The COVID-19 pandemic and nurses' attitudes toward death

Attitudes toward Death among Health Care Professionals in the Balkan Region

Background and Objectives: Death is an unavoidable experience in any person's life and affects not only the dying person but also their caregivers. The dying process has been displaced from homes to health care facilities in the majority of cases. Facing death and dying has become an everyday life of health care professionals (HCP), especially in palliative care (PC) settings. This study aimed to investigate the death attitudes among HCPs in Serbia. Materials and Methods: The Serbian version of the Death Attitude Profile-Revised (DAP-RSp) was used as a measurement instrument. Results: The average age of the 180 included participants was 42.2 ± 9.9 years; the majority were females (70.0%), with more than 10 years of working experience (73.0%), physicians (70.0%) and those working in a non-oncological (non-ONC) field (57.78%). The mean total score of DAP-RSp was 124.80 ± 22.44. The highest mean score was observed in the neutral acceptance dimension (NA) (5.82 ± 0.90) and lowest in the Escape acceptance (EA) (2.57 ± 1.21). Higher negative death attitudes were reported among nurses compared to physicians (p = 0.002). Statistically significant differences were observed in the fear of death (FD) and death avoidance (DA) domains, favoring PC specialists and oncologists (p = 0.004; p = 0.015). Physicians working in Oncology (ONC) showed lower FD values (p = 0.001) compared to non-ONC departments. Conclusions: Attitudes toward death among HCPs are of great importance for the well-being of both HCPs and patients. Negative attitudes can lead to deficient care. The fear of death is highly represented among Serbian HCPs working in non-ONC fields, including both nurses and physicians. This study emphasizes the need for further research to comprehensively explore and understand HCPs' attitudes toward death. This research highlights the need for the development of an educational curriculum across all levels of medical education, aimed at overcoming the fear of death and enhancing coping strategies, which will improve the care for patients diagnosed with terminal illnesses.

Mediating effect of meaning in life on death anxiety and attitude toward palliative care among undergraduate nursing students

BACKGROUND

This study investigates the mediating effect of meaning in life between death anxiety and attitude toward palliative care among nursing students.

METHODS

We enrolled 363 undergraduate nursing students using a convenience sampling method as the respondents and conducted a survey using general information about nursing students, the Chinese version of the FATCOD-B Scale, the Chinese version of the Death Anxiety Scale, and the Chinese version of the Meaning in Life Questionnaire. The SPSS25.0 statistical software was used to analyze the mediating effect.

RESULTS

The mean total attitude score toward palliative care was (104.72 ± 10.62). Death anxiety had a significant negative predictive effect on the attitude toward palliative care (β = -0.520, P < 0.01). When the mediating variable of the presence of meaning in life was included, the negative predictive effect of death anxiety on attitude toward palliative care remained significant (β = -0.379, P = 0.036); the mediating effect (-0.141) accounted for 27.12% of the total impact (-0.520).

CONCLUSIONS

The presence of meaning in life mediates the relationship between death anxiety and attitude toward palliative care. This implies that nursing educators, through their role in educating nursing students about the meaning of life, can significantly influence the development of a positive attitude toward palliative care.

Description and Analysis of Research on Death and Dying during the COVID-19 Pandemic, Published in Nursing Journals Indexed in SCOPUS

AIM

To offer an overall picture of the research published regarding the different aspects of death and dying during the COVID-19 pandemic in journals covering the field of nursing in the Scopus database.

DESIGN

bibliometric analysis.

METHODS

The metadata obtained were exported from Scopus for subsequent analysis through Bibliometrix. Using the VOSviewer co-word analysis function, the conceptual and thematic structure of the publications was identified.

RESULTS

A total of 119 papers were retrieved, with the participation of 527 authors. The publications were found in 71 journals covering the nursing area. The main lines of research revolved around the keywords "palliative care" and "end-of-life care" in regard to the ethical, psychological, and organizational challenges faced by the health professionals who cared for these patients.

