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Relationships among death anxiety,communication apprehension with thedying, and empathy in those seekingoccupations as nurses and physiciansHeather L. Servaty a , Mark J. Krejci b & Bert Hayslip Jr. ca Department of Psychology , University of North Texas , Denton,Texas, USAb Department of Psychology , Concordia College , Moorhead,Minnesota, USAc Department of Psychology , University of North Texas , Denton,Texas, USAPublished online: 14 Aug 2007.

To cite this article: Heather L. Servaty , Mark J. Krejci & Bert Hayslip Jr. (1996) Relationshipsamong death anxiety, communication apprehension with the dying, and empathy in those seekingoccupations as nurses and physicians, Death Studies, 20:2, 149-161, DOI: 10.1080/07481189608252747

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RELATIONSHIPS AMONG DEATH ANXIETY, COMMUNICATION APPREHENSION WITH THE DYING, AND EMPATHY IN THOSE SEEKING OCCUPATIONS AS

NURSES AND PHYSICIANS ~ m m m m m m m m m m m m m m m m m m m m m m w m w m f f i m w w m w m m w m w w m w m w m w w m w w m

HEATHER L. SERVATY

Department of Psychology, University of North Texas, Denton, Texas, USA

MARK J. KREJCI

Department of Psychology, Concordia College, Moorhead, Minnesota, USA

BERT HAYSLIP, JR.

Department of Psychology, University of North Texas, Denton, Texas, USA

In light of tlE modern pherunnenm ?fincreased institutionalized deaths occur- ring in hospitals and in nursing hornes, much qf recent death attitude research has ,focused on health professiouals. The present study explored possible rela- tiunships a m g mmures of death anxiety, communication appehmsion with the dying, and empathy in udrpaduate nursing, piemedical, and control subjects. Main effictsjbr year in school indicated that seniws scored h e - r than ,freshmen on communication apprehension with the dying. The multivariate efectsjbr,f;elrl ?f study were also sipijkant, with uniuariate results indicating that nursing students scored lower than controls on communication apjr/hension with the dying.

Although death remains one of the common threads which binds all living things, there is far from a single approach to or under- standing of the topic. Currently, approximately “80 percent of all

Address correspondence to Heather I>. Servaty, Department of Psychology, Univer- sity of North Texas, Denton, T X 76203, USA.

Death Studies, 20:149-161, 1996 Copyright 0 1996 Taylor & Francis

0748-1187/96 $12.00 + .OO

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persons die i n an institutional setting-hospital, nursing or con- valescent fx i l i ty , or retirement home providing care for the aged” (DeSpelder & Strickland, 1992). Because of their daily, one-on- one contact with the dying process and with death, medical professionals have become the focus of much research (Campbell, Abernethy, & Waterhouse, 1983-84; Dickinson & Pearson, 1980- 81; Field & Howells 1985; Powell, Thorson, Kara, & Uhl, 1990; ‘rhomtn & Pouell, 1991).

hlan) I esearchers agree that hospital staff are in a strategic position to either help or hinder the psychological comfort of dying patients (Cramond, 1970; Dickinson & Pearson, 1980-81; Field & Howells, 1988). In the past, studies have examined the attitiides physicians hold toward death (Campbell, Abernathy, & Waterhouse, 1983-84; Field & Howells, 1986; Howells & Field, 1982) and toward the dying (Dickinson 8c Pearson, 1980-81; Field & Howells ~ 1988; Neimeyer, Rehnke, & Keiss, 1984).

Of greater interest, however, is the work that has centered on how these attitudes influence behavior, specifically relationships with dving persons. In particular, Trent, Glass, & McGee (1981) report that individuals with less death anxiety felt more comfort- able when they spoke with terminally ill people.

I n an attempt to measure the “degree of fear or anxiety an indk idual associates with communicating specifically with dying persons” (Hayslip, 1986- 1987; p. 254), Hayslip developed the Communication Apprehension-Dying Scale (CA-Dying). He found a significant positive correlation between CA-Dying and two indices of death anxiety, conscious fears of one’s own death and the fears of another’s dving.

