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British Journal of Healthcare and Medical Research - Vol. 11, No. 6
Publication Date: December 25, 2024
DOI:10.14738/bjhmr.116.17783.
Vognsen, J., Hernandez-Gantes, V. M., & Chen, Y.-H. (2024). Nurses’ Attitudes Toward Death and Associations with Background
Characteristics. British Journal of Healthcare and Medical Research, Vol - 11(6). 38-48.
Services for Science and Education – United Kingdom
Nurses’ Attitudes Toward Death and Associations with
Background Characteristics
Julie Vognsen
Durham Veterans Affairs Medical Center
508 Fulton Street, Durham, NC 27705, USA
Victor M. Hernandez-Gantes
University of South Florida 4202
Fowler Avenue, EDU 105, Tampa, FL 33620, USA
Yi-Hsin Chen
University of South Florida 4202 E.
Fowler Avenue, EDU 105, Tampa, FL 33620, USA
ABSTRACT
In the United States, the majority of deaths occur in a medical facility. As such, the
nurses’ attitudes toward death are crucial. Thus, this study examined nurses’
attitudes toward death and the impacts of demographic variables on their attitudes.
The Death Attitude Profile-Revised (DAP-R) survey was used, including three
subsets: Anxiety toward death (fear and avoidance), escape acceptance (death as a
way to escape life’s troubles), and neutral acceptance (neither anxious nor too
accepting). A demographic survey documented background characteristics,
including gender, state of residence, year of experience, ethnicity, and area of nurse
practice. There was a total of 168 participants, excluding missing data. Descriptive
statistics and multiple regression analyses were conducted. This study found that
nurses had low anxiety, moderate to high escape, and high neutrality to death. Year
of experience and area of nurse practice (management versus extended care)
showed statistically significant effects on the escape attitude. No overall predicting
models showed statistically significant effects on nurses’ anxiety and neutrality
attitudes toward death. More experienced nurses might have less anxiety, and
Caucasian nurses might have less neutrality than other nurses. Further research is
warranted.
Keywords: attitudes toward death; registered nurses; death anxiety; death escape;
neutral death attitude.
INTRODUCTION
In 2030, an estimated 72 million people in the 65-and-older age group will live in the US,
totaling 20% of the population, with an average life expectancy of about 79 years (Russakoff,
2010). The 85-years-and-older age group, in particular, is the fastest-growing segment in the
US, and it is projected to increase to 19 million in 2050 (Russakoff, 2010). The demand for
related care is increasing as the population continues to live longer and grow older in the US.
Concurrently, it has been argued that this trend will bring renewed attention to the quality of
terminal care since the majority of deaths occur in a hospital or some medical center (Benoliel
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Vognsen, J., Hernandez-Gantes, V. M., & Chen, Y.-H. (2024). Nurses’ Attitudes Toward Death and Associations with Background Characteristics.
British Journal of Healthcare and Medical Research, Vol - 11(6). 38-48.
URL: http://dx.doi.org/10.14738/bjhmr.116.17783.
& Degner, 1995; DeSpelder & Strickland, 2011; Kochanek, Murphy, Xu, & Arias, 2024).). As such,
questions about nurse’s attitudes regarding handling issues of death and dying associated with
terminal care have emerged over the past decades. In this regard, it has been noted that death
and dying are emotionally charged topics, and many healthcare professionals are
uncomfortable with end-of-life issues. Nurses, in particular, are faced with physical and
emotional suffering on a daily basis, yet they are often uncomfortable dealing with the realities
of death and dying (Naropa University, 2014). Nurses and other healthcare professionals are
often in the best position to make a difference in end-of-life care. However, they are caught in
the middle of the complex culture of the healthcare system, their own uneasy attitudes about
death and dying, and the emotional circumstances of patients and their families (End-of-Life
Nursing Education Consortium [ELNEC], 2013). Thus, it is critical to understand how
comfortable nurses are talking about end-of-life issues before they can adequately support and
advocate for the patients; that is, it is important to learn about the nurses’ attitudes toward
death. A body of knowledge has emerged in recent years on end-of-life care topics such as lack
of communication with patients, families, and coworkers, ethical issues, and how nurses view
caring for their dying patients (ELNEC, 2013; Peterson et al., 2013). However, prior research
has not examined how nurses personally feel about death, taking the patient out of the equation.
In this regard, data on nurses’ attitudes toward death should prove valuable.
Emotional labor, which was initially grounded on airline stewardesses’ work, is defined as the
emotions of caring for customers beyond physical and occupational skills (Hochschild, 1983).
