Attitude Towards Death Among Emergency Care Nurses and Midwife Nurses post COVID-19 in Bahrain

The attitude towards death among Emergency Care and Midwife nurses is explored in this research. The sample comprised 50 female emergency care and 50 female midwife nurses (N= 100) between the ages of 25 to 35, with an average age of 27.63 (SD = 2.52). Samples were selected through purposive sampling, and one scale was used, Death Attitude Profile – Revised (DAP-R) by Wong et al., 1994. The study found that midwife nurses scored higher than emergency care nurses in the dimension of escape acceptance. At the same time, there wasn’t a more significant difference between the two nursing departments in the dimension of fear of death, death avoidance, neutral acceptance and approach acceptance. Emergency Care Nurses reported that death is seen as a new beginning, so one’s attitude towards death determines one’s attitude towards life and midwife nurses have scored higher on the dimension of Escape Acceptance which views life and a burden and death to be a getaway.

Death is associated with negative aspects like separation, loss, grief, disasters, accidents, bereavement, tears, mourning, and the list goes on. The taboo attached to death can be seen in how people react to the cause of death; some judge unnatural death to be the consequence of bad karma in the previous birth or sometimes even attributed to having sinned. Death, in general, is not a subject that people will want to discuss; it is seen to be better to be silent about it than to stir negative emotions (Shear, 2022). Research has found high levels of depression (50.4%), anxiety (44.6%), insomnia (34.0%) and distress (71.5%) among healthcare workers in several regions of China (Lai et al., 2020).

Attitude towards death is not just a process that comes before the person has died but also after the death of the individual. To understand separation and its impact on the individuals related to the deceased, it is essential to see the person's attachment process. Kosminsky & Jordon (2016) applied the principles of attachment and separation while experiencing grief. It is normal and adaptive for anyone who has formed an attachment to go through a period of grief.

They stated the following emotional reactions in the case of loss that is shock/numbness, yearning/searching, despair/disorganization, reorganization and recovery (Tacey, 2009).
While, Miller-Lewis et al. (2021) stated that attitudes towards death are categorized as positive, negative or neutral. A positive attitude is most accepting and approaching towards the notions of dying, while a negative attitude is more about avoidance and escape-based psychological strategies, where they try to evade even the thoughts about death. At the same time, it is a balance or seen as a part of life that falls in the neutral category. The death of a person can ignite consciousness about one’s mortality. Just talking about death can make us feel anxious and depressed.

In their research, Kastenbaum and Moreman (2018) state that awareness of death can positively shift one's attitude, preventing defenses like avoidance and denial and instead accepting reality. This transformation helps us to live in the present and be less bothered by what has happened in the past or what will happen in the future. Help the complaining attitude to change into one that is more grateful, extending gratitude for the gift of life and what they could achieve so far, being thankful about life being more accurate, and paying more attention to the details and being more mindful of the world around me and appreciating life in totality.  Based on the work of Tomer et al. (2008), death is seen as having three broad attitudes – fear (also called as anxiety towards death), avoidance (evading any aspect of death) and acceptance (being psychologically prepared). There are three subtypes to acceptance: neutral acceptance- death is an integral part of life; approach acceptance- belief in a happy afterlife; and escape acceptance- where death is seen as a welcomed alternative. It is likely that in a particular culture, there are schemas to help people with cognitive death processing. Lack of education, experience, and cultural and professional limitations may contribute to negative attitudes. In a study, Tranter et al. (2016) reflect on how religious and spiritual perspectives highly correlate with the attitude towards death. Bereavement support is another tool that was highlighted as a necessity.

Death anxiety is experienced by nurses and other healthcare workers who are exposed to sickness, trauma, and violence (Azaiza et al., 2011). Barnett et al. (2021) highlights how preconceived notions about death and lack of training create stress and frustration in healthcare providers. It was also found that intervention by education should be ongoing both when nurses are students and when they are professionals. There was a highlight of palliative care that should be paid more attention to (Hao et al., 2021). Becker (2007) found that medical professionals faced anxiety and depression more than the non-clinical population. But Wood (2022) later reported that medical professionals refused to seek mental health intervention for the same, which tells us of the need for intervention that also incorporates the need to spread awareness in this regard.

 DePaola et al. (1994) found that 82% of the nurses weren’t comfortable talking about death; they commented that caring for dying patients and facing death can be a stressful and challenging experience for nurses. Kudubes et al. (2021) asserted that besides personal and professional experiences, nurses' attitudes toward death may affect the care given to dying individuals.  Puente-Ferdandez et al. (2020) highlighted the impact of trauma while caregiving a person at the end-of-life care. Firestone and Catllet (2009) show that grief theory and support can help nurses understand coping mechanisms. Hutchison and Scherman (2007) brought into the limelight the role of religion and faith play a crucial role in helping them. While researchers Cheong et al. (2020), contributing to the end-of-life care curriculum, found that the palliative care workshops are a beneficial intervention to reduce the anxiety towards death among nurses, improving their skills and knowledge towards palliative care too. In context to the Middle East, cultural and professional limitations, lack of training and education, how the nurses view death mattered in their attitude towards death and how they will address the families after the death of a person (Pyszezynski et al., 2021).

Hypotheses

1. There will be a significant difference between death avoidance among emergency care nurses and midwife nurses.
2. Fear of death will be higher among emergency care nurses than midwife nurses. 
3. There will be a significant difference between neutral acceptance among emergency care nurses and midwife nurses. 
4. The level of approach acceptance will be higher among emergency care nurses and midwife nurses. 
5. There will be a significant difference in the level of escape acceptance among emergency care nurses and midwife nurses. 