Hayslip (1986- 1987) reported that hospice volunteers who expressed difficultv in relating to the dying, as indicated by higher scores on ct;m mu n ica t ion apprehension with the dying were different in three main aspects from those who felt more comfortable. Thev were “less likely to repress fears about their own deaths; more likely to express concerns over their own or another’s dving; and more likely to have negative attitudes to- ward aging/death” (Hayslip, 1986-87; p. 257).

Although numerous factors are thought to affect communi- cation, empathy is one that has also been studied in reference to health professionals (Morath, 1989; Jarski, 1988). Scholars have

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CA-Dying 151

investigated the effects on nurses of their clinical experience with patients and found that there were no significant changes in em- pathy scores as the students moved through their clinical training (Becker & Sands, 1988). Others who have studied nurses, social workers, and teachers have, however, found that emotional em- pathy was significantly and positively correlated with both emo- tional exhaustion and personal accomplishment (Williams, 1989).

In reference to communication patterns, Lochman and Dain (1982) reported that highly empathic physicians, in contrast to their lower-scoring counterparts, more frequently addressed problematic emotional issues in conversations with their patients. Consistent with this finding, Stiff et al. (1988) found empathic concern to have a substantial impact on communication respon- siveness.

Although no published research exists that investigates a re- lationship between empathy and death anxiety, some evidence was found supporting the relationship of anxiety to each of these variables individually. One study reported that individuals who volunteered for hospice work self-reported themselves high in empathy while low in trait anxiety (Wilkinson & Wilkinson, 1986-87). Other research shows conscious death anxiety to be significantly associated with the Taylor Manifest Anxiety Scale (Templer, 1970) and trait anxiety (Robbins, 1989). These findings would lead one to hypothesize a possible relationship between empathy and death anxiety. The present investigation attempts to study this relationship in a more direct manner by specifically examining a possible correlation between death anxiety and em- pathy.

Another factor that must be considered when evaluating the death-related attitudes of health professionals concerns the de- velopment of such attitudes. Some suggest that individual atti- tudes toward death may be formed before participation in any kind of practical, in-house medical training, and that those inter- ested in health occupations may select their career based on these already established attitudes toward death (Campbell, Abernethy, & Waterhouse, 1983-84). Still others believe that the death atti- tudes of health professionals develop in reaction to their occu- pational experience, suggesting that individuals react in certain situations based on the specific medical training they received

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(Lattanner 8c Hayslip, 1984-85; Sundin, Gaines, 8c Knapp,

A number of studies speak to this issue. When surveying practicing nurses and physicians, Campbell, Abernethy, and Waterhouse (1983-84) reported that nurses consistently main- tained a more positive view toward death, while physicians de- scribed it as a highly negative experience. Nurses described the process as “rebirth, tranquility and victory” (p. 46) whereas phy- sicians used words such as “unsafe, alone, forgotten, and cold” (p. 46). These data, confirming a difference between the death attitudes of nurses and physicians, led the authors to suggest the possibility that the two fields select persons a priori for differing attitudes toward death (Campbell et al., 1983).

In this respect, other research has reported that students entering medical school may have higher death threat scores than those in other professions, suggesting to some researchers that people choose their specific field to work out their death-related personal problems (Wahl, 1969; White, 1969; both cited in Nei- meyer, Behnke, 8c Riess, 1984).

It has also been found that practicing nurses scored lower than a control group in personal distress, a subscale of a multi- dimensional measure of empathy developed by Davis (1983), en- titled the Interpersonal Reactivity Index. The personal distress subscale is defined by Becker and Sands, (1988) as “an affective measure of self-oriented feelings of unease in tense, interpersonal settings” (p. 199). Thus, persons with high scores on other di- mensions of empathy, as defined by Davis (1983), such as per- spective taking and empathic concern, tend to have low scores on personal distress. This finding suggests that nurses may choose their field knowing their superior capacity to communicate in difficult situations, which could include those involving death.

