city who had more experience of the death of others were less fear of death but also less likely to provide care to people at the end of life. Iranian nursing students have been found to be more afraid of death and less likely to give care to dying persons than Swedish nursing students (Iranmanesh, Axelsson, H??ggstr??m, et al., 2010).
Aghajani, Valiee and Tol (2010) found that death anxiety was higher in critical care nurses, and these nurses cared for more dying patients than nurses in the general wards. Naderi, Bakhtiar Pour and Shokohi (2010) reported that nurses in differed significantly in death anxiety depending on the type of ward in which they worked. However, greater work experience in nurses resulted in more positive attitudes toward death and caring for dying patients (Lange, Thom & Kline, 2008). Ayyad (2013) found that nurses dealing with critical cases and working in higher stress wards, such as intensive care units, obtained higher mean scores on the RDFS than nurses who working in lower stress wards such as internal medicine. There are also cultural differences. For example, Turkish nurses are found to have more negative attitudes toward death and the caring of dying patients than nurses in other cultures (Cevik & Kav, 2013).
Lehto and Stien (2009) identified defining attributes, antecedents, and consequences of the concept of fear of death in nurses. Defining attributes were emotional, cognitive, experiential, developmental, cultural variables and source of motivation. Antecedents included stressful environments, the experience of unpredictable circumstances, the diagnosis of a life-threatening illness or the experience of a life-threatening event, and experiences with dying patients. Consequences were adaptive and maladaptive reactions. Hinderer (2012) explored critical care experiences of nurses with death of patient are in four themes of coping, personal distress, emotional disconnect, and inevitable death. Karimi Moneghy, Zubin, Yavari, et al. (2013) found five themes in nurses' experience of dealing with dying patients: mental erosion, maladaptive interpersonal interactions, stress from caring for the patients, feelings of sadness, and normalization. This research revealed that nurses can experience serious problems when dealing with dying patients.
Campbell (2013) listed many reasons for fearing death including: the unknown, loneliness, anxiety about tolerating the death experience, loss of family and friends, losing self-control of bodily functions, suffering and pain, unbearable grief, a non-existent or a terrible afterlife, and a failure to achieve one's goals in life. Religious individuals may fear death more because they are afraid of the afterlife and the judgment that will be made about the way they lived their life. Beshai and Lester (2013) found that scores on a scale to measure the belief in a Day of Judgment were associated with scores on a traditional religiosity scale, but not with fears of death and dying. Abdel-Khalek (2002) studied reasons for fearing death in Kuwaiti college students. Women obtained higher scores for three items of the Reasons for Death Fear Scale (RDFS) including fear of hell and doomsday, fear of the vague and unknown issues, and the torture of the grave.
Zargham Boroujeni, Mohammadi, and Haghdoost Oskouie (2007) suggested that one of the most important ideas that will help nurses to deal with death better is a belief in life after death. Being religious helped nurses cope with their dying patients, and religion also brought relief to dying patients and their families. The nurses noted that employment in the nursing field had increased the importance of religion to them and lessened their fear of death.
Until now, there has been no study about the reasons for death anxiety in Iran, and this is the first one. In the present study, it is predicted that there will be significant differences between nurses and other working women on the RDFS.
2. Materials and Methods
The participants were 112 Iranian, Muslim women (56 nurses, 56 non-nurses). The nurses more often had a BA degree or a higher degree (93% vs. 52%) and were a little older (25% vs. 18% were aged 20-49), but the groups did not differ in being married (68% vs. 72%, respectively) or more than 10 years of work experience (18% vs. 14%).
2.2. Research design
The research design was a cross-sectional study of two groups of subjects.
The women were administered a demographic information sheet and the Reasons for Death Fear Scale (RDFS).The demographic information sheet asked for age, education, marital status, employment status and years of employment.
The RDFS, developed by Abdel-Khalek (2002), consists of 18 brief items, and Abdel-Khalek identified four factors: (i) fear of pain and punishment, (ii) fear of losing worldly involvements, (iii) religious transgressions and failures, and (iv) parting from loved ones. The response for the RDFS items uses the following format: strongly disagree (1), disagree (2), neutral (3), agree (4) and strongly agree (5). Total scores can range from 18 to 90. Abdel-Khalek reported good reliability coefficients (> 0.80), and concurrent validity with Templer's Death Anxiety Scale.
In the present sample, internal consistency coefficient by Cronbach's Alpha was 0.92, the two-week test-retest reliability was 0.64, concurrent and divergent validity were good with Collett-Lester Fear of Death Scale (CLFDS), Templer's Death Anxiety Scale, Death Concern Scale (DCS), Death Obsession Scale (DOS) and Death Depression Scale (DDS) for the nurses (Dadfar, Lester, & Abdel-Khalek, 2014).
The nurses were selected from nineteen different wards: Internal Medicine, Intensive Care Unit, Medical Intensive Care Unit, Surgery Intensive Care Unit, Coronary Care Unit, Post-Coronary Care Unit, Nephrology, Dialysis Unit, Surgery, Pain, Orthopedics, Dermatology, Hematology, Oncology, Neurology, Psychiatry, Obstetrics and Gynecology, Children, and VIP wards of Rasoul General Hospital which is affiliated with the Iran University of Medical Sciences in Tehran City. Simple random sampling was used. The comparison women were selected from the staff of the Iran University of Medical Sciences matched with the nurses for demographic variables: age, education, marital status, employment status and years of employment. The women gave informed consent after hearing the purposes of the study. Data were analyzed via independent T tests.
