A comparative study of death anxiety in hospice and emergency nurses

A comparative study of death anxiety inhospice and emergency nurses

S.A. Payne BA(Hons ) RGN DipN PhD CPsychol

Director of Research, Health Research Unit, School of Occupational Therapy

and Physiotherapy, University of Southampton

S.J. DeanMedical Student, Department of Psychology, University of Southampton,

Southampton

and C. Kalus BA(Hon) MSc AFBPS

Consultant Clinical Psychologist, The Rowans, Portsmouth, England

Accepted for publication 11 July 1997

PAYNE S.A., DEAN S.J. & KALUS C. (1998) Journal of Advanced Nursing 28(4), 700±706

A comparative study of death anxiety in hospice and emergency nurses

This paper describes a preliminary cross-sectional study which aimed to

compare levels of death anxiety and coping responses in palliative care and

accident and emergency (A & E) nurses. Forty-three nurses (23 from palliative

care and 20 from A & E) were recruited from a district general hospital and

nearby hospice. Both sites had the same mean annual death rate of 150 patients.

Death anxiety was measured by the Death Attitude Pro®le-Revised Question-

naire and coping responses were elicited by a semi-structured interview. As

hypothesized, hospice nurses had lower death anxiety and they were more

likely to recall both good and dif®cult experiences related to patient care. Unlike

the hospice nurses, a subgroup (20%) of A & E nurses reported that they were

unable to discuss problems with colleagues. The study has implications for the

development of institutional support for staff to enable nurses to provide good

quality care for dying patients and bereaved people.

Keywords: hospices, accident and emergency, nurses, death anxiety, coping

INTRODUCTION

All nurses face the dying and death of some of their

patients, and need to provide empathetic care to the

bereaved relatives. This is known to be a source of

occupational stress (Llewellyn & Payne 1995). It presents

not only a professional challenge but may also present

personal challenges. Certain characteristics of the death,

such as traumatic or mutilating injuries, or of the dying

person such as young patients, especially children, are

known to be problematic (Sanders 1993). Yet the quantity

and quality of pre-registration education on death and

dying is very variable (Field & Kitson 1986).

Quali®ed nurses select areas of specialization depending

upon personal preference and employment opportunities.

In acute hospitals, where the focus is on curing disease,

both societal attitudes and those of mainstream medicine

have contributed to health professionals often viewing

death as a failure (Carr & Merriman 1996). Palliative care

aims to offer an alternative or `better' way to die (McNamara

et al. 1995). Palliative care nurses aim to provide holistic

care for the terminally ill, focusing not only on the patient's

physical needs but with a greater emphasis on their social,

psychological and spiritual needs. For the majority of

Correspondence: S.A. Payne, Health Research Unit, School

of Occupational Therapy and Physiotherapy, University of Southampton,

High®eld, Southampton SO17 1BJ, England.

Journal of Advanced Nursing, 1998, 28(4), 700±706 Experience before and throughout the nursing career

700 Ó 1998 Blackwell Science Ltd

people death is only encountered a few times in their lives,

with the death of close friends and relatives. Hospice

nurses, however, are confronted by death and dying on a

daily basis. There is an assumption that nurses selecting

this area of work will feel comfortable with the open

acknowledgement of death and dying.

In comparison, accident and emergency (A & E) nursing

is concerned with providing life saving care of critically

injured or ill patients, although there is an acknowledge-

ment that not all patients survive and that their bereaved

families need support (British Association for Accident

and Emergency Medicine and the Royal College of Nursing

1995). Sudden bereavement is widely recognized as one of

the most traumatic life events but to date there has been

little research on its impact on A & E staff. These nurses

have to deal with many sudden and traumatic deaths and

with distraught relatives. Tye (1993) found that 52% of A

& E nurses felt unprepared for this aspect of their role.

Attitudes to Death

Neimeyer (1994) de®ned death anxiety as that experi-

enced in everyday life rather than in acute situations

where there are immediate threats to life. He suggested

that it has multiple components including: anticipating

one's self dead, fear of the process of dying and fear about

the death of signi®cant others. Most of the previous

research on the construct death anxiety has related to

feelings surrounding the death of the self rather than

objects of professional concern, namely patients (Neim-

eyer 1994). Health professionals are often in the position

of both having to deal with their personal feelings of death

threat and having to cope with death regularly in their

professional lives. Nichols (1984) has argued that doctors

and nurses cope with the emotional burden of their work

by distancing themselves from patients and concentrating

on the biomedical aspects of disease. While this might be

functional, it runs counter to current trends in nurse

education which emphasizes the psycho-social aspects of

care. A review of the literature by Neimeyer (1994)

indicates that health professionals with high levels of

death anxiety are more likely to use àvoiding' coping

strategies.