Brent, Speece, Gates, and Kaul (1992-93) compared the death attitudes of first-year medical and nursing students with no previous experience in caring for dying patients in order to explore the kinds of attitudes the two groups brought with them as they began their professional careers. The researchers studied the ways in which those attitudes influenced professional career choice and how the factors associated with gender differences interacted in affecting those attitudes. In addition, the authors

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explored the kinds of nonprofessional death-related experiences that influenced students attitudes. Results indicated that on five of the six attitude measures, female nursing students expressed a more positive attitude than either male or female medical stu- dents. Brent et al. (1993) also found that the number of hours of death and dying coursework and student age each appeared to contribute significantly to the attitudes, with those students with more experience having more positive attitudes.

The present study attempted to extend the above work by examining premed students as well as nursing students. First- year medical students have already had four years of undergrad- uate training, most often in the areas of biology or chemistry. It therefore seemed important to look not only at first-year medical students, but also to study first-year premed students, who lack such training.

The basic rationale of the investigation was that the death- related attitudes of students studying to be health professionals may be affected by their undergraduate training. To further investigate at what point in one’s career possible differences in death attitudes and empathy emerge, the study utilized as par- ticipants students who had not yet entered the workforce, but who were studying to be either physicians or nurses. It also explored relationships between death anxiety, empathy, and communica- tion apprehension with the dying.

Method

Subjects

The 129 volunteers in this study were drawn from students at- tending Concordia College in Moorhead, Minnesota. The three freshmen groups included a Freshman Nursing group (FN; n = 13, M Age = 18.54, Male = 1, Female = 12), a Freshman Premed group (FPM; n = 23, M Age = 19.74, Male = 7, Female = 16), and a Freshman Control group (FC; n = 31, M = 18.52, Male = 11, Female = 20). Senior groups included a Senior Nurs- ing group (SN; n = 11; M Age = 24.82; Male = 1, Female = lo), a Senior Premed group (SPM; n = 23, M Age = 21.52, Male

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= 14, Female = 9), and a Senior Control group (SC; n = 28, M Age = 21.57, Male = 8, Female = 20). Of 227 packets sent, 129 were returned for a total return rate of 56%. Return rates ranged from a low of 39% (11 of 28) for senior nursing students to a high of 71% (23 of 32) for senior premed students, with return rates for the remaining groups ranging from 50% to 68%. The premed students in the investigation had not received any formal death and dving training, while the nursing students had been exposed to death and dying discussions of an informal nature in various courses.

Materials

T h Mehrabzan and Eprtvzn Empathy Scale (EMP; Mehrabian & Epstein, 1972). According to Mehrabian and Epstein (1972), the object in developing the empathy scale was to offer an alternative measure of general (covering many situations) emotional empa- thy based primarily upon salience of mood. A sample item is, “It makes me sad to see a lonely stranger in a group.” Mehrabian and Epstein (1972) contrast their work with Dymond’s (1949) cognitive role-taking approach to empathy and Stotland’s ( 1969) empathic emotional response approach, the latter of which relies on self-report and physiological indicators. The scale’s validity was substantiated via findings from a Milgram-like experiment wherein highly empathic subjects behaved less aggressively than subjects scoring lower on the empathy scale (Mehrabian 8c Ep- stein, 1972). In a second study, students with higher empathic scores were more likely to help a confederate who was emotionally upset about a personal problem (Mehrabian & Epstein, 1972).

The empathy scale is presented as a four-point Likert scale of 33 items, with higher scores indicating greater emotional empa- thy. The split-half reliability for this instrument is .84 and it has a correlation 01 .06 with the Crownc and Marlowe (19CXl) social desirability scale (Mehrabian 8c Epstein, 1972).

7 ’ h ~ h u t h Anxzpty Scalp (LIAS; ‘IPmpler, 1970). This self-report scale wac designed to assess attitucks toward a widc range ol dt.a~h-~.t.lated experiences. A saniple item is, “I am not particu- larlv afraid of getting cancer.” The test-retest reliability of the

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scale is 2 3 , while the alpha coefficient indexing internal consis- tency is .76 (Templer, 1970).

The Communication Apprehension with the Dying Scale (CA- Dying; Hayslip, 1986-87). This scale was designed to measure the de- gree of fear or anxiety an individual associates with having to communicate with dying persons. A sample item is, “I would feel comfortable in developing an intimate conversation with a dying person.” The test-retest reliability is .78, while internal consistency is .86 (Hayslip, 1986-87).