CONCLUSION

The results obtained offer a range of data and images that characterize the scientific production published on this topic, coming to the conclusion that, due to the multifaceted and multidisciplinary approach to the experience of death, care, and accompaniment in the dying process, bibliometric maps improve the comprehensive understanding of the semantic and conceptual structure of this field of research. This study was retrospectively registered with the OSF Registries on the 14 March 2024.

"They choke to death in front of your very eyes": nurses' lived experiences and perspectives on end-of-life care during COVID-19

BACKGROUND

The COVID-19 pandemic led to an intensified fear and threat of dying, combined with dying and grieving in isolation, in turn significantly impacting nursing in end-of-life situations. The study aims (1) to understand the lived experiences of nurses who provided care to end-of-life patients during COVID-19; and (2) to explore whether providing care under such circumstances altered the perspectives of these nurses regarding end-of-life care.

METHODS

Applying the phenomenological-interpretive qualitative approach, 34 in-depth semi-structured interviews were conducted between March 2020-May 2021 with nurses from eight hospitals in Israel who were recruited through purposive and snowball sampling. Thematic analysis was applied to identify major themes from the interviews.

RESULTS

Five main themes emerged from the analysis, including: (1) a different death; (2) difficulties in caring for the body after death; (3) the need for family at end-of-life; (4) weaker enforcement of advance care directives; and (5) prolonging the dying process.

DISCUSSION

During the pandemic, nurses encountered numerous cases of death and dying, while facing ethical and professional issues regarding end-of-life care. They were required to administer more aggressive care than usual and even necessary, leading to their increased moral distress. The nurses' ethical concerns were also triggered by the requirement to wrap the corpse in black garbage-like bags to prevent contagion, which they felt was abusing the dead. The findings also demonstrate how family presence at end-of-life is important for the nursing staff as well as the patient. Finally, end-of-life situations during the pandemic in Israel were managed in an individual and personal manner, rather than as a collective mission, as seen in other countries.

CONCLUSIONS

The study offers insights into the nurses' attitudes towards death, dying, and end-of-life care. An emphasis should be placed on the key elements that emerged in this study, to assist nurses in overcoming these difficulties during and after medical crises, to enhance end-of-life care and professionalism and decrease burnout.

Attitudes and experiences related to the deaths of COVID-19 patients among nursing staff: A qualitative evidence synthesis

AIM

To identify and synthesize the experiences and attitudes of nursing staff regarding the deaths of COVID-19 patients.

REVIEW METHODS

A qualitative evidence synthesis was carried out, using Noblit and Hare's meta-ethnographic approach. The review protocol was listed in PROSPERO (CRD42022330928). Studies published from January 2020 to January 2022 that met the criteria were searched in PubMed, Web of Science, Scopus, CINAHL, CUIDEN and PsycInfo. A total of 12 articles were included.

RESULTS

Thirty-three metaphors emerged, which were grouped into three main themes: Determining factors of care, Feelings about death and Strategies for coping with death. Nurses reported the high emotional toll, the absence of family and the lack of staff, protocol and training as determining factors. Furthermore, staff had doubts about the quality of care that COVID-19 patients received. As coping strategies, nurses developed avoidance behaviours towards COVID-19 patients, selective memories, resilience, and/or leaving the profession.

CONCLUSIONS

The difficulty in providing adequate nursing care and the high number of deaths has increased anxiety and stress among nurses. These factors, alongside their lived experiences of seeing patients suffering, many dying alone without family members, have had psychological repercussions on nursing staff.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

The results demonstrate a high emotional toll and doubts surrounding their caregiving role caused by the lack of professional training needed to face a pandemic. This research shows what has been learned for future pandemics and highlights basic components that could provide a foundation for coping interventions for healthcare professionals.

IMPACT

WHAT PROBLEM DID THE STUDY ADDRESS?: The challenges posed by COVID-19 patient deaths for nursing staff around the world and also by the pandemic circumstances in which those deaths occurred. WHAT WERE THE MAIN FINDINGS?: The high number of deceased patients who were isolated from family members, communication with family members and doubts surrounding care given during the pandemic have created feelings of fear, stress and anxiety, as well as obsessive thoughts that have changed nursing staff's perception of death due to COVID-19. WHERE AND ON WHOM WILL THE RESEARCH HAVE AN IMPACT?: Results will be useful for preparing for future pandemics, and for policymakers and health staff in supporting healthcare professionals by creating programmes to help them cope with the emotional toll they have felt after dealing with death in such unprecedented circumstances.