Neimeyer (1994) devised a multidimensional question-

naire to measure personal attitudes towards death. It

includes: fear of death, death avoidance, neutral accep-

tance (a state where death is neither feared or welcomed,

simply accepted), approach acceptance (a belief in a

happy afterlife), and escape acceptance which describes

death as a welcome alternative to a life full of pain and

suffering. Individuals may exist in any of the three states

of death acceptance. Alternatively individuals may hold a

strong fear of death or simply avoid thinking about it

altogether. Neimeyer suggests the personal attitudes we

hold about death strongly in¯uence how we live our lives.

Individuals who exhibit a high neutral acceptance or

approach acceptance can live happy, ful®lled lives. Those

with a strong fear of death may be unable to live life to the

full, particularly ®nding dif®culty with close relationships

as they may fear the death of those they love.

Recent research has suggested that hospice nurses have

low death anxiety and exhibit a greater comfort in caring

for the terminally ill, in contrast to hospital nurses who

exhibited high death anxiety and were reluctant to spend

time with dying patients (Carr & Merriman 1996). The

purpose of the study was to compare levels of death

anxiety between A & E nurses and palliative care nurses,

and to relate these to self-reported coping responses. It is

hypothesized that a nurse's skill and con®dence in pro-

viding good quality care to dying and bereaved people,

relates to not only his/her level of experience and training

but to personal attributes such as degree of death anxiety.

METHOD

Design

The study employed a cross-sectional design and was

conducted in the A & E Department of a large district

general hospital and at a nearby hospice in the south of

England. Within each unit the mean annual death rate was

150 deaths (» 3 per week). A questionnaire, followed by a

short structured interview, was used to obtain data from

nurses.

Participants

Sixty nurses from A & E (n � 30) and from the hospice

(n � 30) were invited to participate in the study by letter.

Measures

The Death Attitude Pro®le-Revised (DAP-R) (Wong et al.

1994a) is a 32-item standardized measure of attitudes

towards death comprising ®ve sub-scales of 6 or 7 items

each, assessing: fear of death, death avoidance, neutral

acceptance, approach acceptance and escape acceptance.

Participants rated each question on a 7-point scale, with

responses ranging from `strongly disagree' to `strongly

agree'. The scales demonstrate good reliability and valid-

ity, and there are established gender- and age-related

norms (Wong et al. 1994a).

A second questionnaire was devised for the study,

asking why nurses chose to work in that speciality, the

years spent in that speciality and to list any post-basic

quali®cations. A short semi-structured interview was

developed to elicit information about individual strategies

for coping with deaths in the clinical situation. There

were six questions:

� Could you tell me about a patient that you cared for

particularly well?

Experience before and throughout the nursing career Death anxiety in nurses

Ó 1998 Blackwell Science Ltd, Journal of Advanced Nursing, 28(4), 700±706 701

� In contrast could you tell me about a patient whose care

you found particularly dif®cult?

� If you have had a dif®cult day do you ®nd yourself

thinking about it when you go home?

� Is there someone you can talk to at home?

� What about at work?

� Do you feel that support is available if you need it?

Procedure

The collaboration of clinical managers was obtained at

each site. The DAP-R questionnaire was administered

individually to the nurses in an undisturbed private area

within each setting. They were left alone for 10 minutes to

complete the questionnaire. This was followed by the

short semi-structured interview which was audio-tape

recorded with participant's consent. All interviews were

performed by the same interviewer. Hospital Ethical

Committee permission was obtained. Con®dentiality and

the right to withdraw from the study at any time was

assured. Due to the sensitive nature of the research topic,

it was arranged that any participants who appeared to be

distressed would be referred to a clinical psychologist for

con®dential support.

Analysis

Data from the questionnaires were entered onto a spread-

sheet using the Statistical Package for Social Scientists

(SPSS). Responses to the 32 questions were coded from `1-

strongly agree' to `7 - strongly disagree'. Responses to the

questions were found to be normally distributed so data

were analysed using Student's t-tests. The data from the

DAP-R and content analyses were compared between the

hospice and A & E nurses to determine differences in

death anxiety and coping. Comparisons between the data

were undertaken to identify features of a supportive

environment.

