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

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.

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14 The Open Nursing Journal, 2013, 7, 14-21
1874-4346/13 2013 Bentham Open
Open Access
How Death Anxiety Impacts Nurses’ Caring for Patients at the End of
Life: A Review of Literature
L. Peters
1
, R. Cant
*,1
, S. Payne
2
, M. O’Connor
1
, F. McDermott
1
, K. Hood
1
, J. Morphet
1
and
K. Shimoinaba
1
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.
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 [1]. 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 [1],
with societal preference strongly advocating the preservation
of life in many fields, such as in medicine [2]. 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
[3]. These attitudes are attached to human emotions, which
*Address correspondence to this author at the Monash University 100 Clyde
Rd Berwick, VIC Aust 3806, Australia; Tel: +61 3 99047159; E-mail:
Robyn.Cant@monash.edu
are in turn attached to actions taken towards the object of the
emotions [4] 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
[5]. 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’ [6]
accompanied by feelings of fear or dread [7] (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 [8].
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.

Nurses’ Death Anxiety The Open Nursing Journal, 2013, Volume 7 15
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
[11-15], oncology nurses [4, 16, 17], emergency or critical
care nurses [12, 18], hospice or palliative care nurses [19,
20], nephrology nurses [21] and a study of multidisciplinary
staff members including nurses [22]. In addition, one study
of nursing students’ views [23] 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 [24]. 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.
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 [10]. 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. [19] 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 [4]. Zyga et al. [25] 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 [25]. Similarly, in a study of
355 inpatient and outpatient oncology nurses in USA, those
with more work experience had more positive attitudes towards
death [17]. 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 [20] 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
50
th
percentile on the scorecards. Nurses’ level of death
anxiety appeared to be mediated by nurses’ older age and
also length of nursing practice.
Table 1. Some Definitions of Death Anxiety
Death anxiety (Tomer 1996) [6] A negative emotional reaction provoked by the anticipation of a state in which the self does not exist.
Death anxiety (Farley 2010) [9] A feeling of dread, apprehension or solicitude (anxiety) when one thinks of the process of dying, or ceasing to ‘be’.
Fear of death (Wong et al., 1994) [10].
Specific and conscious thoughts against death.