Method

Sample

The research consisted of a quantitative survey method; data was collected from a hundred nursing staff. The sample comprised 50 female emergency care and 50 female midwife nurses (N = 100) between the age groups of 25 to 35 years with an average age of 27.63 (SD = 2.52) from different hospitals in Bahrain, who could speak and read English and consented to participate in the research. Of these, 28 nurses were unmarried, while 72 were married. It was made sure that they were licensed under the Health Regulatory of Bahrain. The emergency care nurses or the midwife nurses who experienced a recent traumatic experience of the death of a family member were excluded from the research.

Measures

Death Attitude Profile – Revised

Wong et al. (1994) presented a 32-item questionnaire that measures attitude towards death in four dimensions: Fear of Death, Death Avoidance, Neutral Acceptance, Approach Acceptance, and Escape Acceptance. The results are obtained by calculating the sum of all the scores of the items representing these dimensions and high score indicated more prone attitudes towards death. In current study alpha coefficient of .81 was achieved for this scale.

Procedure

The purposive sampling targeted the sample; the participants were informed that all their information would be kept confidential. A face-to-face meeting was held with the hospital's management to discuss the goal and grant permission to research the staff; it was only after the participants complied with the consent forms that the questionnaires were distributed. Four demographic questions were asked after receiving consent before handing out the questionnaire. The completed questionnaire was collected, and data was statistically analyzed to derive the mean, standard deviation and t scores.

Results

Independent sample t-test was applied to determine differences on dimensions of fear of death.

Table 1. Group Differences on Dimensions of Attitudes Towards Death Among Emergency Care Nurses and Midwife Nurses

Note. Avoid. = Avoidance; Accept. = Acceptance; App. = Approach

The results revealed non-significant difference between the mean scores of the two categories of nurses on the dimensions of fear of death, death avoidance, neutral acceptance and approach acceptance.  However, significant differences are found on the dimension of escape acceptance indicating that midwife nurses exhibited higher tendencies of escape acceptance regarding their attitudes towards death as compared to emergency care nurses.

Discussion

Fear of death is a feeling of apprehension when thinking about one’s death or dying in general; a person experiencing this fear is disturbed by the subject of life and death in any way. Findings showed that there is a non-significant difference in the means of the two groups being studied. However, the average score of emergency care nurses is slightly higher than that of midwife nurses. The participants have close to moderate scores; this can be attributed to their constant encounters with life-saving events in their profession; the awareness and encounters have helped them understand the death process (Kastenbaum & Moreman, 2018). Even recently, Hao et al. (2021) and Wood (2022) concluded that the attitude towards caring for terminally ill patients was related to Nurse's attitudes towards Death and their current contact with the patient. Nurses in both areas of work can reduce the severity of experiencing fear of death by participating in frequent communication with the patients they attend.

Death avoidance is the attempt made by man to evade the thought of death to the best of one’s capabilities. Results showed a non significant difference between the means of the emergency care nurses and midwife nurses. Midwife nurses, though, have a higher average score in comparison to Emergency Care Nurses. The nurses scored moderately higher, and this is in line with the recent research by Pyszczynski et al. (2021) that highlights by Terror Management Theory (Becker, 2007), which proposes that man tries to avoid thoughts of mortality, reducing the terror when they are reminded of death
Neutral acceptance is that death is a natural process that has no escape; it is more reality oriented. Death is seen as undeniable and part of life and one cannot put it into a category of good or bad. There is a non significant difference between the means of emergency care nurses and midwife nurses. Emergency care nurses, however, have a higher average score than Midwife nurses. Neutral acceptance is essential, as it points out that a repressive orientation can lead to neurotic concerns. Therefore, accepting this phenomenon rationally can help sort out fears related to Death (Miller-Lewis et al., 2021).

Approach acceptance investigates life after death, spiritual beliefs and one's religious ideas of life after death (Tomer et al., 2008). Findings show non significant difference between emergency care nurse and midwife nurse's attitudes regarding approach acceptance. The female midwife nurses, though, have a higher average score than emergency care nurses. This study supports the research done by Shear (2022), where the attitudes of nurses were studied, and most respondents were hopeful regarding the afterlife, and death was viewed as a gateway. The last variable is escaping acceptance; it’s the attitude to see life as a pain and death as the ultimate deliverance of one’s suffering. Findings showed significant differences indicating the difference between the means of emergency care nurses and midwife nurses. It has been found that female midwife nurses are close to high on the escape acceptance dimension. This attitude sees life as being more burdened than death, which supports the work by Puente‐Fernández et al. (2020), where he points out that life is not seen as a pleasant experience while death is seen as an escape.

Limitations and Suggestions

Only female nursing staff was studied, particularly from two departments. The sample was collected from Bahrain; there can be variations in the study if data is collected from the other five Middle Eastern countries, too. The sample can be expanded, and individuals of different genders and cultures can be studied. In addition, organizational education and training regarding managing the mental health aspect of their staff should be investigated in future research..

Implications

With the help of this study, it is possible to remove the taboo attached to speaking and addressing questions related to death. Secondly, it can help to work on unhealthy attitudes towards life in the context of a hopeful experience rather than that of fear, avoidance, or escape and psychoeducation about its consequences. Thirdly, it helps to reach out to those who reach out to us in existentialism and make a theoretical model or framework to know how to intervene better in times of crisis.
 
Conclusion

Findings exhibited that midwife nurses while looking at death with fear, which can be attributed to their constant encounters with life-saving events in their profession. While midwife nurses scored mildly higher than emergency care nurses in evading the thought of death (death avoidance). It is also notable that there is a considerably higher score among midwife nurses who view life as a burden while death is an escape. This research can help explore training and psycho-educative programs in healthcare sectors to help the staff to restructuring their attitude towards personal care, which in turn can improve their patient care experience.

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Received 16 November 2022
Revision received 03March 2024