Emergency and palliative care nurses’ levels of anxiety about death and coping with death: A questionnaire survey

doi:10.1016/j.aenj.2013.08.001

Australasian Emergency Nursing Journal

Volume 16, Issue 4, November 2013, Pages 152-159

https://doi.org/10.1016/j.aenj.2013.08.001 Get rights and content

Summary

Background

Caring for dying patients and their families presents many challenges, and may be negatively affected by nurses’ Fear of Death. This study investigates attitudes of emergency and palliative care nurses towards death and dying.

Methods

A mixed methods design including questionnaire and interview, was utilised. This paper reports questionnaire results from the Death Attitude Profile-Revised Scale and coping skills.

Results

Twenty-eight emergency nurses and 28 palliative care nurses from two health services participated. Nurses held low to moderate Fear of Death (44%), Death Avoidance (34%), Escape Acceptance (47%) and Approach Acceptance (59%). Emergency nurses reported higher death avoidance and, significantly lower coping skills than palliative care nurses. Both reported high acceptance of the reality of death (Neutral Acceptance 82%), and indicated they coped better with a patient who was dying than with, the patient's family.

Conclusions

Nurses generally held positive attitudes towards death and dying. Participants could cope with caring for dying patients, but were significantly less comfortable coping with patients’ family members. Nurses should be aware of the impact their attitude towards death may have on providing supportive nursing care for the dying.

Introduction

Personal, cultural, social and philosophical belief systems influence individual's attitudes towards death.1, 2 Studies suggest that nurses’ attitudes towards death may influence the supportive behaviours they provide when caring for a dying patient.³ The clinical setting has also been reported to influence care provided to the dying patient and their family.4, 5, 6 In the emergency department (ED), the competing demands of other patients, and poor structural design fail to provide either the time or privacy required to provide optimal end of life care.4, 6 Alternatively, palliative care nurses frequently deal with death and dying.⁷ This study investigates the attitudes of emergency nurses and palliative care nurses to death and dying, and explores how participants perceive they cope with death in the professional setting.

The World Health Organisation (WHO) defines palliative care as “an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual”.⁸ ^par.1 End of life (EOL) care is generally considered to be the care provided in the “last few days of life, when a person is irreversibly dying, also known as the terminal phase”.⁹ ^par.5 In the ED, EOL care has been defined as the care delivered during the time directly preceding death.¹⁰

Palliative and end of life care is delivered over a period of weeks to months or years, in the home or within a specialty palliative care setting.5, 11 In contrast, death in the ED may be sudden, and can occur within hours of the patient presenting. EOL care can however, include interventions to actively prevent death.⁵

In the palliative care setting, death may be anticipated, planned and facilitated. The ED workplace culture is ‘rescue-oriented’, and death is perceived as preventable. Typically patients presenting to the ED are unexpected and unknown to ED staff. In these circumstances, it can be difficult to know whether the illness or condition is potentially reversible. In a setting where the focus is on cure, death can be seen as a failure of treatment, rather than something to be welcomed.12, 13, 14 Further, the suddenness of the presentation means there is no relationship between ED staff and the patient or family, and this makes meeting family needs more difficult.

Time and workload have been reported as obstacles to the delivery of optimal EOL care in the ED.⁶ Patients are sorted in order of priority, by severity of illness or injury. Emergency nurses need to prioritise the demands of caring for those who have a chance of survival, with the needs of an actively dying person.5, 15

Palliative care nurses are confronted by death on a daily basis, and there is an assumption that nurses selecting this field of work will feel comfortable with the open acknowledgement of death and dying.¹⁴ Death in palliative care is expected and anticipated by family members. By contrast, death in ED is frequently traumatic and unexpected by family members, and bereaved family members need support.¹⁶

Both culture and religious faith impart particular beliefs about death and dying.2, 17 Exposure to death has also been found to influence the way nurses perceive death.¹⁴ It has been reported that exposure to the death of others can make individuals conscious of their own mortality, giving rise to anxiety and unease. ‘Death anxiety’ is described as a feeling of dread, apprehension or solicitude (anxiety) when one thinks of the process of dying, or ceasing to ‘be’.¹⁸ Death anxiety has been reported to negatively affect the quality of care nurses provide to dying patients.2, 19, 20

The contrast in death experiences between palliative care and emergency department settings is well recognised, with ‘sudden, traumatic’ deaths in the ED, and expected, facilitated deaths in palliative care. Given these opposing experiences, it might be presumed that nurses within each specialty would have opposing views on death, contrasting levels of death anxiety, and therefore differing foci in patient care.