16 The Open Nursing Journal, 2013, Volume 7 Peters et al.
Table 2. Summary of Death Anxiety Studies and their Outcomes
Author/Setting/
Nursing Discipline
Design/Sample &
Instruments
Findings Outcomes Effect/Correlations
Black (2007) [22]
Healthcare
Professionals
including nurses in
New York state,
USA
Cross-sectional survey
(N=135) (nurses, doctors
social workers): who
managed older patients- using
Death Attitude Profile-
Revised (DAP–R).
Age correlated positively with
fear of death, (p= .004),
avoidance of death (p= .007);
negatively with neutral
acceptance of death (p =.001),
escape acceptance of death
(p=.034). Negative correlations
were found between
collaborating with other
professionals regarding
directives and fear of death,
avoidance of death, and escape
acceptance of death.
Death anxiety was a predictor of
professionals’ communication
with others about advance
directives. Experts in end-of-life
care recommend probing the
relationship between healthcare
provider communication
behavior and personal death
attitudes.
Significant inverse
relationship between 2
attitude subscales
‘Avoidance’ and
‘Escape’ and caring for
dying.
Braun 2010 [4]
Oncology nurses in
Israel
Survey of nurses (N=147)
using Frommelt Attitude
Toward Care of the Dying
Scale (FATCOD), Death
Attitude Profile - Revised
(DAP-R)
Nurses had moderate levels of
fear of death (x
2
=4.11), death
avoidance (x
2
=2.93), approach
acceptance (x
2
=3.53), & escape
acceptance (x
2
=3.6), with
correlation of Fear of death with
Death avoidance & Approach
acceptance. Approach
acceptance was correlated with
Death avoidance & Escape
acceptance. Mean FATCOD:
125.7.
Nurses’ personal attitudes
towards death were associated
with their attitudes to caring for
dying patients, with most
demonstrating positive attitudes.
A mediating role was found for
death avoidance, suggesting
some may use avoidance to cope
with fear of death. Culture and
religion may be key to attitudes
(most were Jewish).
Significant positive
relationship between 4
subscales.
Deffner 2005 [11]
Registered nurses in
USA
Correlation study- Cross
sectional survey (N= 190)
using Death Anxiety Scale
Regression analysis showed
death anxiety level was
significantly inversely related to
comfort level of nurse when
communicating with patients/
families regarding death (p =
.000). Age, education, years of
nursing, exposure to
communication education for
dealing with death showed
negative Gamma values or R,
indicating that discomfort
decreases as age, education,
experience, current nursing
employment, work in other
areas, and exposure to
communication education
increase.
Comfort level of the nurse during
communication with patients and
families is adversely affected by
an increase in the nurse's own
death anxiety, and positively
affected by exposure to
communication education.
Importantly, nurses should
identify their
level of death anxiety/be exposed
to education on communicating
with patients/families regarding
death.
Significant inverse
relationship: comfort
and attitude to death.
Dunn 2005 [16]
Oncology and med-
surg registered
nurses in USA
Cross-sectional survey
(N=58) using Fromelt
Attitudes Towards Care of the
Dying (FATCOD) and Death
Attitude Profile- Revised
(DAP-R) scale
Nurses who reported spending
more time with dying patients
had more positive attitudes. No
significant association was
found between nurses’ attitude
towards death and attitude to
caring for dying patients.
Nurses were positive about
caring for the dying; there was no
effect of death anxiety on attitude
towards caring for dying patients;
some subscales were associated
with demographic variables &
scales.
Education programs on
death and dying are
recommended.
Non-significant
relationship death
anxiety and caring for
dying.
Ho et al. 2012 [21]
Renal registered
nurses in Spain
Cross sectional survey
(N=202) using Frommelt
Attitude Toward Care of the
Dying Scale-Form B.
Nurses were managing elderly
patients at end of life (EOL);
they held positive attitudes
towards caring for the dying,
88.9% viewed EOL care as an
emotionally demanding task,
95.3% reported that addressing
death issues require special
skills and 92.6% reported that
education on EOL care is
necessary.
Further education about end of
life care was recommended for
Spanish renal nurses.
N/A

