Volume 10, Issue 3 (10-2022)
Jorjani Biomed J 2022, 10(3): 35-42 |
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Ghazanfari M J, Chaghian Arani R, Mollaei A, Mollaei A, Falakdami A, Takasi P, et al . Death Anxiety and Related Factors in Nurses during the COVID-19 Pandemic: A systematic Review. Jorjani Biomed J 2022; 10 (3) :35-42
URL: http://goums.ac.ir/jorjanijournal/article-1-902-en.html
URL: http://goums.ac.ir/jorjanijournal/article-1-902-en.html
Mohammad Javad Ghazanfari1 
, Raziyeh Chaghian Arani2 , Amirabbas Mollaei3 , Aghil Mollaei4 , Atefeh Falakdami3 , Poorya Takasi3 , Pooyan Ghorbani Vajargah3 , Shaqayeq Esmaeili5 , Hedayat Jafari6 , Tahereh Yaghoubi7 , Samad Karkhah8
, Raziyeh Chaghian Arani2 , Amirabbas Mollaei3 , Aghil Mollaei4 , Atefeh Falakdami3 , Poorya Takasi3 , Pooyan Ghorbani Vajargah3 , Shaqayeq Esmaeili5 , Hedayat Jafari6 , Tahereh Yaghoubi7 , Samad Karkhah8
1- Department of Medical-Surgical Nursing, School of Nursing and Midwifery, Kashan University of Medical Sciences, Kashan, Iran
2- Student Research Committee, School of Medicine, Kashan University of Medical Sciences, Kashan, Iran
3- Department of Medical-Surgical Nursing, School of Nursing and Midwifery, Guilan University of Medical Sciences, Rasht, Iran
4- Department of Biostatistics, School of Health, Mazandaran University of Medical Sciences, Sari, Iran
5- Imam Khomeini Hospital, Mazandaran University of Medical Sciences, Sari, Iran.
6- Associate Professor of Nursing, Department of Medical Surgical Nursing, School of Nursing and Midwifery, Traditional and Complementary Medicine Research Center, Addiction Institute, Mazandaran University of Medical Sciences, Sari, Iran
7- Assistant Professor, Traditional and Complementary Medicine Research Center, Addiction Institute, Mazandaran University of Medical Sciences, Sari, Iran.
8- 1. Department of Medical-Surgical Nursing, School of Nursing and Midwifery, Guilan University of Medical Sciences, Rasht, Iran.2. Burn and Regenerative Medicine Research Center, Guilan University of Medical Sciences, Rasht, Iran.3. Quchan School of Nursing, Mashhad University of Medical Sciences, Mashhad, Iran. ,sami.karkhah@yahoo.com
2- Student Research Committee, School of Medicine, Kashan University of Medical Sciences, Kashan, Iran
3- Department of Medical-Surgical Nursing, School of Nursing and Midwifery, Guilan University of Medical Sciences, Rasht, Iran
4- Department of Biostatistics, School of Health, Mazandaran University of Medical Sciences, Sari, Iran
5- Imam Khomeini Hospital, Mazandaran University of Medical Sciences, Sari, Iran.
6- Associate Professor of Nursing, Department of Medical Surgical Nursing, School of Nursing and Midwifery, Traditional and Complementary Medicine Research Center, Addiction Institute, Mazandaran University of Medical Sciences, Sari, Iran
7- Assistant Professor, Traditional and Complementary Medicine Research Center, Addiction Institute, Mazandaran University of Medical Sciences, Sari, Iran.