There were no significant differences between nurses and comparison women for demographic variables. Table 1 shows significant difference between two groups for the items of the RDFS. The two groups did not differ in their total score on the RDFS (59.0 vs. 57.2 for the nurses and comparison group, respectively). The nurses had significantly higher scores on only two items of the RDFS, items 16 and 17. The nurses expressed more concern over grieving over what they would leave behind (wealth, valuables, etc.) and over the loss of self or identity.
Table 1- Means, standard deviation and t-tests for the items and total score on the RDFS for nurses (n = 56) and comparison women (n = 56)
Reasons for fearing death Nurses
M SD Non nurses
M SD T
df = 110 p
1. Fear of heavenly punishment 3.37 1.39 3.36 1.35 .69 -
2. Worry about one's offspring 3.89 1.13 3.53 1.13 1.37 -
3. Too many sins 3.28 1.20 3.00 1.27 1.21 -
4. Life teems with meaningful things 3.00 1.22 3.03 1.06 -1.65 -
5. Parting from the relatives and beloved 3.78 1.47 3.64 1.66 .58 -
6. Leaving behind secular pleasures 2.48 1.23 2.51 1.19 - .15 -
7. Fear of hell and doomsday 3.58 1.31 3.35 1.31 .93 -
8. The terribly strenuous moment when the soul parts from the body 3.51 1.38 3.48 1.25 .43 -
9. Failure to perform religious duties and obligations 3.39 1.27 3.39 1.05 .000 -
10. Death entails so many vague and unknown issues 3.41 1.21 3.57 .93 - .78 -
11. The element of surprise in death 3.42 1.18 3.30 1.07 .58 -
12. Lack of faith 2.85 1.34 2.94 1.13 - .38 -
13. The grieving of loved ones 3.58 1.20 3.35 1.16 1.03 -
14. Torture of the grave 3.80 1.32 3.87 1.04 .55 -
15. Acute pains associated with dying 3.48 1.42 3.58 1.02 - .45 -
16. Grieving over what one will leave behind, e.g. wealth, valuables, etc. 2.41 1.29 1.94 .942 2.17 .003
17. Loss of self or identity 2.87 1.29 2.37 1.16 2.14 .003
18. Death puts an end to one's plans and objectives 2.94 1.35 2.89 1.15 .22 -
Total score 58.99 15.30 57.23 10.87 .69 -
The results of present study indicated, although nurses did not have a higher fear of death than other working women, nurses had higher scores on two items of the RFDS: (i) grieving over what one will leave behind, e.g. wealth, valuables, and (ii) loss of self or identity. It may be that the nursing profession provides an intellectual defense against death anxiety and, therefore, reduces their conscious death anxiety. It would be of interest in future research to explore less conscious reactions to death, such as using subliminal stimuli.
Fear of death and anxiety surrounding death and dying may develop early in the training of nurses (Chen, et al., 2006), and nurses need to be aware of their own attitudes about the phenomenon of death (Peters, et al., 2013). Nurses require special attention for their death anxiety, and there is a need to provide institutional support to assist them in providing quality care for their dying patients (Aghajani, et al., 2010). Nurses also need support from their families. Ignoring the needs of nurses can have adverse effects on their patients (Karimi Moneghy et al., 2013).
Research indicates nursing students feel unprepared and unable to care for the dying patients at the end of their training. Studies on attitudes of nursing to caring for dying patients play a main role in education of nursing (Leombruni, Miniotti, Bovero, et al, 2014). Nurses should attain a balance in caring for patients who are dying. It is a major challenge both in interactions of nurses with patients, families of them, and perceptions of nurses of themselves and their efforts in end-of-life care for patients (Zargham Boroujeni, et al, 2009). When nurses want to cope with the death of a patient, they use from such resources: communication with patients, their families and coworkers (Peterson, Johnson, Halvorsen, et al , 2010).
Grief education and support of others are useful for nursing staff. These actions can help to develop of strategies in nursing staff as they able to cope with death and dying of patients (Wilson, & Kirshbaum, 2011). Critical care reactions of nurses to patient death and dying should understand. This understanding can help to promote both care provided to critically ill dying patients, families of them and to consider of needs of nurses (Hinderer, 2012, Chan, 2014).
Nurses, addition to their critical role in the health care, have the most of deal with the health as well as death, so health care managers can use the results of this study for mental health issues. Faced with emotional issues related to death and dying, nurses (and other health care professionals) need skills and experience to control their death anxiety. They should receive education about death and dying in their work setting in order to improve the quality of their care for very ill and dying patients. It is important to note that the findings of this study are based only on Iranian and Muslim female nurses. The results need to be generalized to other cultures before reliable conclusions can be drawn.
This paper is based on a doctoral thesis in clinical psychology by the senior author. The researchers have no conflicts of interest, and the research was not funded. We thank all of subjects who participated in the study.
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