Journal of Gerontological Nursing


Larry C Mullins, PhD; Sharan Merrian, EdD


Thanatology classes for nurses cause anxieties about their own deaths.


Thanatology classes for nurses cause anxieties about their own deaths.

In a previous issue of the JOURNAL OF GERONTOLOGICAL NURSING, information was provided concerning a "humanistic view of the nurse and the dying patient."1 The article pointed out that death has a negative connotation in American society, with responses ranging from denial through fear to acceptance. It was further emphasized that three-fourths of all deaths occur outside the home, and one-half occr in hospitals.2'3

Nurses and nurses' aides especially those working in nursing homes, are often faced with the situation of dealing with terminally ill patients. As Mullins points out: "Nurses have special relationships with the terminally ill, incontrasi with other hospital staff, because nurses and patients usually are together for a time sufficient to establish a relationship."1'4

The nurse/ patient relationship has the potential of either enhancing or hindering the patients' understanding of their deteriorating physical state. In addition, the nurses' attitudes and behavior are affected by this same mutual interchange. This is noted in the Standards of Geriatric Nursing Practice, Pan Ii:

"The nurse seeks to resolve her conflicting attitudes regarding aging, death, and dependence so that she can assist older persons and their relatives to maintain life with dignity and comfort until death ensues.5

Nursing home patients establish strong contact with nurses, thus, it is important that nurses assess their attitudes about the aged and the dying. Once determined, positive attitudes among nursing personnel regarding this subject may be facilitated through instructional sessions. Thus, the purpose of this study is to determine the effectiveness of workshops conducted with nursing home nursing personnel, promoting cognitive gains and positive attitudes toward the elderly and the dying. In this context, the following questions are examined:

* Cognitive Gain

Will the exposure to materials on death and dying result in the acquisition of knowledge in these areas?

* Attitudes Toward the Elderly

Will exposure to information on death and dying foster a more positive attitude toward the elderly?

* Anxiety About Death

Will exposure to information on death and dying lessen anxiety about death?

Research Procedures

Research Design - The desired outcome of the instructional unit includes cognitive and affective changes among nursing home personnel. Four nursing homes were assigned to treatment and control groups. The effectiveness of the treatment in promoting increased knowledge about the dying patient and the elderly, in fostering positive attitudes toward the elderly, and in facilitating less anxiety about death is assessed by comparing posttest data from experimental and control groups.





The data analyses consisted of ttests for each of the previously discussed questions: A) Cognitive gains, B) Attitudes toward the elderly, and C) Anxiety about death. The dependent variables are posttest scores with pretest, treatment, and previous death training functioning as independent variables. Analysis provides a test within each category of research questions on the impact of pretesting, current death training programs, and previous death training.

Site and Subject Selection - This research was conducted in four nursing homes that are part of a chain of proprietary intermediatecare facilities in Virginia. Medicare patients comprised 70% of the patients in these homes and fewer than 25% had a primary or secondary psychiatric diagnosis.

Nursing staff, including aides, licensed practical nurses, and registered nurses served as subjects. Each facility had approximately 35 nursing personnel involved in the study, for a total of 138 subjects.

Training Program - The first training period was broken into three segments: (a) presentation of general information on death and dying (and aging) and the examination of the nurses; personal thoughts on dying and the elderly; (b) presentation of information examining the feelings and attitudes held by nurses regarding dying patients; and (c) facilitating the nurses' understanding of the responses of those persons approaching death.

The second segment was devoted specifically to the nurse/dying patient relationship. The following topics were included: (a) the dying process and the impact this has on nurse's understanding; (b) the impact of collegial support; (c) the importance of mutual knowledge and awareness of the patient's condition; (d) examination of the notion of social loss; (e) the importance of nurse/physician communication, and (O an examination of the aspects of emotional caring.













Measurement Instruments- Previous Death Training - The nursing personnel were asked: "Have you had any training at any time which has prepared you for working with persons who are expected to die, or are terminally ill?" This question was part of a more extensive set of background information obtained.

Death Anxiety - Templer's death anxiety scale was used to determine the nursing staffs concern about death.5 The Death Anxiety Scale is a 15 item Likert-type scale with good reliability and validity. Examples of the items are: (a) I am very much afraid to die, and (b) It does hot make me nervous when people talk about death.

Information about working with the dying - A 1 5 item instrument was developed for this research, measuring information about the dying and the nurse working with the terminally ill. Using a true/false format, the nurses responded to such items as: (a) Death is only a biological reality; and (b) Most elderly are more afraid of abandonment and isolation than of death.