8- 1. Department of Medical-Surgical Nursing, School of Nursing and Midwifery, Guilan University of Medical Sciences, Rasht, Iran.2. Burn and Regenerative Medicine Research Center, Guilan University of Medical Sciences, Rasht, Iran.3. Quchan School of Nursing, Mashhad University of Medical Sciences, Mashhad, Iran. ,
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Conclusion
Overall, nurses' DA levels during the COVID-19 pandemic were moderate. Also, 31.05% of nurses had a high DA level during the COVID-19 pandemic. Age, sex, work experience, working hours per week, childbearing, several patients needing end‑of‑life care, cases of direct participation in resuscitation operations, cases of patient death, depression, mental health status, and life satisfaction were influential factors in DA nurses during the COVID-19 pandemic. Thus, nursing policymakers should pay special attention to these factors related to nurses' health maintenance and promotion programs to increase the quality of nursing care for COVID-19 patients. Also, it is recommended that psychological and communication support be provided to nurses during the COVID-19 pandemic.
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Introduction
Since December 2019, the COVID-19 pandemic has had significantly impacted the health care system, especially nursing (1-11). High workload, insufficient resources, and many stressors in the workplace have led to the imposition of physical and psychological pressures on nurses, which exposes them to Death Anxiety (DA) (2). DA is a multifaceted concept that includes worries about fear of death for oneself and others, denial of death, reluctance to interact with dying people, and avoiding death. Although DA is a universal concept, its manifestations can vary in individuals with different cultural, mental, social, and professional backgrounds (12). Meanwhile, nurses are exposed to critically ill and dying patients, leading to stress, anxiety, and DA (13, 14). Adverse outcomes of DA among nurses include depression, loss of meaning in life, and psychological distress. These adverse outcomes can reduce professional participation, performance, and quality of care. However, some nurses deal with DA by using avoidant behaviors such as frequent absences from the workplace to reduce exposure to death-related issues and their psychological effects (12). Hence, a study in Turkey found that nurses experienced high levels of depression, anxiety, and insomnia during the COVID 19 pandemic compared to other health care workers (2). Another study in Turkey showed that the DA of nurtures was at a moderate level (15). Also, a study in Iran showed that 53.5% of nurses had high DA levels (16).
Therefore, this systematic review aimed to assess the DA and its associated factors in nurses during the COVID-19 pandemic.
Materials and Methods
The present review was according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyzes (PRISMA) checklist (17).
Search strategy
An extensive search was conducted on Scopus, PubMed, Web of Science, Iranmedex, and Scientific Information Database (SID) databases via keywords including "Death", "Death Anxiety", "Nurses", and "COVID-19", from December 2019 to November 10, 2021. The syntax used in the strategy of search in the PubMed database was (("Death anxiety") OR ("Death") OR ("Anxiety") OR (“Fear”)) AND ((“Nurses”) OR (“Personnel, Nursing”) OR (“Registered Nurses”) OR (“Registered Nurse”) OR (“Health Personnel”) OR (“Health Worker”) OR (“Health Caregiver”)) AND ((“COVID-19”) OR (“2019-nCoV disease”) OR (“Coronavirus”) OR (“Sars-Cov-2”) OR (“2019 novel coronavirus infection”)). The equivalent of keywords in Farsi was used to search Persian databases. The two researchers independently carried out the search process. Gray literature was ignored due to a lack of accurate findings (18).
Inclusion and exclusion criteria
Original Persian and English papers focusing on DA and related factors in nurses during the COVID-19 pandemic were included in this systematic review. Case reports, conference proceedings, studies with qualitative designs, and reviews were excluded. Also, published studies aimed to assess the DA among nursing students were excluded from this review.
Study selection
EndNote X8 software was used to manage the data. Duplicate articles were deleted electronically and manually, respectively. The title, abstract, and full text of the studies were evaluated based on inclusion/exclusion criteria. In addition, a reference list of eligible papers was evaluated to prevent the loss of relevant data. The selection process of studies was conducted by two reviewers, independently. Studies related to the purpose of the present study were included based on inclusion/exclusion criteria. The third researcher evaluated the paper if a disagreement arose between the reviewers.