The interviewer conducted a content analysis. One

interview was transcribed verbatim and this was used to

identify the type of responses made. Interview data were

categorized after careful and repeated examination of the

audio-tapes.

RESULTS

Characteristics of respondents

In total 43 nurses agreed to participate, 20 from A & E and

23 from palliative care, which is a response rate of 71á6%.

The A & E nurses had a mean age of 33 years (range 25±

50 years) and hospice nurses had a mean age of 37 years

(range 25±52 years), which was not statistically different

(t-test Ð 1á48, d.f. 38, P < 0á14). The mean number of years

spent in each speciality was: 4 years (range 1±17 years) for

A & E nurses; 3 years (range 1±10 years) for hospice

nurses. On average A & E nurses had two post-basic

quali®cations while hospice nurses had three. Nurses'

reasons for choice of speciality are shown in Table 1.

Differences between hospice and A & E nurseson death anxiety

From the previous literature the researchers hypothesized

that hospice nurses would feel more comfortable with

death than A & E nurses. This has been supported by the

data in relation to responses to 8 items from the DAP-R,

which are shown in Table 2, but in all other items (24) the

groups were not statistically signi®cantly different.

On the sub-scale of `death avoidance', three items (3, 12

and 19, shown in Table 2) signi®cantly discriminated

Table 1 Nurses' reasons for choice of speciality

Accident and Emergency (n = 20) Hospice (n = 23)

Rank Comments Responses Rank Comments Responses

1. Variety of patients 13 1. Dissatisfaction with care in hospital 7

2. Variety of procedures 10 2. Rewarding 7

3. Adrenaline/excitement/

experience of the

emergency situation

6 3. To have time to give

all aspects of care

6

4. Job satisfaction/enjoyment 3 4. Improve quality of life remaining 5

5. Lack of routine 2 5. Something I always wanted to do 5

6. Challenging 2 6. Work closely with properly 3

7. Busy environment 1 7. To ensure digni®ed death 3

8. Patients grateful for effort 1 8. Find subject of death fascinating 3

9. Like helping people 1 9. Personal experience of

terminal illness

2

10. More time to spend with

patients than on the wards

1 10. To be able to follow through

post-death with families

2

S.A. Payne et al.

702 Ó 1998 Blackwell Science Ltd, Journal of Advanced Nursing, 28(4), 700±706

between hospice and A & E nurses. In all cases, as

predicted, hospice nurses report being less `death avoid-

ant'. On the sub-scale of `fear of death', two items (2 and 7,

shown in Table 2) indicate that A & E nurses were

signi®cantly more likely to report concerns about their

own death than hospice nurses. On the sub-scale of

àpproach acceptance', two items (8 and 27, shown in

Table 2) demonstrated that A & E nurses were signi®cantly

less likely to consider that there were positive elements to

death. On the sub-scale of èscape acceptance', one item

(5, shown in Table 2) revealed that A & E nurses were

signi®cantly less likely to perceive death as a release. On

the sub-scale of `neutral acceptance', no statistically

signi®cant differences were found.

Content analysis of the interviews

Responses were compared between the A & E and hospice

nurses. Illustrative quotes are used to characterize the

various views expressed. In the interview the researchers

were interested in situations in which nurses felt they

cared for patients particularly well, situations they found

particularly dif®cult, and perceived sources of support. Of

the 20 A & E nurses interviewed, half could not remember

caring for a patient particularly well which was explained

by the limited time patients spent in A & E. Time was seen

as a problem:

More dif®cult in here Ð they [patients] don't stay for very long. [A

& E]

Of the 10 nurses who could remember situations where

they had given particularly good care, eight of these related

more to the care of the relatives. Only two nurses described

patients who they felt they cared for well, both involved

injuries which they had never had to deal with before.

Of the 23 hospice nurses, only three nurses could not

recall a patient that they felt they had cared for well. Most

commented on the relationship they built up with a

particular patient that appeared to in¯uence their memory

of them:

Spent a lot of time chatting, felt very close. [Hospice]

Helped him to prepare for death¼ Maybe too emotionally

involved. [Hospice]

Also, many felt they had helped the family to come to terms with

the loss of their loved one.