Attitudes toward the elderly - To assess attitudes toward the elderly, adjective descriptions rather than declarative statements were used. One such instrument developed by Rosencranz and McNevin, dealing with attitudes toward the elderly was adapted for use in this research.6 The instrument has 32 adjective pairs assessed in the context of: "When I think of people who are old, 1 think of people who are. . .?" This type of questioning is most effective in determining positive or negative attitudes.

Evaluation Hypotheses - Program effectiveness was determined by comparing the performance of experimental and control groups on measures of knowledge and attitude. The research hypotheses for the study were as follows:

Cognitive Gains

(a) Nurses receiving death instruction should score significantly higher on the Facts on Death instrument compared to those not receiving instruction.

(b) Nurses who are pretested should score significantly higher on the Facts on Death instrument compared to those not pretested.

(c) Nurses with previous death educational instruction should score significantly higher on the Facts on Death instrument compared to those with no previous instruction.

Altitudes Toward the Elderly

(a) Nurses receiving death instruction should rate the aged significantly more favorably on Rosencranz and McNevin's Aging Semantic Differential.

(b) Nurses who are pretested should rate the aged significantly more favorably on the Aging Semantic Differential.

(c) Nurses who have previously had death education instruction should rate the aged significantly more favorably on the Aging Semantic Differential.

Anxiety About Death

(a) Nurses receiving death instruction should experience significantly less death anxiety on Templer's Death Anxiety Scale.

(b) Nurses who are pretested should experience significantly less death anxiety on the Death Anxiety Scale.

(c) Nurses who have previously had death educational instruction should experience significantly less death anxiety on the Death Anxiety Scale.

Research Findings

Demographic Data- All participants in both the experimental and control groups answered a set of questions regarding demographic characteristics, work enjoyment and satisfaction, length of nursing home employment, and exposure to death and dying information. This information was used to provide a descriptive profile of the sample and to aid in the analysis. Table 1 summarizes the information acquired from the demographic information sheet.

Almost 90% of the participants in both groups were female, 73% were nurses' aides, 69% were white, and 64% had at least graduated from high school. In addition, the vast majority enjoyed their work (97%), and were quite well satisfied with their jobs (94%). The participants had worked in a nursing home an average of 16.5 months, and over half (55%) had at least some exposure to death training in the past. The majority of the participants were white, female aides who were quite sufficiently educated, satisfied with their work, and who had some exposure to death education. Comparing the characteristics of those in the experimental and control groups, control groups have proportionately more females, are better educated, and have a higher proportion of staff who are white. In addition, the average length of employment is longer among those in the control groups.

Research Results - Table 2 summarizes the results of the comparisons of the posttest means for each of the three conditions. Two of the three hypotheses were supported. It was found that nurses currently receiving death information scored significantly higher on the Facts on Death instrument than those not receiving instruction. In addition, previous death training was significantly associated with the death information level of the nurses. Those who had previous training on issues pertaining to death scored significantly higher on the Facts on Death instrument. Whether the nurses had been pretested or not made no difference in their level of information retention. In essence, there were significant cognitive gains among those who received the training.

Attitudes Toward the Elderly - The Índex is the summation of three dimensions: (a) instrumental-ineffective, (b) autonomous-dependent, (c) personal acceptability-unacceptability. Table 3 shows the comparisons of the posttest means for the three conditions under consideration. It is clear that neither current or previous death training, nor pretesting had any substantial impact on the nurses' attitudes toward the elderly.

Also, the attitudes held by the nurses were generally ambivalent. The aged patient, as seen by the RNs, LPNs, and aides, was not instrumental or ineffective, autonomous or dependent, personnally accepted or unacceptable. The second hypotheses were not supported.

Nurse's Death Anxiety - Table 4 indicated that the posttest death anxiety scores were significantly greater among those who received the training in comparison to those who did not. Succinctly, the third hypothesis specifying that nurses who received death instruction should experience signficantly less death anxiety was not supported. In fact, the effect of the death training program was opposite to that expected. Those who received the training had 16% greater death anxiety in comparison to those who were not exposed to the information. On a scale of one to five, 3.58 compared to 3.09- a difference of 0.49.

Interestingly, those who had previous death training also showed significantly greater death anxiety in contrast to those who had not had such exposure. This is counter to the effect such training is expected ?? have. Thus, this hypothesis is also not supported by this data.