Data extraction and quality assessment
The first author's name, year of publication, location, ward, sample size, male/female ratio, age, single /married ratio, level of education, work experience, tool, and key results were extracted from the included studies. Quality assessment of eligible papers was performed using the appraisal tool for cross-sectional studies (AXIS tool). This tool assesses the quality of cross-sectional papers using 20 items (19). Data extraction and quality assessment of included studies were performed by two researchers independently. Studies with favorable quality were included in this systematic review. The third researcher evaluated the paper if a disagreement arose between the reviewers.
Results
Study Selection
1084 papers were obtained via search in databases, and two studies were obtained via assessment of the reference list of eligible documents. 211 duplicate studies were excluded. After evaluating the title and abstract of the articles, 649 papers were not in line with the purpose of this study, and 211 studies were not original. After evaluating the full text of the articles, four papers were included in this review (Figure 1).
Since December 2019, the COVID-19 pandemic has had significantly impacted the health care system, especially nursing (1-11). High workload, insufficient resources, and many stressors in the workplace have led to the imposition of physical and psychological pressures on nurses, which exposes them to Death Anxiety (DA) (2). DA is a multifaceted concept that includes worries about fear of death for oneself and others, denial of death, reluctance to interact with dying people, and avoiding death. Although DA is a universal concept, its manifestations can vary in individuals with different cultural, mental, social, and professional backgrounds (12). Meanwhile, nurses are exposed to critically ill and dying patients, leading to stress, anxiety, and DA (13, 14). Adverse outcomes of DA among nurses include depression, loss of meaning in life, and psychological distress. These adverse outcomes can reduce professional participation, performance, and quality of care. However, some nurses deal with DA by using avoidant behaviors such as frequent absences from the workplace to reduce exposure to death-related issues and their psychological effects (12). Hence, a study in Turkey found that nurses experienced high levels of depression, anxiety, and insomnia during the COVID 19 pandemic compared to other health care workers (2). Another study in Turkey showed that the DA of nurtures was at a moderate level (15). Also, a study in Iran showed that 53.5% of nurses had high DA levels (16).
Therefore, this systematic review aimed to assess the DA and its associated factors in nurses during the COVID-19 pandemic.
Materials and Methods
The present review was according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyzes (PRISMA) checklist (17).
Search strategy
An extensive search was conducted on Scopus, PubMed, Web of Science, Iranmedex, and Scientific Information Database (SID) databases via keywords including "Death", "Death Anxiety", "Nurses", and "COVID-19", from December 2019 to November 10, 2021. The syntax used in the strategy of search in the PubMed database was (("Death anxiety") OR ("Death") OR ("Anxiety") OR (“Fear”)) AND ((“Nurses”) OR (“Personnel, Nursing”) OR (“Registered Nurses”) OR (“Registered Nurse”) OR (“Health Personnel”) OR (“Health Worker”) OR (“Health Caregiver”)) AND ((“COVID-19”) OR (“2019-nCoV disease”) OR (“Coronavirus”) OR (“Sars-Cov-2”) OR (“2019 novel coronavirus infection”)). The equivalent of keywords in Farsi was used to search Persian databases. The two researchers independently carried out the search process. Gray literature was ignored due to a lack of accurate findings (18).
Inclusion and exclusion criteria
Original Persian and English papers focusing on DA and related factors in nurses during the COVID-19 pandemic were included in this systematic review. Case reports, conference proceedings, studies with qualitative designs, and reviews were excluded. Also, published studies aimed to assess the DA among nursing students were excluded from this review.
Study selection
EndNote X8 software was used to manage the data. Duplicate articles were deleted electronically and manually, respectively. The title, abstract, and full text of the studies were evaluated based on inclusion/exclusion criteria. In addition, a reference list of eligible papers was evaluated to prevent the loss of relevant data. The selection process of studies was conducted by two reviewers, independently. Studies related to the purpose of the present study were included based on inclusion/exclusion criteria. The third researcher evaluated the paper if a disagreement arose between the reviewers.