Procedure

A list of all premed students was acquired through the faculty director of the premed program at a small liberal arts college in Minnesota. Nursing students were identified through a list pro- vided by the chair of the nursing program. Control subjects were randomly selected from the overall college population through use of the registrar’s office computer list.

During January of 1992, all potential participants received a packet in their campus post office boxes containing all three measures in addition to an instruction sheet, a demographic in- formation form, and an informed consent form. The demo- graphic information form included a list of 15 yes-no questions concerning different possible death experiences such as, “I have experienced the death of a grandparent.” The number of items to which subjects responded with a “yes” were added for a total death experience score. Premed, nursing, and control subjects did not differ ($I > .05> in total death experience scores.

Individuals choosing to participate filled out the above mea- sures and returned them in one envelope, while the informed consent form was returned in a separate envelope.

Results

Pearson correlations were computed among death anxiety, com- munication apprehension with the dying, and empathy. Signifi- cant positive correlations were found between death anxiety and

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TABLE 1 Communication Apprehension with the Dying, Death Anxiety, and Empathy

Correlations among Sex, Death Experience,

~-

Death Death Sex,‘ Experience” Empathy <:A-Dying Anxiety‘

- - - - - Sex Death Experience .06 - - - -

Empathy .21* - .01 CA-Dy ing - .09 -.15 .12* - Death Anxiety .11 .07 .20“ .42** -

- - - -

“Sex was coded as Male = 1 and Female = 2. ”Death experience was defined in terms of subjects’ acknowledgment of having prcvi-

ously experienced u p to 15 separate losses of others (e.g., parent, sibling, grandparerit, close friend).

“Ienipler Death Anxiety Scale. * p < .05. **p < .Ol.

communication apprehension with the dying, as well as between death anxiety and empathy (see Table 1). In addition, a positive correlation was obtained between empathy and sex, with females tending to score higher on the empathy scale than males.

A 2 x 3 MANOVA was performed using 2 levels of year and 3 levels of field of study on the 3 instruments measuring death anxiety, communication apprehension with the dying, and em- pathy (see Table 2). While there was no interaction effect between year in school and field of study, main effects for year in school

TABLE 2 Apprehension with the Dying, Death Anxiety, and Empathy

Table of Means for All Subject Groups for Communication

Groups

Senior Nursing Senior Premed Senior Control Freshman Nursing Freshman Premed Freshman Control

(;A-Dying

M SD

69.18 10.11 76.22 12.60 81.82 18.12 80.62 11.73 85.22 11.80 87.94 13.91

Death Anxiety,‘ Empathy

M s D ~

M SD

6.64 1.03 5.87 2.70 7.68 3.40 7.08 3.04 7.26 3.25 7.84 2.85

43.09 16.06 29.04 17.20 33.82 17.90 35.54 14.09 36.09 23.94 39.26 20.24

“‘Iernpler Death Anxiety Scale.

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were obtained on the multivariate level, F 3,121 = 3.69, p < .01. Univariate analysis indicated a significant difference in commu- nication apprehension with the dying between freshmen and se- niors, with seniors scoring lower than freshmen, F 1,121 = 11.24,

The multivariate effect for field of study was also significant, F 6,244 = 2.32, p < .05. Univariate analysis indicated a signifi- cant difference in communication apprehension with the dying scores between nursing and control participants, with the former group scoring significantly lower than the latter, F 1,123 = 4.47, p < .01, while nursing subjects and premed subjects scored sim- ilarly. When death experience and sex were utilized as covariates, resu 1 ts were unchanged.

p < .001.

Discussion

The present study is consistent with Hayslip’s (1986-87) finding that CA-Dying is positively related to other death attitude var- iables. Findings suggest that those persons who have less anxiety about death-related events also tend to report lower apprehension about talking with people who are dying. As the measure of death fear used here was a general one, further study should work to determine which death-associated events, if any, relate more or less to CA-Dying.