A UK study compared the levels of death anxiety between hospice nurses and emergency nurses. It found the levels of death anxiety were similar, although one-quarter of emergency nurses showed both less acceptance of death and more fear than hospice nurses.¹⁴ This trend was also found in another study.²¹

The present study arose from a need to explain the approaches to death and dying of Australian nurses who are frequently exposed to death and dying in emergency departments and in palliative care services. The study aimed to answer the research questions: (i) Do both emergency department nurses and palliative care nurses experience anxiety about regular patient deaths? and (ii) how do nurses in these units perceive they cope with exposure to frequent patient deaths? The findings would form the basis of interventions to support emergency nurses and palliative care nurses, aiming to ultimately improve the quality of care that is provided to dying patients and their families.

Section snippets

Materials and methods

This study is a replication of the study by Payne et al.¹⁴ using questionnaire and in-depth interview of 43 nurses. This paper reports the results of the first phase of the study a quantitative survey. Nurses employed in the emergency department or the in-patient palliative care unit of two metropolitan health services in Melbourne, Australia were invited to participate. On average, per week, 2–3 deaths occurred in the selected emergency departments and 8–10 in the palliative care units. Aiming

Results

Replicating the study by Payne et al. and the sample size,¹⁴ 56 registered nurses participated: 28 from two emergency departments and 28 employed in two specialist palliative care inpatient units.

Discussion

The overall study results found similar attitudes in ED nurses and PC nurses according to the Death Attitude Profile-Revised Scale, although, importantly, also a significant difference for one of five DAP-R subscales. The results when grouped by the DAP-R subscales showed ED nurses held significantly stronger attitudes towards avoiding death, according to the factor Death Avoidance (39.5% versus PC: 28.5%). This factor, including five items such as ‘I avoid death thoughts at all costs’; ‘I try

Conclusion

Nursing care of the dying is a particularly demanding role that requires nursing skill and experience in nursing. The current study revealed moderate levels of death anxiety in nurses in emergency departments and palliative care inpatient units that were no higher than those of nurses in other work categories. Emergency and palliative care nurses, while positive about their skills to cope with death and dying, were significantly less comfortable coping with a patient's family members than with

Funding

This research study was funded by a grant from the School of Nursing and Midwifery, Monash University, Melbourne, Australia.

Authorship

LP and MO secured funding; LP and RC developed the study protocol; LP and RC conducted data collection and LP and RC analysed the data. RC and LP prepared the manuscript with SP, MO, FM, JM, KH and KS providing critical review of important intellectual content. All authors approved the manuscript.

Provenance and conflict of interest

All the authors on this research project have no financial or other conflict of interest in this project. This paper was not commissioned.

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Research paperEmergency and palliative care nurses’ levels of anxiety about death and coping with death: A questionnaire survey

Summary

Background

Methods

Results

Conclusions

Introduction

Section snippets

Materials and methods

Results

Discussion

Conclusion

Funding

Authorship

Provenance and conflict of interest

J Emerg Nurs

J Emerg Nurs

J Emerg Nurs

Aust Crit Care

J Pain Symptom Manage

Associations between oncology nurses’ attitudes toward death and caring for dying patients

Oncol Nurs Forum

Nurses’ attitudes toward death and caring for dying patients

Oncol Nurs Forum

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

End-of-life models and emergency department care

Acad Emerg Med

Surviving and thriving: the nurse-patient relationship in palliative care

Death anxiety: an analysis of an evolving concept

Res Theory Nurs Pract

Nursing experience and the care of dying patients

Oncol Nurs Forum

A comparative study of death anxiety in hospice and emergency nurses

J Adv Nurs

Policy on the Australasian Triage Scale

Using polytomous item response models to assess death anxiety

Nurs Res

Research paper
Emergency and palliative care nurses’ levels of anxiety about death and coping with death: A questionnaire survey