Research ArticleABSTRACT
Background: One of the most complex and emotional aspects of nursing is the interaction between the nurse and the dying patient.
Aims: To examine nurse’s attitudes towards death and the effect of a death incident while working in a nursing home.
Method: Data were collected using the Death Attitude Profile-Revised (DAP-R) questionnaire. The completion of the questionnaires was conducted during December- February 2020 and included a sample of 70 nurses.
Findings: Nurse’s level of education, years of working experience and job position play an important role in relation to nurses’ attitudes towards death. Additionally, important factors related to positive attitudes towards death include: the frequency that nurses care for a dying patient, talk openly about death, and discuss a death incident that has occurred with a colleague.
Conclusion: It is necessary to provide education beginning from an undergraduate level that will continue in the workplace, including the development of palliative care programs.
Keywords: Nurses’ Attitudes; Death- Dying; Nursing Homes
Introduction
The Elderly
Since the mid-20th century there has been an increase in the global elderly population, along with low birth rates and an increase in life expectancy (Kossioni [1]). This dramatic increase of the aging population coincides with a higher frequency of disease and health problems for this specific population. In addition, governments must manage the health care needs of the elderly as well as prioritize health on a global scale. Unfortunately, studies show that prejudice and negative stereotypes towards the elderly are widespread and extend throughout modern society, even in the health care field (Tadd, et al. [2]). The proportions of the European population will not only be larger by 2060, but it will also be older. The population is expected to grow by about 4% and from 507 million in 2013, it is estimated that by the year 2060 the population will reach 523 million people (Eurostat [3]). Specifically, in the EU, men’s life expectancy will increase from 77.6 years in 2013 to 84.7 years by 2060, while women’s life expectancy will increase from 83.1 years in 2013 to 89.1 years by 2060, indicating a difference in the age gap between men and women (Boltz, et al. [4]).
Greece is among the top six rapidly aging countries among Japan, South Korea, Spain, Portugal, and Italy (Hellenic Statistical Authority [5]). The data demonstrates that the life expectancy of people living in Greece will increase in the coming years. Specifically, life expectancy in Greece is likely to increase from 2013 to 2060, by 6.9 years for men (an increase from 78 years to 84.9 years) and by 5.7 years for women (an increase from 83.3 years to 89 years) (Hellenic Statistical Authority [5]).
Nursing Homes in Greece
Greece has no special health services for the elderly. The elderly population is served by the National Health System (NHS) as all citizens are provided health care services at hospitals and clinics. Besides the hospital, doctors offer their services in private clinics and as part of the NHS and through health centers. However, in Greece there are no available care facilities specifically designed for the elderly, though, in recent years, programs such as “Help at home”, the Centers for the Elderly as well as Day Care Centers for the Elderly and Friendship Clubs have been established. Although the above government actions offer significant benefits for the elderly population, the hospitality offered is usually short and their main purpose is to keep the elderly as an autonomous, equal and active member of the community. Thus, the care of the elderly in Greece is mainly supported by their family. However, families face a modern fast pacing way of life, as well as increasing personal and professional responsibilities, leading to the need to set up long term care units for the elderly. This is because families cannot help their loved ones, so they choose alternative ways to offer long term care for their aged family member (Greek Care Homes Association [6]).
The establishment and operation of nursing homes in Greece (Independent Living and Assisted Living) are determined by law and provide the elderly with healthy accommodation, healthy and adequate nutrition, continuous care and personal hygiene, physiotherapy sessions, medical and nursing care. Admission to such homes is based on the individual’s health care needs and timely admission to the appropriate health care facility. By law (Law 3198/2014), the capacity of permeant accommodation for the elderly can range between 10 to 100 beds. A license to operate a nursing home is provided by the Ministry of Health. In Greece today there are about 100 legal nursing homes of non-profit or for-profit nature that accommodate about 3,000-5,000 elderly people (Greek Care Homes Association [6]).