Nurses’ Death Anxiety The Open Nursing Journal, 2013, Volume 7 17
(Table 2) contd…..
Author/Setting/
Nursing Discipline
Design/Sample &
Instruments
Findings Outcomes Effect/Correlations
Hutchison and
Sherman 1992 [23]
Student nurses in
USA
Non-random trial of didactic
or experiential death & dying
training for students (N=74):
pretest- posttest using
Templer Death Anxiety Scale
(DAS)
No differential effects of
training technique were found.
However, DAS post-test scores
were significantly lower than the
pre-test scores for both groups;
also maintained at 8-week
follow-up.
There was inconclusive evidence
of the effect of training on
students’ level of death anxiety.
Training positively impacted on
students’ levels of anxiety.
Anxiety was lower after
training and at 8 weeks.
Inci 2007 [12]
Oncology & ICU
Nurses in Turkey
(not in English)
Pretest-postest- Surveys:
Effects of death education -
using Death Anxiety Scale
(DAS), Death Depression
Scale (DDS), & Attitude
Scale Euthanasia, Death and
Dying Patients (EDDP).
DAS and DDS scores decreased
significantly (p=<.05) after
training; Non significant change
in EDDP (p>0.05). No effect of
death education by age, years of
work, how they were affected by
terminal patient nursing or the
meaning attributed to death.
There was a positive effect on
nurses’ death anxiety after death
and dying training over 7
sessions, however there was no
impact of nurses’ age, years
working or how they reported
being affected.
Anxiety was lower after
training.
Iranmanesh et al.
2008 [13]
Hospital general
and oncology
nurses in Iran
Cross sectional survey of
nurses (N=114) using
translated
Death Attitude Profile-
Revised (DAP-R) and
Frommelt's Attitude towards
Caring for Dying Patients
(FATCOD)
Fear of death was negatively
(r -.199) correlated with attitude
toward giving care to the dying.
Neutral to moderately positive
attitude toward caring for dying
(FATCOD mean 3.55/15). Most
were likely to give care and
emotional support to persons at
the end of life whilst taking an
authoritative approach.
Lack of education and
experience, as well as cultural
and professional limitations, may
have contributed to the negative
attitude toward some aspects of
the care for people who are dying
among the nurses surveyed.
Significant inverse and
also positive
relationships between
attitude to death and
caring for dying.
Lange, Thom and
Kline 2008 [17]
Inpatient &
outpatient oncology
nurses in USA
Cross-sectional survey (n=
355) using FATCOD &
DAP-R instruments.
Statistically significant
relationships were found among
age, nursing experience,
previous experience with caring
for the terminally ill, and scores
on FATCOD and DAP-R.
Nursing experience and age
were the variables most likely to
predict nurses' attitudes toward
death and caring for dying
patients.
RNs with more work experience
tended to have more positive
attitudes toward death and caring
for dying patients. Less
experienced oncology nurses will
benefit from increased education,
training, and exposure to
providing and coping effectively
with end-of-life care.
Significant inverse
relationship: attitude to
death and caring for
dying.
Matsui & Braun
2010 [14]
Hospital adult and
childrens’ nurses
caring for terminal
patients in Japan
Pretest- posttest survey
(N=190 RNs;176 care
workers): using Death
Attitude Profile (DAP),
Japanese version, and
Attitude Scale about
Euthanasia, Death, and Dying
Patient.
After 7x 90min sessions of nurse
education on death and dying-
multiple regression showed
better attitudes toward caring for
the dying were positively
associated with seminar
attendance and negatively
associated with fear of death.
There was no difference
between RNs and care workers’
responses.
Attitudes (measured by
FATCOD) were not
correlated with job certification
or work setting
but with death attitudes and
seminar attendance. Staff
education is important for
maintaining and improving
standards in end of-life care in
institutional settings.
Significant inverse
relationship: attitude to
death and caring for
dying.
Myashita et al.
2007 [15]
Hospital general
nurses in
Japan
Cross-sectional survey (n=
178) using FATCOD &
Death Attitude Inventory
(DAI). (Japanese versions) &
Pankratz Nursing
Questionnaire.
Multivariate linear regression
identified various subscales that
were related to caring; Death
anxiety domain, DAI (r= –.17, P
=.02), death relief (r = –.19, P =
.012), death avoidance (r= .33, P
= .001), and life purpose (r =
.38, P = .001) were significantly
correlated with DAI (positive
attitude toward caring for the
dying).
Most participants had a positive
attitude toward caring for the
dying patient and recognized the
need for patient- and family-
centered care. Educational and
administrative efforts to
strengthen nursing autonomy are
necessary.
Significant inverse &
positive relationships
for attitude to death and
caring for dying.
Payne et al. 1998
[19]
Hospice and
emergency nurses
in England
Mixed methods: survey
(N=60) using Death Attitude
Profile-Revised Questionnaire
& semi-structured interview.
Hospice nurses had lower death
anxiety, as shown by 8 of 32
items with significantly more
positive responses than
emergency nurses. Subscale
differences were not reported.
Limited differences were shown
between disciplines. Between
groups- hospice nurses appeared
to have low death anxiety despite
frequent exposure to deaths.
Significant difference
by demographics.