Prepared family well. Allowed her husband to come to terms with

it before she died. [Hospice]

Nurses were asked: Ìs there any patient whose care you

have found particularly dif®cult?' Of the 20 A & E nurses,

11 could not recall a particular person due to limited time

spent with patients. One nurse commented:

No, most people who are dying are relatively easy, they are ready

to die and have accepted it, it is the relatives that are more

dif®cult. [A & E]

For the nurses that could recall a dif®cult patient, six

involved the death of children:

Yes, the day two children died as I have children of a similar age

at home. [A & E]

Table 2 Table to show the mean and standard deviation, and t values of the items found to be statistically signi®cant on the Death

Attitude Pro®le-Revised questionnaire

Accident and

Emergency (n = 20) Hospice (n = 23)

Item Content of item Mean SD Mean SD t-Test P

2 The prospect of my own

death arouses anxiety in me

3á83 2á01 2á75 1á74 )1á86 0á035

3 I avoid death thoughts

at all costs

6á22 0á67 4á95 1á57 )3á52 0á001

5 Death will bring an end

to all my troubles

3á74 1á79 4á80 1á96 1á85 0á035

7 I am disturbed by the

®nality of death

4á87 1á67 3á90 1á65 )1á92 0á031

8 Death is an entrance to a

place of ultimate satisfaction

3á35 0á94 4á40 1á14 3á32 0á001

12 I always try not to

think about death

5á48 1á04 4á80 1á44 )1á79 0á040

19 I avoid thinking about

death alogether

5á87 1á10 4á95 1á47 )2á34 0á012

27 Death offers a wonderful

release of the soul

3á17 0á98 3á90 1á02 2á37 0á011



Two nurses could remember patients because they

revived personal memories:

Yes, a patient with leukaemia as during that time my father was

dying from leukaemia. [A & E]

Yes, a patient with a brain tumour as I had a relative die of a brain

tumour, so I thought about that patient more. (A & E)

Issues surrounding the resuscitation of patients ap-

peared to cause stress for A & E nurses.

The 2-year-old drowning, we tried for 3 hours to resuscitate her

and the stress was increased by the mother being there. Nobody

agreed to it. [A & E]

One nurse commented that not knowing the outcome

was stressful:

No feedback from ITU so don't know outcome and therefore

worrying as don't know how they coped. [A & E]

Of the 23 hospice nurses, only two could not recall a

patient whose care they had found dif®cult. For one nurse

the particular patient who had stuck in her mind was a

patient she had witnessed die an unsatisfactory death in

hospital many years before. Five nurses could recall

patients whose symptoms were uncontrolled:

Lady with particularly dif®cult pain. Sought always for you to

make things better. [Hospice]

One nurse found a patient with two young children

dif®cult:

Very close to home. [Hospice]

Two nurses found the illness itself dif®cult to cope

with:

His physical state, something I had not experienced before, his

eyes and tongue were protruding. [Hospice]

Yes, because of illness felt out of my depth. [Hospice]

For other nurses it was the relatives that were a source

of stress:

Lot of trouble with will¼ family more concerned with will than

supporting patient. [Hospice]

Dwelling on work issues at home

Respondents from both clinical sites indicated that they

continued to ruminate on work-related issues after a

dif®cult day (Table 3). Only six (13á9%) nurses reported

that they did not take worries home. The majority of

respondents had a person who they could talk to at home,

although eight (18á6%) nurses did not (Table 4).

As can be seen from Table 5, all the hospice nurses felt

that they were able to talk to colleagues at work, which

was signi®cantly different from A & E nurses. Hospice

nurses commented on the supportive environment:

Yes, absolutely we are very privileged here. [Hospice]

It's easy to cry here¼ very supportive especially coming from a

palliative care ward within the NHS where there isn't the time or

staff to support each other. [Hospice]

Yes, lots of hugs, cuddles and tears. [Hospice]

One nurse commented:

There is a ®ne line between being frightened and fascinated by

death¼ Working here had helped me in that respect. [Hospice]

In contrast, the A & E nurses who did feel they could

talk to colleagues described having to seek out those

nurses they were particularly friendly with. Those who

felt unable to talk to colleagues commented:

Feel reluctant to talk here¼ There is a lot a back-stabbing here,

don't know what people might say. [A & E]

A lot of girls won't con®de in other people. [A & E]

Institutional support was available at both sites, in the

form of regular staff meetings at the hospice and de-

brie®ng sessions in A & E which occurred after major

events. But one nurse commented:

I think it is more for the medical side. [A & E]

Table 3 Responses to the question: If you have had a dif®cult day

do you ®nd yourself thinking about it when you go home?