Like the stewardesses’ role, nurses are expected to have appropriate and steady emotional
responses as part of customer care and are required to have their personal attitudes in check
when caring for patients experiencing issues such as death. That is, nurses are expected to be
sympathetic, caring, and involved with their patients at all times. As such, when dealing with
dying patients, nurses may have to hide feelings and experience an emotional cost that can lead
to burnout (Barry & Yuill, 2011; Gray, 2009). To this end, showing emotional uncertainty or
distress during patient care may be viewed as a sign of incompetence. In this regard, there is
limited research on the connection between individual factors and the way nurses perform
emotional labor (Hochschild, 1983). Thus, individual factors should be taken into account when
looking at the emotional labor an employee may experience. If the nurse has a negative attitude
toward death, she must emotionally labor to disguise those negative views and present a
positive presence to her patient. In this context, Chu (2002) reinforced that service employees
must display positive emotions, which translates to a positive experience for the customer
(Bryan, 2007; Louikdou et al., 2009). In addition, based on the review of literature, the extent
of experience and gender have also been identified as having an impact on attitudes toward
death in connection to nurses’ emotional labor (Hansen et al., 2009; Neimeyer et al., 2004;
Russac et al., 2007; Thacker, 2008). Based on the tenets of the emotional labor theory and
relevant review of literature, it was posited that nurses with more work experience would
exhibit more positive attitudes toward death compared to novice nurses. Likewise, it was
posited that background variables such as gender, ethnicity, area of nursing work, and state of
residency might also be associated with attitudes toward death and serve as factors as implied
by the emotional labor theory.
The Nurses’ Attitudes Toward Death
It has been documented that nursing home staff with higher death anxiety had more negative
views toward the elderly and aging (Neimeyer et al., 2004). It has also been found that nurses
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are less likely to talk about death and dying (Vickie & Cavanaugh, 1985). In general, nurses often
report discomfort talking about end-of-life issues with their patients, which appears to be
consistent behaviors across country lines (Ford, 2010; Ho, Barbero, Hidalgo, & Camps, 2010;
Murrish, 2010). For sure, there is plenty of research focusing on nurses’ feelings about death,
but there is limited research focusing on just the attitudes of the nurse, taking away the patient
element. When the patient is included in the research question, the nurse might be thinking as
a nurse tasked with patient care and not as an individual. Under these conditions, it has been
reported that nurses should be self-aware of their attitudes about death and their patients to
provide better end-of-life care (Khader, Jarrah, & Alasad, 2010; Kim & Lee, 2003).
Factors Associated with Attitudes Toward Death
In the US, it has been reported that attitudes toward death may vary based on gender, age,
ethnicity, and the occurrence of traumatic events. Russac and colleagues (2007) found that 20
to 30-year-old men and women score high on death anxiety, with women scoring significantly
higher than men. The authors also found that both groups declined in death anxiety as their age
increased. Furthermore, there is research indicating that African Americans are more afraid of
the unknown in relation to dying, while older Caucasians display more fear of the actual dying
process (DePaola, Griffin, Young, & Neimeyer; 2003; Neimeyer, Wittkowski, & Moser, 2004).
Personal and societal traumatic experiences (e.g., 9/11 tragedy) can influence the level of death
anxiety in society as well (Neimeyer et al., 2004).
The purpose of this study was twofold: (a) to explore nurses’ attitudes toward death and (b) to
determine whether nurses’ attitudes are associated with background variables. This study
targeted the nursing workforce in the US. Nurses’ attitudes toward death were collected using
a survey based on the Death Attitude Profile Revised (DAP-R) developed by Wong, Reker, and
Gesser (1994). In addition, background variables were defined as gender, ethnicity, years of
nursing practice, nursing specialty, educational level, and state of residence. To meet the
purpose of the study, the following research questions were used to drive the inquiry:
1. What are the nurses’ profiles of attitudes toward death (i.e., anxiety toward death,
neutral acceptance, escape acceptance)?
2. What background variables (i.e., gender, years of experience, nursing area, state of
residence, and ethnicity) impact nurses’ attitudes toward death?
METHODS
Participants
A total of 248 nurses in the US participated in the study. However, surveys with missing values
were excluded, and the final sample was reduced to 168 participants. The majority of
respondents were from New Jersey (91%), and the rest (9%) were from other states, including
Colorado, Minnesota, Delaware, Pennsylvania, New York, Florida, Utah, and Wyoming. The
respondents were predominately female (92%) and primarily Caucasian (80%). These
numbers were similar to national participation in the nursing workforce (National Council of
State Boards of Nursing, 2015). Regarding age, the range was from 20-73 years old with an
average of 51 years (SD = 12). Overall, survey participants represented eight areas of nursing
work, including medical-surgical (21%), education (20%), outpatient (15%), extended care
(11%), critical care (10%), management (10%), maternal-child (7%), and psychiatry (6%).