18 The Open Nursing Journal, 2013, Volume 7 Peters et al.
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 [3, 4, 13, 14, 16, 17]. 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) [4].
In Israel, Braun [4] 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 [13], 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. [15] 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 [14] 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 [3] 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 [11]
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
(Table 2) contd…..
Author/Setting/
Nursing Discipline
Design/Sample &
Instruments
Findings Outcomes Effect/Correlations
Rooda 1999 [3]
Metropolitan
private hospital
nurses and visiting
nurses (USA)
Cross-sectional survey
(N=403) using Frommelt
Attitude Toward Care of the
Dying Scale, and Death
Attitude Profile-Revised
(DAP-R),
DAP-R scores were related to
sex, religious affiliation, and
current contact with terminally
ill patients. FATCOD scores
(e.g., showing acceptance of
death) were positively related to
current contact with dying
patients, negatively correlated
with two DAP-R subscales (Fear
of Death and Death Avoidance),
and positively correlated with
two other DAP-R subscales
(Approach Acceptance and
Neutral Acceptance).
Nurses' attitudes toward death
and their current contact with
terminally ill patients were
predictive of their attitudes
toward caring for terminally ill
patients.
Significant inverse
relationship: 2 subscales
of DAP-R and between
attitude to death and
caring for dying.
Santisteban 2006
[20]
Various
practitioners in
palliative care unit
in Spain
Cross-sectional survey
(N=24) using Templer's DAS
and Maslach's MBI
Average death anxiety was 5.75.
Nurses scored highest on
depersonalization. Factors
related to team relationships
were most stressing. Assistant
nurses hardly ever sought family
or colleague support to discuss
work-related topics.
Average death anxiety was 5.75,
similar to other studies, but this
figure varies depending on the
presence of spiritual beliefs or
otherwise. Differences in MBI
variables were seen between
professions.
Mean death anxiety
5.75.- context not
reported.
Zyga 2012 [25]
Renal nurses
including palliative-
trained- in Greece
Descriptive quantitative
survey
(N=49) using Death Attitude
Profile-Revised (DAP-R)
Nursing experience and age
predicted nurses' attitudes
towards death. Nurses with
specific education on palliative
care had less difficulty talking
about death and dying and did
not have a fear of death.
Hospital-based teams (palliative
care, supportive care or symptom
assessment teams) had
statistically significant different
relationships with fear of death
and neutral acceptance scores.
Significant difference
by demographics.

Nurses’ Death Anxiety The Open Nursing Journal, 2013, Volume 7 19
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 [26]. 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 [27]. Some nurses in this role use strategies to
avoid discussing with patients their emotional issues or
concerns, thus maintaining an emotional distance [28]. 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 [13]. 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 [11] 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 [29]. 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 [30]. Escape (the ‘flight’ response) or avoidance (pre-
flight response) allows individuals to distance themselves
from the perceived threat [31]. 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 [17, 25]. Three studies explored such teaching
programs regarding death education [12, 14, 23].
In Turkey, Inci [12] 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 [14] 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 [25].
Nursing students are the registered nurses of the future
and therefore their beliefs are informative. Hutchison and
Sherman [23] 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.
DISCUSSION
The care of dying patients presents ethical challenges for
nurses, contradicting the medical mandate which is strongly
focused on restoring patients to health [2]. 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 [32].
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 [14, 25] with likely
subsequent improvement in nurses’ coping with death and
dying. Hutchison and Shermans’ work [23] 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

20 The Open Nursing Journal, 2013, Volume 7 Peters et al.
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 [33]. 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 [34]. In this field nurses also
need to deal with the expectation that the nurse-patient
relationship is about to be severed [27]. Nurses in Spain
viewed caring for patients at the end of life as emotionally
demanding work [21]. 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 [35].
McClement [36] 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 [7, 37]. Younger nurses
may not be experienced nurses and may not be well skilled
in dealing with emotional work [26]. Erikson and Grove [26]
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
[26]. 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 [1]. Overall,
these results suggest that younger nurses are more at risk of
negative attitudes to end of life care.
In line with previous research [5] 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 [13]. 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
[38] 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 [39] 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

Nurses’ Death Anxiety The Open Nursing Journal, 2013, Volume 7 21
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.
ACKNOWLEDGMENTS
Declared none.
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Received: October 8, 2012 Revised: November 26, 2012 Accepted: November 27, 2012
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