Response

Accident and


Yes 90% (18) 83% (19)

No 10% (2) 7% (4)

Fisher Exact Test 0.48, P < 0:48

Table 4 Responses to the question: Is there someone

you can talk to at home?

Response

Accident and


Yes 85% (17) 78% (18)

No 15% (3) 22% (5)


Table 5 Responses to the question: Are you able to talk to

colleagues at work?

Response

Accident and


Yes 80% (16) 100% (23)

No 20% (4) 0


S.A. Payne et al.


DISCUSSION

This preliminary study, conducted at two sites, which

have the same mean annual death rate, has demonstrated

that on a self-report measure of death anxiety nurses have

fairly similar responses. However, in a quarter of the

responses there were statistically signi®cant differences.

As anticipated, A & E nurses are more likely to avoid

thinking about death than hospice nurses. They also

showed a greater fear of death and less acceptance than

hospice nurses. These results support those of Carr &

Merriman (1996) who found that hospice nurses had low

death anxiety compared to hospital nurses who showed

high death anxiety and a reluctance to spend time with

dying patients.

There are a number of reasons to be cautious in

interpreting the results. Although the study sites shared

the same mean death rate, there was obviously consider-

able variation in individual exposure to death. Future

studies should investigate this as the data from patients

indicated differences in perceived distress from witness-

ing deaths (Payne et al. 1996). The sample size was small

with a response rate of 71% which was due to the research

team's limited resources and time. As this was a cross-

sectional study, it is not possible to draw inferences about

causality. For example, were the differences found due to

intrinsic features of the nurses which led them to make

different career choices, or due to structural features of the

work environment which differ in the acknowledgement

and containment of staff distress? Future research could

usefully explore these issues.

This study relied on self-report measures and it is

important to remember that there are potential differences

between perceived methods of coping and actual behav-

iours. Nurses may be unwilling to report less socially

acceptable coping responses such as drug taking and

taking `sick' days off.

Folta (1965) suggested that people with a high death

anxiety are more likely to work within the health profes-

sion. While this may be true for A & E nurses who

exhibited high death anxiety, this does not follow for the

hospice nurses. When questioned about why they chose to

work in that particular speciality the hospice nurses gave

reasons such as `Find subject of death fascinating' and

`something I always wanted to do' as well as `personal

experience of terminal illness'. These responses do not

suggest an anxiety about death, instead they indicate a

comfort with dealing in death. In contrast when A & E

nurses were questioned about why they chose to work in

that speciality they gave reasons such as `busy, excite-

ment, lack of routine' and `variety of patients/procedures',

with no reference to wanting to work with dying patients.

It may be that it is people with a low death anxiety and

high approach acceptance of death who feel able to work

closely with dying patients, but for A & E nurses who do

not choose to work with the dying they may be faced with

death as an unfortunate consequence of the job.

The researchers suggest there is evidence from the

interview data that nurses varied on their ability and/or

willingness to re¯ect on the care provided. The pace of

nursing care is likely to be different between the two

specialities but all nurses are now encouraged to be

re¯ective practitioners. The description of distressing

features such as child deaths and traumatic deaths were

similar to those reported in previous research (Payne et al.

1996). Areas such as the death of young people and

problems during resuscitation appear to be stressful for

the A & E nurses, yet there appeared to be limited

opportunity to discuss these issues. The A & E Department

were aware of the training needs in bereavement of their

staff which, following the study, have been provided by

the researchers.

In conclusion, this study suggests that hospice nurses

appeared to have low death anxiety despite spending

almost every day with dying patients. The evidence shows

there is a need for an easily accessible and con®dential

support network within A & E. As well as a support

system, education in areas such as bereavement and

communication skills could be bene®cial since many of

the A & E nurses reported that some of their most dif®cult

times were spent with bereaved relatives. The experience

of palliative care health professionals in developing be-

reavement services and support systems for staff could

provide guidance in other health care settings.

Acknowledgements

The researchers would like to thank the nurses who took

part in the study. The research was funded by the Nuf®eld

Foundation.

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Documents

A comparative study of death anxiety in hospice and emergency nurses