REPORTING METHOD

The authors have adhered to the PRISMA guidelines and the eMERGe Reporting Guidance.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

Registered Nurses' attitudes towards end-of-life care: A sequential explanatory mixed method study

AIMS

To examine registered nurses' attitudes about end-of-life care and explore the barriers and facilitators that influence the provision of high-quality end-of-life care.

DESIGN

A sequential explanatory mixed methods research design was used.

METHODS

An online cross-sectional survey was distributed to 1293 registered nurses working in five different hospitals in the Kingdom of Saudi Arabia. The Frommelt Attitudes Towards Care of the Dying Scale was used to assess nurses' attitudes towards end-of-life care. Following the survey, a subset of registered nurses were interviewed using individual semi-structured interviews.

RESULTS

Four hundred and thirty-one registered nurses completed the online survey, and 16 of them participated in individual interviews. Although nurses reported positive attitudes towards caring for dying patients and their families in most items, they identified negative attitudes towards talking with patients about death, their relationship with patients' families and controlling their emotions. The individual interview data identified the barriers and facilitators that registered nurses experience when providing end-of-life care. Barriers included a lack of communication skills and family and cultural and religious resistance to end-of-life care. The facilitators included gaining support from colleagues and patients' families.

CONCLUSION

This study has identified that while registered nurses hold generally favourable attitudes towards end-of-life care, they have negative attitudes towards talking with patients and families about death and managing their emotional feelings.

RELEVANCE TO CLINICAL PRACTICE

Education providers and leaders in healthcare settings should consider developing programmes for undergraduate nurses and nurses in clinical practice to raise awareness about the concept of death in a cross-section of cultures. Nurses' attitudes towards dying patients will be enhanced with culture-specific knowledge which will also enhance communication and coping methods.

REPORTING METHOD

This study used the Mixed Methods Article Reporting Standards (MMARS).

The mediating effects of attitude toward death and meaning of life on the relationship between perception of death and coping with death competence among Chinese nurses: a cross-sectional study

Background

It is important to understand how the perception of death affects the competence to cope with death.

Objectives

To explore whether the perception of death has an indirect effect on competence to cope with death through the mediation of attitude toward death and meaning of life.

Methods

A total of 786 nurses from Hunan Province, China, selected by random sampling method and asked to complete an online electronic questionnaire between October and November 2021 were included in the study.

Results

The nurses’ scored 125.39 ± 23.88 on the competence to cope with death. There was a positive correlation among perception of death, competence to cope with death, the meaning of life, and attitude toward death. There were three mediating pathways: the separate mediating effect of natural acceptance and meaning of life, and the chain mediating effect of natural acceptance and meaning of life.

Conclusion

The nurses’ competence to cope with death was moderate. Perception of death could indirectly and positively predict nurses’ competence to cope with death by enhancing natural acceptance or sense of meaning in life. In addition, perception of death could improve natural acceptance and then enhance the sense of meaning in life to positively predict nurses’ competence to cope with death.

From the first to the fourth critical period of COVID-19: what has changed in nursing practice environments in hospital settings?

BACKGROUND

The COVID-19 pandemic reinforced the need to invest in nursing practice environments and health institutions were led to implement several changes. In this sense, this study aimed to analyze the impact of the changes that occurred in nursing practice  environments between the first and fourth critical periods of the pandemic.

METHODS

Quantitative, observational study, conducted in a University Hospital, with the participation of 713 registered nurses. Data were collected through a questionnaire with sociodemographic and professional characterization and the Scale for the Environments Evaluation of Professional Nursing Practice, applied at two different points in time: from 1 to 30 June 2020 and from 15 August to 15 September 2021. Data were processed using descriptive and inferential statistics.