The positive relationship found between empathy and death anxiety may at first seem counterintuitive. Although the absolute level of the correlation is rather low, it may indicate that those with greater anxiety about death-related events tend to cope with such anxiety by empathically reaching out to individuals who are not dying. It is also possible that reporting greater empathy may be a form of compensation for those who experience greater death anxiety. It is important to note that recent criticisms of the DAS’s factor structure in accurately assessing death attitudes may be a possible explanation for this counterintuitive finding (Thor- son & Powell, 1991; Levin, 1989-90).

The finding that seniors are less apprehensive than freshmen about communicating with a dying person suggests that length of education, number of life experiences, age, and maturity may

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all play a role in influencing levels of CA-Dying. While a dif- ferential professional acculturation and/or training effect, relative to controls, seems apparent from differences in CA-Dying scores by year in school (as shown in Table l ) , these differences were not statistically significant in that a lcvel by field-of-study interaction was not obtained. Thus, because the study was cross- sectional in nature, it is not possible to form definite conclusions regarding the effects of such training on CA-Dying over the course of time. A longitudinal design that investigated the above- mentioned variables and tracked individuals throughout their ed- ucation would make it possible to draw clearer conclusions. In addition, the inclusion of variables such as religious beliefs, socio- economic status, and cultural factors \sould probably add impor- tant information in this regard.

The finding that nursing students were less apprehensive about Communicating with dying people than were the controls, regardless of vear in school, suggests that one’s choice of field of stud) is an important influence on CA-Dying scores. It is also possible that individuals chose nursing because of lower appre- hension about communicating with dying persons, suggesting that they may be less concerned than those who choose other majors (see Campbell et al., 1983-84). These findings corre- spond to the Brent et al. (1992-93) finding that nursing students expressed more positive attitudes concerning talking with dying patients about death and dving and general interaction with dying persons than did beginning medical students.

However, the present data also suggest that, contrary to ex- pectation, prerned students are more similar to the controls than to nursing students in their CA-D! ing scores which indicates that premed students may enter their undergraduate training with CA-Dving scores that resemble those of people who are not planning medical careers rathcr than those of their counter- parts in nursing. In light of this, it is worth noting that Powell et al. ( 1990) found that individuals entering and those graduating from medical school both had lower scores on the Death Anxiety Scale than controls. They also found no change over four years in Death Anxiety Scores among medical students. Their findings, taken with the results of the present investigation, suggest that

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changes in death-related attitudes of those seeking occupations as physicians may occur during their undergraduate rather than medical school training. However, the present data were collected after the freshmen premed participants had been in college for one semester, so this conclusion remains tentative.

Because all freshmen participants, including nursing majors, had been enrolled for one semester at the time of testing, the finding that the nursing group scored lower on CA-Dying than the control group may indicate that even minimal experience in the nursing curriculum may lower CA-Dying scores. Because of the cross-sectional nature of the investigation, however, a priori selection of a nursing major based on estimates of one’s own ease in communicating with ill or dying persons cannot be ruled out as an alternative explanation. In addition, senior nursing majors’ CA-Dying scores may also result from their fourth-year hos- pital practicum. It is again important to note that a longitudinal study would allow for the tracking of freshmen through their undergraduate training, recording the numbers of students who either withdraw from or change to a nursing major. On the basis of the present data, the causal nature of the relationship between occupational choice and death attitudes remains ambiguous.

These findings, however, do seem to suggest that experience, whether drawn from life or from academiclprofessional training, may be the pivotal factor in lowering levels of apprehension about communicating with the dying. Hayslip (1986) found that those who had experienced hospice volunteer training showed signifi- cantly lower CA-Dying scores after such training, relative to their waiting-list control counterparts.

Hayslip (1986-87) suggests that one use of the CA-Dying scale is as a screening tool for identifying those who feel uncom- fortable about communicating with dying people. The present findings reinforce the role of the CA-Dying score as a reason- able criterion by which people who may have difficulty relating to those who are dying may be identified, especially if after either experiential or didactic coursework or training, such scores re- main high. Alternatively, the data also suggest that CA-Dying scores are a reasonable measure of the efficacy of training in preparing health professionals to interact with dying persons.

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