Perceptions of Death
Inevitably, relationships with patients who are in the final stages of life, cause an emotional response to people caring for them such as doctors and nurses. Within the health care setting, where contact with grief and pain is a daily norm, as is the case for hospital staff, staff tend to develop either a defensive attitude or empathize with the patient and family. This defensive attitude creates an emotional shield for doctors and nurses that prevents them from feeling the patient’s grief. This behavior often comes across as distant, cold and even at times inhumane. On the other hand, when health professionals demonstrate feelings of empathy towards their patients, emotions between the patient and staff are confused, the fears of one become the fears of the other and vice versa (Marcysiak, et al. [7]). Doctors and nurses need to be aware of their feelings about death and not deny grief, as it is an integral part of their professional life (AlSenany, et al. [8]). According to (Burles, et al. [9]) palliative care is a therapeutic approach that improves the quality of life of patients and their families, who face problems related to life-threatening diseases. It is based on the prevention and alleviation of the manifestations of the disease, along with other unpleasant physical symptoms such as pain management, as well as psychosocial and spiritual issues (Madden, et al. [10]).
Palliative care has a fundamental role in the care of patients during the end-of-life stage, thus being a basic human right. The approach and duration of care depend on the condition and stage of the individual’s illness (Reymond [11]). Relationships with family members of the dying patient are an important factor of emotional stress for the nursing staff. Nurses are often called upon by persistent relatives to provide information at a diagnostic or therapeutic level (Ghandourh [12]). Relatives, on their part, seek the nurse’s advice and guidance, as they are overwhelmed with fear of their loved ones impending death (Shinde, et al. [13]).
Nurses’ Attitudes
Stress due to the fear of death and loneliness is an important issue that affects the quality of life of the elderly. A study conducted by (Lehto, et al. [14]) demonstrated the beneficial effects of laughing as a remedy for loneliness and fear of death in older people living in nursing homes. Nurses need to incorporate laughter therapy into routine nursing home programs. According to another study, the most common attitude nurses demonstrate towards death is to offer support to patients and their families by expressing emotions such as grief, compassion and empathy (Marcysiak, et al. [15]). Nurses must maintain a balance between self-care and patient care. Thus, it is very common for them to experience intense physical and mental fatigue since they cannot emotionally distance themselves from their patient’s situation. Therefore, in order to emotionally protect themselves, nurses must seek support from other colleagues or councellors (Burles, et al. [9]).
Older Adults’ Attitudes towards Death
Many older adults living with their family feel that they have lost their dignity, independence and feel neglected or ignored. (Konstantinidis, et al. [15]) found that older people living alone had a higher rate of financial distress, symptoms of depression and low life satisfaction as death approached. People who live in a nursing home seem to have a negative self-perception and low self-esteem compared to those who live with their family (Bui, et al. [16]). Research conducted by (Kenealy, et al. [17]) demonstrated that the quality of life of older adults was significantly affected by their place of residence. The study found that older adults’ that lived in nursing homes had lower quality of life and more health problems, in contrast to those who lived with a family member. Subsequently, a study by (Wincur, et al. [18]) found that there is a close relationship between psychosocial well-being and cognitive performance in groups of elderly people living in the community. The same study revealed that people living in the community have positive outcomes and better mental health than people living in institutions. A study conducted by (Sorescu [19]) demonstrated that older adults experience poor quality of life while living in nursing homes due to health professionals inadequate training and lack of support. The same research states that health professionals who are not trained in matters related to the care of the elderly resort to mistaken and unhelpful techniques. A study by (Heydari, et al. [20]) found that people who lived with their families have a better quality of life than those who live in nursing homes. It appears that in terms of their physical and mental health, elderly people living in nursing homes demonstrate poor health and emotional distress. The literature review revealed that there is a lack of research studies conducted in Greece on this issue.
Aims
The purpose of this study was to examine nurse’s attitudes towards death and the effect of a death incident while working in a nursing home.
