1. Background
There have been several studies on specific emotions related to death. The purpose of the present study was to investigate death obsession, death anxiety, and depression as predictors of death depression in an Iranian sample of married nurses. The concept of death distress involves death anxiety, death depression, and death obsession (1). Death-related distress, which is a negative attitude towards death, is associated with different emotional states, mainly anxiety and fear.
The scientific literature on death-related topics is dominated by studies purporting to investigate death anxiety (2-4). In this regard, Abdel-Khalek introduced the concept and scale of death obsession (5). Rajabi also developed the Farsi version of this scale (6). The third concept of death distress is depression (7), which is a form of sadness or consciousness related to the person’s death, death of others, and general meaning of death (8). Kubler-Ross claimed that depression is the fourth stage of the dying process (9).
Death, as a global phenomenon, is feared by many people around the world. Every human being eventually dies, and there is a clear reason for fear of death, as it is the strangest phenomenon in the world and an inevitable part of human life, surrounded by numerous unknown variables. Preoccupation with death is discussed in all religious traditions, and religious individuals are thought to use interpretations of death to give meaning to their lives (10). According to previous research, anxiety due to preoccupation with death is known as death anxiety (11, 12), depressive symptoms resulting from thoughts or reactions to death indicate death depression (7), and dominance of death-related thoughts represents death obsession.
Various studies have shown close relationships between death, depression, and mourning (13), as well as death anxiety and death depression (14-16). Also, death depression and death anxiety are related to depression and anxiety (8, 17), and death anxiety, death depression, and death obsession are associated with anxiety, obsession, and depression (5, 18). Rajabi et al. also reported significant correlations between death depression and depression and between death obsession and death anxiety (19).
Some stressful situations are characteristic of specific hospital units. Nurses are generally exposed to stress induced by physical, psychological, and social aspects of workplace. Many studies have shown that nurses suffer from mental health problems, such as depression, anxiety, distress, death anxiety, death obsession, interpersonal conflicts, and lack of awareness or support (20-22). Gray-Toft and Anderson identified seven sources of stress for nurses, such as coping with death (23).
Nurses are frequently faced with dying patients and death during work. This experience makes them conscious about their mortality, often giving rise to anxiety and uneasiness. Nurses who have strong anxiety about death may be less comfortable when providing nursing care for patients at the end of their life (24). On the other hand, care for dying patients may cause negative emotions, such as sadness and depression. Overall, death is an important and frequent event in nursing profession, especially in specific wards for the elderly.
2. Objectives
Considering the importance of a healthy relationship between nurses and patients and lack of research on death depression among nurses in Iran, we aimed to investigate death obsession, death anxiety, and depression as predictors of death depression in a sample of married female nurses.
3. Methods
In this correlational study, a convenience sample of 146 married female nurses was selected from different wards (i.e. pediatric, emergency, cardiac, Ob/Gyn, orthopedics, surgery, psychiatry, oncology, dermatology, and ophthalmology) of Imam Khomeini, Golestan, and Shafa governmental hospitals, as well as Mehr and Arya private hospitals, affiliated to Ahvaz Jundishapur University of Medical Sciences during six months in 2016. The subjects were recruited according to the inclusion criteria: 1) having at least one child; 2) having at least three years of cohabitation with the spouse; 3) having no marital conflicts or problems; and 4) psychological disorders.
To collect the data, permission was obtained from different wards of hospitals. The purpose of the research was explained to the participants. Also, the subjects were asked not to work during assessments. For ethical considerations, full informed consents were obtained from the participants, and the questionnaires were completed anonymously to ensure confidentiality of data.
3.1. Data Collection Tools
3.1.1. Death Depression Scale-Revised (DDS-R)
This scale was developed by Templer et al. in 1990 to assess depression symptoms associated with death. DDS-R contains 15 items, rated on a five-point Likert-scale (No, 1; very much, 5); the scores ranged from 19 to 95 (19). Al-Sabwah, Abdel-Khalek, and Tomás-Sábado et al. measured Cronbach’s alpha and test-retest reliability coefficients for this scale in an interval of four weeks and reported values equal to 0.92, 0.90, and 0.87, respectively (20, 25). Rajabi et al. also reported a reliability coefficient of 0.93 and indicated significant validity coefficients for the death anxiety scale, death obsession scale, and Beck Depression Inventory (BDI-13) (21). In this study, Cronbach’s alpha reliability coefficient was 0.94 for DDS-R.
3.1.2. Death Obsession Scale
DOS includes 15 items, rated on a five-point Likert scale (1, no; 5, very much). DOS aims to assess preoccupations, impulses, and persistent death-related ideas. The total score of DOS ranges from 15 to 75 (5, 6). The alpha coefficients were satisfactory for an Iranian population (6). Cronbach’s alpha reliability coefficients have been also measured in Kuwaiti and American studies (0.96 and 0.91, respectively) (26). According to a previous study, there is concurrent validity between DOS and obsessive-compulsion inventory (6). In the current study, Cronbach’s alpha reliability coefficient was 0.94 for DOS.