Data extraction and quality assessment
The first author's name, year of publication, location, ward, sample size, male/female ratio, age, single /married ratio, level of education, work experience, tool, and key results were extracted from the included studies. Quality assessment of eligible papers was performed using the appraisal tool for cross-sectional studies (AXIS tool). This tool assesses the quality of cross-sectional papers using 20 items (19). Data extraction and quality assessment of included studies were performed by two researchers independently. Studies with favorable quality were included in this systematic review. The third researcher evaluated the paper if a disagreement arose between the reviewers.
Results
Study Selection
1084 papers were obtained via search in databases, and two studies were obtained via assessment of the reference list of eligible documents. 211 duplicate studies were excluded. After evaluating the title and abstract of the articles, 649 papers were not in line with the purpose of this study, and 211 studies were not original. After evaluating the full text of the articles, four papers were included in this review (Figure 1).
Figure 1. The process of selecting studies
Study Characteristics
818 nurses were enrolled in four studies (15, 16, 20, 21). All studies were cross-sectional. Of the participants, 64.68% were female, 50.74% were married, and 94.49% had a Bachelor of Science in Nursing (BSN) degree. The mean age and work experience of nurses were 31.21 (SD=5.43) and 7.60 (SD=6.73) years, respectively. Most studies used the Templer’s Death Anxiety Scale (T-DAS) to evaluate nurses ’DA during the COVID-19 pandemic (n=3) (16, 20, 21). Most papers were performed in Iran (n=3) (16, 20, 21) (Table 1).
Methodological Quality of included study
Based on the AXIS tool, one study did not have a representative of the selection process; one study didn’t identify limitations of research; two papers didn’t mention sources of funding/conflicts of interest, and ethical approval/consent was attained (Figure 2).
DA and factors associated with its in nurses during the COVID-19 pandemic
The mean DA in nurses during the COVID-19 pandemic was 7.30 (SD=2.23). Also, 31.05% of nurses had a high DA level during the COVID-19 pandemic. Age (n=2), sex (n=1), work experience (n=1), working hours per week, childbearing, several patients needing end‑of‑life care, cases of direct participation in resuscitation operations, cases of patient death (n=1), depression (n=1), mental health status (n=1), and life satisfaction (n=1) were influential factors in DA nurses during the COVID-19 pandemic. A study in Iran found a significant negative relationship between DA and variables such as sex and mental health status (16). Also, another study in Turkey found a significant negative relationship between DA and life satisfaction during the COVID-19 pandemic (15).
Discussion
This systematic review showed that nurses' DA levels during the COVID-19 pandemic were moderate. Age, sex, work experience, working hours per week, childbearing, several patients needing end‑of‑life care, cases of direct participation in resuscitation operations, cases of patient death, depression, mental health status, and life satisfaction were influential factors in DA nurses during the COVID-19 pandemic.
Although nurses' DA was at a moderate level, there were vast differences in the DA range in the included studies (DA range in the included studies: 2.92% to 69.09%). A study in Turkey (15) showed that 14.35% of nurses had a high DA level. In contrast, a study in Iran (20) found that this rate was 69.09%. The causes of these contradictions include culture, religion, and nurses’ attitudes toward death and care for dying patients (16, 20, 22).
As presented in the present study, age, sex, work experience, working hours per week, childbearing, several patients needing end‑of‑life care, cases of direct participation in resuscitation operations, cases of patient death, depression, mental health status, and life satisfaction were influential factors in DA nurses during the COVID-19 pandemic. Stress and burnout during the COVID-19 pandemic can predict DA in nurses (15). A study in Spain found that stress, anxiety, and high workload can lead to burnout in nurses and, ultimately, higher levels of DA in them (22). Therefore, it is recommended that future research be done by considering variables such as culture, religiosity, and religion in nurses in this field. Psychologists and behavioral scientists can play an essential role in reducing nurses' DA by developing educational interventions in this area.