Materials and Methods
The Death Attitude Profile – Revised (DAP – R) questionnaire created by (Wong, et al. [21]) was used to collect the data. This questionnaire consists of 32 statements related to different attitudes towards death, using a seven-point Likert scale (1: Strongly disagree, 7: Strongly agree). Specific items are categorized into 5 dimensions, Fear of Death (7 items), Neutral Acceptance (5 items), Escape Acceptance (5 items), Approach Acceptance (10 items) and Death Avoidance (5 items). The score of each item ranged from 1 to 7. A high item score demonstrated a tendency of the behavior for the specific dimension (Wong, et al. [21]). The research tool was translated into the Greek language and evaluated in terms of reliability demonstrating good reliability by (Malliarou, et al. [22]). In the present study, the reliability for each dimension was calculated (α = 0.812 Fear of Death, α = 0.733 Neutral Acceptance, α = 0.705 Escape Acceptance, α = 0.752 Approach Acceptance, α = 0.826 Death Avoidance) and was considered satisfactory. The second part of the questionnaire included four (4) questions by which the impact of death on nurses working in nursing homes in the Prefecture of Achaia were investigated. Finally, the third part of the questionnaire included questions related to participants demographic characteristics. The research was conducted during December-February 2020.
Procedure
Due to the Covid-19 pandemic and the restrictive measures in force, it was decided to distribute the questionnaire in electronic form (Google forms). All procedures were performed in compliance with relevant laws and institutional guidelines. This study received ethical approval by the institutional review board of the University of Patras (Greek registration number: 7364). Nursing homes (7 in total) based in the prefecture of Achaia (one of the largest prefectures in the country) were identified and letters informing administers about the purpose of the study and asking for their permission were sent. Upon receiving confirmation from the nursing homes administration and agreeing to take part in the study, the questionnaire was then uploaded to the nursing home website. Nurses working in the nursing homes had access to the questionnaire and those who wished to participate, completed the online questionnaire. The first page of the questionnaire included information related to the purpose of the study and questionnaire completion guidelines. Information regarding nurse’s anonymity, confidentiality and voluntary participation were also included. Participants who agreed to join the study completed the questionnaire. The time needed to complete the questionnaire ranged from 6-9 minutes.
Sample
A convenience sample of Registered Nurses was recruited. A total of 70 nurses working in nursing homes completed the questionnaire.
Statistical Analysis
Descriptive analysis was used to describe the sample and parametric tests comparing the mean value between two independent samples (t-test) was applied, setting the significance level p-value <0.05. Finally, Pearson’s correlation was used to assess the relationship between variables. The data were analyzed employing the SPSS v.25.0 software.
Results
Demographic Characteristics
The majority of the sample were women (78.6%) and almost half were single (48.6%). More than half of the participants had a university level education (57.1%), while the majority did not have a master’s level of education (84.3%). Most participants lived in an urban area (78.6%), less than half of the participants had an annual family income of 10,001-20,000 euros (44.3%) and overall had more than 10 years of working experience (x = 11.32 years).
Attitudes Related to Death
(Table 1) Participants attitudes related to Fear of Death. Based on the finding it is evident that in relation to participants Fear of Death they remain undecided (Mean = 4.04, Std = 1.449). Participants on average moderately agree that death is without a doubt a grim experience (Mean = 4.86).
Table 1: Participants attitudes related to Fear of Death.
Neutral Acceptance
Regarding the dimension of Neutral Acceptance, on average the participants moderately agree (Mean= 5.16, Std= 1.122).
Approach Acceptance
A neutral attitude is apparent regarding the participants attitudes to the Approach Acceptance dimension of the questionnaire (Mean= 3,78, Std =1,774). Participants seem to agree that “Death will bring an end to all my troubles.”
Escape Acceptance
(Table 2) Participants attitudes related to Escape Acceptance. Participants moderately disagree that death is perceived as a means of escape (Mean = 3,40, Std = 1,369).
Table 2: Participants attitudes related to Escape Acceptance.
Death Avoidance
Table 3: Correlation of dimension scores related to attitudes towards death and gender.