3.1.3. Death Anxiety Scale (DAS)
DAS was developed by Templer (12). It consists of 14 questions (e.g., “I am very scared of dying”). The items are scored on a five-point Likert scale, and the total score ranges between 14 and 70 (4). In the Arabic and Persian versions, the scale shows acceptable test-retest reliability, Cronbach’s alpha coefficients, and construct validity coefficients (4, 27). In this study, the reliability coefficient of the scale was 0.87.
3.1.4. BDI-13
BDI-13 is a 13-item instrument (28), which has been shown to be valid and reliable for distinguishing healthy individuals from unhealthy people (29). Rajabi indicated that BDI-13 has an acceptable reliability coefficient, and there is convergent validity between the short form and the original form (BDI-21). In a previous study, principal components analysis was carried out in an Iranian sample, and two factors, namely negative emotions towards the self and lack of enjoyment, were extracted (28).
3.2. Procedures
Before conducting the research, nurses from each ward were given brief information on how to answer the questionnaires. Farsi versions of the scales were administered in a nursing station and individually. The participants were fully assured of the confidentiality of their responses before the study.
3.3. Data Analysis
Different statistical methods were applied, including regression analysis to estimate the predictors of death depression, i.e., death obsession, death anxiety, and depression, and Cronbach’s alpha reliability coefficients were measured to test the reliability of the scales.
4. Results
The mean age of the participants was 30.56 years (standard deviation, 6.27; age range, 22 - 52 years), and years of service was 12 years. The multicollinearity statistics, including tolerance coefficient for depression (T, 0.75), death depression (T, 0.85) and death anxiety (T, 0.82), indicated a poor correlation between the predictors (Table 1).
Table 1.Death Anxiety, Death Obsession, and Depression as Predictors of Death Depressiona
| Variables | B | β | t |
|---|---|---|---|
| Intercept | 8.21 | - | 2.84* |
| Death anxiety | 0.65 | 0.47 | 7.26* |
| Death obsession | 0.39 | 0.32 | 4.74* |
| Depression | 0.28 | 0.13 | 2.14* |
aF ratio, 79.35; P < 0.001.
The findings showed that death anxiety, death obsession, and depression, as predictive variables, could explain 62% of variance in death depression (F, 79.35; P < 0.001). Death anxiety (β, 0.47) played a more important role in explaining death depression than death obsession (β, 0.32) and depression (β, 0.13). In all tests, the regression formula was as follows:
y′ = 8.21 + 0.47 (death anxiety) + 0.32 (death obsession) + 0.13 (depression)
5. Discussion
Many people become distressed and depressed due to thoughts about their own death or death of important people in their lives. Several studies have confirmed the existence of depression related to death (9). However, to the best of our knowledge, no study has examined the predictors of death depression. The present findings confirmed that death anxiety, death obsession, and depression together explained a major part of variance in death depression.
However, nurses as healthcare professionals are obliged to work during all hours of the day to meet the patients’ needs. Shift work may lead to various physical and psychological disturbances, which in turn affect other aspects of nurses’ lives (30). In other words, inappropriate emotional reactions, such as stress, anxiety, and depression, are known as integral parts of modern nursing care and cause many problems for nurses and patients. In this regard, Scott et al. showed a correlation between shift work and prevalence of major depressive disorders during and after work (31). Moreover, Dadfar et al. reported that nurses have more concerns and death obsession, compared to the non-nursing staff (32).
Although every individual eventually faces death, nurses are forced to deal with frequent exposure to this phenomenon in daily care for patients. In this regard, Smith et al. concluded that patients’ exposure to death, lack of preparation to deal with their emotional problems, high workload, and related factors cause anxiety among nurses (33). In addition, the results of several studies have confirmed the presence of death anxiety among nurses and nursing students (34-36). The literature has also indicated a significant positive correlation between death depression and death anxiety and general depression and anxiety (8, 17).
Many studies have shown a positive relationship between death anxiety, death depression, and death obsession on one hand, and general anxiety, obsession, and depression on the other (5, 18, 19). Naderi et al. found that death anxiety is different among nurses in various hospital wards, whereas no significant difference was observed with respect to other variables, such as optimism and sense of humor (36). Also, Alvarado et al. showed a relationship between improved spirituality and low levels of death depression and anxiety (37).
Other researchers have shown a relationship between death anxiety and depression (14, 16). Due to work-related stress and exposure to serious diseases (such as cancer) and reality of death, it can be claimed that nurses unconsciously project this reality in their lives. Accordingly, this working class engages in death-related thoughts in their life and experiences more disorders, such as death depression, anxiety, and obsession, compared to others.
5.1. Conclusions
Based on several studies, novices in nursing profession should be provided with the necessary training, since inexperienced nurses may face problems, such as death anxiety, more than others according to Lamb (37). A similar study is suggested to examine the differences in death anxiety, death depression, death obsession, and related variables between nurses with shift work and those with fixed shifts. The results of this study can be generalized with caution to other similar populations. This research is also suggested to be replicated for other professions exposed to death. It should be noted that this study was limited to a single sample, and confirmation of the findings is needed by physicians as an equivalent sample.