RESULTS

Overall, the pandemic had a positive impact on nursing practice environments. However, the Process component remained favourable to quality of care, while the Structure and Outcome components only moderately favourable. Nurses working in Medicine Department services showed lower scores in several dimensions of the Structure, Process and Outcome components. On the other hand, nurses working in areas caring for patients with COVID-19 showed higher scores in several dimensions of the Structure, Process and Outcome components.

CONCLUSIONS

The pandemic had a positive impact on various dimensions of nursing practice environments, which denotes that regardless of the adversities and moments of crisis that may arise, investment in work environments will have positive repercussions. However, more investment is needed in Medicine Department services, which have historically been characterised by high workloads and structural conditions that make it difficult to promote positive and sustainable workplaces.

Estrutura das representações sociais da enfermagem sobre a morte decorrente da COVID-19

Introdução: Ainda que se saiba que a morte faz parte do ciclo da vida, diante de uma doença com muitos aspectos ainda desconhecidos como a COVID-19, torna-se importante compreender como os trabalhadores de enfermagem representam esse fenômeno, uma vez que são os únicos profissionais de saúde que continuam o cuidado ao indivíduo mesmo após a finitude da vida. Objetivo: analisar a estrutura das representações sociais sobre morte e morrer decorrentes de COVID-19 elaboradas por profissionais de enfermagem. Materiais e métodos: estudo qualitativo ancorado na vertente estrutural da Teoria das Representações Sociais com ênfase na Teoria do Núcleo Central, desenvolvido junto a 32 profissionais de enfermagem da cidade de Natal, estado do Rio Grande do Norte, Brasil. A coleta de dados foi realizada online mediante utilização da técnica de associação livre de palavras. Para a análise dos dados recorreu-se às análises prototípica e de similitude. Resultados: o provável núcleo central das representações foi constituído pelos termos tristeza e medo, e a composição do sistema periférico e da zona de contraste reforçam esse núcleo. Discussão: o núcleo central das representações dos profissionais de enfermagem sobre morte e morrer decorrentes de COVID-19 se constitui em um Themata polêmico de representação, e destaca os prejuízos à saúde psicossocial dos trabalhadores de enfermagem da linha de frente. Conclusões: perante às representações elaboradas sobre a morte e morrer decorrentes de COVID-19, é necessário o desenvolvimento de estratégias de enfrentamento que colaborem para a saúde psicossocial dos trabalhadores de enfermagem.

Impact of COVID-19 on the Environments of Professional Nursing Practice and Nurses' Job Satisfaction

(1) Background: The repercussions of work environments were widely studied before the pandemic. However, there are still many difficulties to be discovered considering the impact generated by it. Thus, this study aimed to analyse the impact of COVID-19 on nursing practice environments and nurses' job satisfaction. (2) Methods: A correlational study was conducted in a hospital in northern Portugal, with the participation of 416 registered nurses. Data were collected in June 2021 through questionnaires. The study was approved by the Institutional Ethics Committee. (3) Results: COVID-19 had a favourable impact on the structure component of the practice environments; the process component decreased compared to the pre-pandemic period; the outcome component remained moderately favourable to the quality of care. Nurses were not very satisfied or not at all satisfied with their valuation and remuneration; moderately satisfied with the leadership and staffing; and satisfied with the organisation and resources, co-workers and valuation by patients and families. In more favourable environments, nurses' job satisfactions were higher. (4) Conclusions: Identifying the dimensions with the best and worst scores allowed the institution's managers to concentrate efforts on where improvements were needed, thus preparing professional contexts for the recovery of care activities.