In addition, the results show there were no significant differences between the tested and nontested. Thus, the remaining hypothesis within this set was also not supported by these results. It appears that pretesting had no sensitizing effect on the nurse's level of death anxiety.


The results point up the mixed nature of training programs of this sort. The literature suggests no fully clear pattern, or effect, of short-term training programs (or for that matter, iong-term training programs). In reviewing the literature of the past eight years concerning the effects of death and dying training programs, it is evident that some programs result in favorable change. Also, some training programs, such as the current effort, show a mixed result.

Most studies show a positive benefit of death training.7*'*'10'11'12 Using different samples, different methodologies, and differing amounts of training, most find, in training programs used, death anxiety is decreased and / or attitudes toward aging and the aged became more positive. Trent, Glass, and McGee found a significant decrease in death anxiety, but no significant changes in participant satisfaction levels, or locus of control,10 using an experimental design with middle-aged and older adults in a 12-hour training program. 10

Sweeney, utilizing an experimental design with college students over a 4week period, examined the effects of "in vivo" systematic desensi tiza tion with symbolic modeling.8 She found a significant resolution in death anxiety as a result of the program. Watts, using college students in a death education unit of a health course, found a favorable deathrelated attitude change as a result of the unit.12 Nash, Connors, and Gemperle, using interviews and collecting descriptive data from personnel who worked with the terminally ill, found that the 12-hour program had a "positive" impact on participants1 attitudes.11 In this, they advocated the saturation technique, i.e., intensive workshop experience.

Other studies have resulted in no significant effect from the training. Abernathy, in an experimentally designed study to determine the effect of a short-term training program on counselor attitudes toward the elderly found no significant change resulting from the treatment.13 Shandor using registered nurses and freshmen college students in an experimentally designed 6-week "Coping with Death and Dying" course, found that the course had some, but minimal impact on changing attitudes toward death and dying patients.14 Using an experimental design, in order to determine whether a course, focusing on aging, and changes in attitudes of first year medical students. Cicchetti, Fletcher, Verner, and Coleman found little change in attitudes toward the elderly. Also, using an experimental design, Hoelter and Epley found no effects on death related attitudes of a death and dying course for students.18

Among the relatively few to show a negative effect of death and dying training is Pratt.18 Using an experimental design, Pratt investigated the effect of a Death and Self-Discovery Workshop. Those who received the training had a higher fear of death and a lower assessment of purposein-life.

The indications of this literature, though mixed, seems to support the notion that death education training is generally beneficial for the reduction of death anxiety. Most studies have dealt with populations relatively isolated from the experience of death. In work situations where death is dealt with daily, a death and dying training program, may not have short-term ameliorating effects on death anxiety. Although death anxiety increased, the nurse's level of information about death also increased. The information concerning the nurse's relationship to the dying patient was also enhanced.

The fact that death anxiety was greater among those receiving the training is not necessarily a "negative" result. If the increase in the anxiety about death stimulates the nurse to spend more time considering his/her own demise, it may also stimulate greater empathy with their patients facing death. Hopefully, the anxiety the nurses experience will be transformed into a constructive energy outlet stimulating greater patient understanding.

The above, in combination with the significant amount of new information, will give the nurse a better base from which to relate to their elderly patients. It is important to note that the nurses' essential ideas about the aged did not change. What did change were the insights they received about themselves, theirjobs, their professional orientation toward death, the patients' responses to death, and their relationships to the dying. In short, greater knowledge was gained and hopefully greater personal responsibility was assumed.

Educationally, these results point out the potential unsuitability of short-term training on death among nurses within nursing homes. Death and dying is obviously a highly emotionally charged issue, which necessitates a longer-termed emphasis, especially within the institutional setting.

Earl, Argondizzo, and Kutscher in a well-edited book sponsored by the Foundation of Thanotology show, through the included selections, the complexities inherent in the care given to the dying.18 Benoliel, for example, presents a detailed course outline for a nursing school curriculum.19 Clearly, this detailed course would be preferable to less intense instruction. However, this approach is infeasible for nursing homes as structured.

A series of classes need to be built into the existing in-service mechanism for staff instruction (over and above these required already). These classes should emphasize many of the topics suggested by Benoliel, Pratt, and the present authors. Î9'n The instruction should be given weekly for several months. The effectiveness of such programs, based on content and number, would be subject to empirical verification.


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