Limitations
This review included English and Persian studies, which assess DA and related factors in nurses during the COVID-19 pandemic. However, the main limitation of the present study was language bias. Also, not all studies in this field may be found despite a systematic search of various databases.
Implications for nursing managers and policymakers
Based on the findings of the present study, nurses' DA was at a moderate level during the COVID-19 pandemic. The current pandemic puts nurses at a high DA level due to increased workload and job stress which can affect the physical and mental health of nurses and, consequently, reduce the quality of nursing care. Therefore, nursing policymakers can reduce DA of nurses by using appropriate educational programs and coping strategies with DA to consider DA-related factors in nurses such as culture, religion, cases of direct participation in resuscitation operations, cases of patient death, depression, and mental health status, and life satisfaction.
818 nurses were enrolled in four studies (15, 16, 20, 21). All studies were cross-sectional. Of the participants, 64.68% were female, 50.74% were married, and 94.49% had a Bachelor of Science in Nursing (BSN) degree. The mean age and work experience of nurses were 31.21 (SD=5.43) and 7.60 (SD=6.73) years, respectively. Most studies used the Templer’s Death Anxiety Scale (T-DAS) to evaluate nurses ’DA during the COVID-19 pandemic (n=3) (16, 20, 21). Most papers were performed in Iran (n=3) (16, 20, 21) (Table 1).
Methodological Quality of included study
Based on the AXIS tool, one study did not have a representative of the selection process; one study didn’t identify limitations of research; two papers didn’t mention sources of funding/conflicts of interest, and ethical approval/consent was attained (Figure 2).
DA and factors associated with its in nurses during the COVID-19 pandemic
The mean DA in nurses during the COVID-19 pandemic was 7.30 (SD=2.23). Also, 31.05% of nurses had a high DA level during the COVID-19 pandemic. Age (n=2), sex (n=1), work experience (n=1), working hours per week, childbearing, several patients needing end‑of‑life care, cases of direct participation in resuscitation operations, cases of patient death (n=1), depression (n=1), mental health status (n=1), and life satisfaction (n=1) were influential factors in DA nurses during the COVID-19 pandemic. A study in Iran found a significant negative relationship between DA and variables such as sex and mental health status (16). Also, another study in Turkey found a significant negative relationship between DA and life satisfaction during the COVID-19 pandemic (15).
Discussion
This systematic review showed that nurses' DA levels during the COVID-19 pandemic were moderate. Age, sex, work experience, working hours per week, childbearing, several patients needing end‑of‑life care, cases of direct participation in resuscitation operations, cases of patient death, depression, mental health status, and life satisfaction were influential factors in DA nurses during the COVID-19 pandemic.
Although nurses' DA was at a moderate level, there were vast differences in the DA range in the included studies (DA range in the included studies: 2.92% to 69.09%). A study in Turkey (15) showed that 14.35% of nurses had a high DA level. In contrast, a study in Iran (20) found that this rate was 69.09%. The causes of these contradictions include culture, religion, and nurses’ attitudes toward death and care for dying patients (16, 20, 22).
As presented in the present study, age, sex, work experience, working hours per week, childbearing, several patients needing end‑of‑life care, cases of direct participation in resuscitation operations, cases of patient death, depression, mental health status, and life satisfaction were influential factors in DA nurses during the COVID-19 pandemic. Stress and burnout during the COVID-19 pandemic can predict DA in nurses (15). A study in Spain found that stress, anxiety, and high workload can lead to burnout in nurses and, ultimately, higher levels of DA in them (22). Therefore, it is recommended that future research be done by considering variables such as culture, religiosity, and religion in nurses in this field. Psychologists and behavioral scientists can play an essential role in reducing nurses' DA by developing educational interventions in this area.
Limitations
This review included English and Persian studies, which assess DA and related factors in nurses during the COVID-19 pandemic. However, the main limitation of the present study was language bias. Also, not all studies in this field may be found despite a systematic search of various databases.