Participants demonstrate a neutral attitude towards Death Avoidance (Mean = 4.09, Std = 1.216). Parametric test (t-test) was used to identify any significance differences between the demographic characteristics and the five dimensions. It was found significance differences only with gender. (Table 3) Correlation of dimension scores related to attitudes towards death and gender. There is a statistically significant difference among the participants gender and the dimensions Death Avoidance (p <0.05) and Fear of Death (p <0.05). Therefore, gender appears to affect beliefs related to death and seems to play an important role in differentiating death behavior. Specifically, women agree more with the views related to Death Avoidance and Fear of Death than men. However, nurses job position, years of working experience as well as level of education do not seem to play a significant role in differentiating attitudes related to death (p> 0.05). (Table 4) Correlation of Death profile and the effect of a death event. Results indicate that the dimension of Neutral Acceptance towards death is negatively correlated (r = -0,228) with discussing a death incident when it occurs. In other words, when nurses discuss a death incident, they tend not to maintain a neutral attitude towards death. Also, the dimension of neutral acceptance towards death is positively correlated to the effect of a death event on the participants personal life (r = 0.210). Participants’ views on the Fear of Death dimension are negatively related to the effect of a death incident on their personal life (r = -0,490) and the relief that results from discussing a death incident (r = -0,246). Discussing a death incident has a positive effect on the dimension of Escape Acceptance (r = 0,156), that is, when in the case of discussing a death incident, participants tend to agree that death is a means of escape. Finally, the dimension of Death Avoidance is negatively affected by the effect of a death incident on the participants daily life (r = -0,305).
Table 4: Correlation of Death profile and the effect of a death event.
Discussion
According to the results of this study, when a death incident occurs, nurses are significantly affected. Talking about death offers relief to most of the participants while when there don’t discuss death it affects them negatively. Almost half of the participants claim they are not affected by a death incident while a very small percentage were not negatively affected at all when they did not discuss a death incident. Research by (Malliarou, et al. [22]) agrees that discussing a death incident has a therapeutic effect on health professionals and is a very helpful way to relieve emotions caused by a death, which participants often think about after it occurs. This study also highlighted participants ways of dealing with emotions that arise from a death incident. Generally, they choose to isolate themselves, avoid discussing it with colleagues, cry, choose to think about it at home, or completely ignore the incident as a way of coping. Participants feel that their personal life is affected by a death incident to a considerable extent. Similar results have been reported by other studies (Malliarou, et al. [22,23]). These results demonstrate the need for bereavement counseling offered in these health care settings to patients and their family members but also to health professionals caring for patients in the final stage of their life.
Death is without a doubt a macabre experience for all participants. The findings indicate that participants express that the thought of death causes anxiety, they avoid thinking about death, are disturbed by the finality of death, and have a strong fear of death. In addition, the results of this study demonstrate that participants have a neutral attitude in the dimension of Escape Acceptance. Participants seem to tend to agree that death is a union with God and eternal bliss. Other similar studies have reported that participants believe that death will reunite them with their loved ones, provide a passage to an eternal and blessed place (Torres- Mesa, et al. [24]), offer relief to their soul, and that their faith will provide them comfort in the afterlife (Malliarou, et al. [22]). The finding of this study suggest that participants think of death, but most try not to. A statistically significant difference was found between nurses’ behavior towards death and gender regarding Death Avoidance and Fear of Death. Gender seems to have an important role in differentiating death behavior. More specifically, women agree more with the views of these dimensions regarding death (Death Avoidance and Fear of Death) than men. Similar results were reported by (Lopera [25]).
It is worth mentioning that a neutral attitude towards death is negatively related to the discussion of a death incident when it occurs. In the case where nurses discuss a death incident, they tend not to maintain a neutral attitude towards death. Also, participants’ views on the fear of death are negatively related to the impact of a death incident and the relief that results from talking about it. In other words, the more they fear death, the higher the impact a death has on their lives.
Study Limitations
Although this study revealed important information, the sample was small. Therefore, future research is deemed necessary using a larger sample from additional nursing homes in Greece.
Conclusion
The findings suggest that if nurses had more knowledge and understanding of the care needed by the dying patients and their family, they would be in a better position to provide quality care to patients during the final stages of life. Education on this topic, that will start from an undergraduate level and will continue in the workplace, which will focus on palliative care for nurses who wish to further improve their knowledge and attitudes is necessary
Acknowledgement
The authors are sincerely grateful to all individuals who participated in the study.
Conflicts of Interest
No conflict of interest has been declared by the author(s).
Funding Statement
This research received no specific grant from any funding agency, commercial or not-for-profit sectors.
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