Lived Experiences of Female Nurses with COVID-19 Deaths on Their Watch

The COVID-19 pandemic has had a tremendous effect on health systems, leading to a spike in stress, anxiety, and depression conditions among healthcare workers worldwide. Considering the mental health status of nurses, a pillar of the health system, is crucial for assuring the quality of the healthcare provided during and after pandemics. This study aimed to explore the experiences of female nurses who witnessed their patients dying of COVID-19. Seven female COVID-19 nurses were interviewed in person. Thematic analysis of the respondents' verbatim answers was implemented. Six main themes were identified. Theme 1 illustrates nurses' experience of emotional and psychological trauma as they witnessed their patients with COVID-19 die under their care. Theme 2 reveals aftershock reactions, including somatization, isolation, and emotional disengagement. Theme 3 highlights the hindrances and difficult situations related to the in-hospital care of COVID-19 patients. Theme 4 demonstrates victorious feelings and celebration of the patient's survival. Theme 5 emphasizes the nurse's ability to be calm and recognize the takeaways or lessons they have learned from this phase for their careers and lives. Theme 6 sheds light on nurses' emerging abilities and competencies. This study will hopefully provide a basis for a debriefing program that might be beneficial to the nurses and the health system. This might affect nurses' ability to work closely with patients, cope emotionally with challenges, and fulfil their professional tasks.

Using a mediating model of death attitude and meaning in life to understand nursing students attitude about hospice care

BACKGROUND

Nurse-led hospice teams are an emerging trend in contemporary health care practice in China. However, Chinese nursing students are often ill-prepared to work in hospice care. Study findings on the attitude of nursing students toward the care of people who are dying and death varied among different countries and regions.

OBJECTIVES

To propose and empirically test a mediating model that examines how death attitude and meaning in life interact to affect Chinese undergraduate nursing students and their attitude toward the care of people who are dying.

DESIGN

A cross-sectional study.

PARTICIPANTS

A convenience sample of 1410 Chinese undergraduate nursing students.

METHODS

Data were collected from July to December 2020 using Chinese versions of the Frommelt Attitude Toward Care of the Dying Scale, Form B (FATCOD-B-C), Death Attitude Profile-Revised (DAP-R-C), and Purpose in Life Test (CPLT-C). SPSS version 22.0 and AMOS version 24.0 were used for statistical analysis.

RESULTS

The average FATCOD-B-C score was 98.28 ± 8.02. Death attitude and meaning in life were positively correlated with attitude toward care of the dying (p < 0.001), but death attitude was negatively correlated with meaning in life (p < 0.001). Pathway analysis showed that fear of death was significantly and positively correlated with attitude toward care of people who are dying. A mediating role was found among neutral acceptance, escape acceptance, and meaning in life to some extent. Meaning in life suppressed effects among the model.

CONCLUSION

This study revealed that Chinese undergraduate nursing students' attitude toward care of the dying was a positive nurturing process. Future nurse education should first identity the fear of death, neutral acceptance, or escape acceptance of nursing students' death attitude, and then develop a hospice curriculum based on fear management.

General population-based study on preferences towards end-of-life care in Southern Thailand: a cross-sectional survey

Background

End-of-life care preferences are potentially due to individual choice and feature variation due to culture and beliefs. This study aims to examine end-of-life care preferences and any associated factors, among the general Thai population. This could inform physicians in regards to how to optimize the quality of life for patients that are near the end of their lives.

Methods

A cross-sectional study surveyed the general population in the Thai province of Songkhla; from January to April 2021. The questionnaires inquired about: 1) demographic information, 2) experiences with end-of-life care for their relatives, and 3) end-of-life care preferences. To determine end-of-life preferences, the data were analyzed using descriptive statistics. The data concerning patient demographics and end-of-life care preferences were compared using Fisher’s exact test.

Results

The majority of the 1037 participants (67.6%) were female. The mean age among the adult and older adult groups were 40.9 ± 12.2, 70.0 ± 5.1, respectively. Half of them (48%) had an experience of observing someone die and 58% were satisfied with the care that their relatives had received. Most participants identified the following major end-of-life care preferences: having loved ones around (98.1%), being free from distressing symptoms (95.8%), receiving the full truth (95.0%), and having meaning in their lives (95.0%). There were no statistically significant differences in regards to end-of-life care preferences apart from being involved in treatment decisions, between adult and older adult groups.

Conclusion

There was only one difference between the end-of-life preferences of the adult group versus the older adult group in regards to the topic of patient involvement in treatment decisions. Furthermore, receiving the full truth regarding their illness, being free from distressing symptoms, having loved ones around, and living with a sense of meaning were important end-of-life care preferences for both groups. Therefore, these should be taken into account when developing strategies towards improving patient life quality during their end-of-life period.