Implications for nursing managers and policymakers
Based on the findings of the present study, nurses' DA was at a moderate level during the COVID-19 pandemic. The current pandemic puts nurses at a high DA level due to increased workload and job stress which can affect the physical and mental health of nurses and, consequently, reduce the quality of nursing care. Therefore, nursing policymakers can reduce DA of nurses by using appropriate educational programs and coping strategies with DA to consider DA-related factors in nurses such as culture, religion, cases of direct participation in resuscitation operations, cases of patient death, depression, and mental health status, and life satisfaction.
Table 1. Features of eligible studies in this systematic review
| First Author/year | Location | Ward | Sample Size | M/F ratio (%) | Age (mean±SD) |
Single/Married ratio (%) | Level of education (BSN/MSN/Ph.D.) (%) | Work experience (mean±SD) |
Questionnaire | Key results | DA rate (Mean±SD) |
| Belash et al., 2021 (20) | Iran | ICU | 110 | N/A | 31.47 (SD=2.10) | 39.09/60.91 | N/A | N/A | T-DAS |
DA was among ICU nurses during the COVID-19 pandemic at the following levels:
There was a significant correlation between DA and variables such as age, working hours per week, childbearing, and several patients needing end‑of‑life care, cases of direct participation in resuscitation operations, and cases of patient death.
|
8.93 (SD=3.79) out of 15 |
| Farokhnezhad Afshar et al., 2021 (16) | Iran | Emergency department/ICU/Operating room/Oncology/Psychiatry/ General/dialysis/Nursing office | 208 | 50.96/49.04 | 32.45 (SD=6.45) | 43.75/56.25 | 91.35/8.65/0 | 9.24 (SD=7.53) | T-DAS | 53.36% of nurses had a high DA level during the COVID-19 pandemic. There was a significant negative correlation between DA and variables such as sex (P=0.001) and mental health status (P < 0.05). | 4.37 (SD=0.97) out of 15 |
| Karabağ Aydın et al., 2021 (15) | Turkey | ICU/Emergency department/ Medical-surgical/Operating room | 411 | 34.79/65.21 | 28.11 (SD=6.27) | 62.04/37.96 | 100.00/0/0 | 5.96 (SD=5.94) | R-DAS |
Nurses' DA levels were moderate during the COVID-19 pandemic. DA was among nurses at the following levels:
There was a significant negative correlation between DA and life satisfaction during the COVID‑19 pandemic (P < 0.05).
|
57.33 (SD=16.20) out of 100 |
| Nobahar et al., 2021 (21) | Iran | General/ICU | 89 | 20.22/79.78 | 32.80 (SD=6.90) | 15.73/84.27 | 92.13/7.87/0 | N/A | T-DAS |
Nurses' DA levels during the COVID-19 pandemic were as follows:
There was a significant correlation between DA and variables such as age, work experience (P=0.05), and depression (P=0.05) during the COVID‑19 pandemic.
|
7.32 (SD=1.75) out of 15 |
Figure 2. Quality of eligible studies
Conclusion
Overall, nurses' DA levels during the COVID-19 pandemic were moderate. Also, 31.05% of nurses had a high DA level during the COVID-19 pandemic. Age, sex, work experience, working hours per week, childbearing, several patients needing end‑of‑life care, cases of direct participation in resuscitation operations, cases of patient death, depression, mental health status, and life satisfaction were influential factors in DA nurses during the COVID-19 pandemic. Thus, nursing policymakers should pay special attention to these factors related to nurses' health maintenance and promotion programs to increase the quality of nursing care for COVID-19 patients. Also, it is recommended that psychological and communication support be provided to nurses during the COVID-19 pandemic.
Type of Article: Review Article |
Subject:
Nursing
Received: 2022/05/5 | Accepted: 2022/08/2 | Published: 2022/08/16
Received: 2022/05/5 | Accepted: 2022/08/2 | Published: 2022/08/16
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