Participants appeared to be normally distributed with a range of 1 to 52 years in nursing work,
with an average of about 24 years (SD = 14 years) in the profession.
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Vognsen, J., Hernandez-Gantes, V. M., & Chen, Y.-H. (2024). Nurses’ Attitudes Toward Death and Associations with Background Characteristics.
British Journal of Healthcare and Medical Research, Vol - 11(6). 38-48.
URL: http://dx.doi.org/10.14738/bjhmr.116.17783.
Instruments
Attitudes toward Death Survey:
Attitudes toward death were determined by the Death Attitude Profile-Revised (DAP-R) survey
(Wong, Reker, & Gesser, 1994). The survey featured five subsets of statements regarding death
and dying: Fear of Death, Death Avoidance, Neutral Acceptance, Approach Acceptance, and
Escape Acceptance. Each subset focused on specific feelings about death and dying for a total of
32 questions (Wong et al., 1994). For the purposes of this study, fear of death and death
avoidance were collapsed into one category labeled as anxiety toward death. The subsets on
approach and escape acceptance were also collapsed into one category and labeled as escape
acceptance, which referred to the extent individuals view death as a way to escape life’s
troubles. The category of neutral acceptance refers to attitudes toward death that are neither
anxious nor too accepting. The Likert scale used in the survey ranged from 1 to 7, with 1 being
“strongly disagree” to 7 representing “strongly agree”. The standardized Cronbach’s alpha for
the entire survey equaled .82, and for the three subsets was .92 for anxiety (12 items), .93 for
escape acceptance (15 items), and .49 for neutral acceptance (5 items).
Demographic Variable Survey:
To document background characteristics, a demographicsurvey targeted data about age,
gender, ethnicity, years of nursing practice, area of nursing practice, and state of residence.
A Focus Group Interview:
A focus group was designed to gather further insights on attitudes toward death as a means to
verify survey results. A focus group protocol (available upon request) was used to facilitate
related discussion. A group of six registered nurses who worked at a Veterans Hospital in a
southern state in the US was recruited. The nurses’ years of experience ranged from 1 year to
40 years, with the average being 17.8 years. The focus group was conducted at a time that was
convenient for participants for about 60 minutes, and was facilitated by the first author, and
was tape-recorded for analysis.
Statistical Analyses
Descriptive statistics, including mean and standard deviation, were computed for the three
subscales of attitudes toward death (i.e., anxiety, escape, and neutrality) as well as based on
demographic variables (i.e., gender, education level, area of work, and ethnicity). Three
multiple regression analyses were conducted to explore the impact of demographic variables
on three attitudes toward death.
RESULTS
General Attitudes Toward Death
Table 1 presents descriptive statistics for three subscales (i.e., anxiety, escape, and neutrality)
of attitudes toward death based on demographic variables. The demographic variables
included gender, area of work, and ethnicity. As shown in Table 1, the highest mean attitude
toward death was observed for neutral attitude with the mean score of 5.79, indicating a very
high level of neutrality (i.e., neither anxious nor too accepting). In turn, the mean response for
the escape attitude was 4.69, reflecting a slight tendency toward acceptance of death, while
anxiety was rated as moderately low with a mean of 2.77. These results suggest that nurses, as
a group, exhibited high neutral attitudes toward death, with just slight tendency toward
escaping views, and low anxiety.
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In terms of gender, the results suggested that males showed a slightly higher anxiety towards
death, compared to females. Similarly, a slight difference was observed on the level of escape
attitude with females tending toward the moderately high level compared to males. Both males
and females reported equivalently high levels of neutrality. In general, it appeared that attitudes
toward death based on gender were relatively similar, which means no statistically significant.
Regarding ethnicity, the results suggested comparable average attitudes representing
moderately low anxiety for Caucasian and non-Caucasian respondents. Regarding escape
attitudes, non-Caucasian nurses tended to have a slightly higher escape than Caucasian nurses.
For neutral attitudes, Caucasians had a slightly higher attitude toward neutrality than non- Caucasians. The differences in attitudes between Caucasians and non-Caucasians occurred by
chance.
As for state of residence, nurses in New Jersey tended to have slightly higher attitudes toward
anxiety and escape but lower neutrality than those in other states. These differences in attitudes
were not statistically significant.
About the breakdown of attitudes based on the area of nursing work, the reported levels of
anxiety were relatively equivalent clustering toward moderately low anxiety, ranging from a
mean of 2.56 for nurses working in education to a mean of 3.26 for nurses working in maternal- child units. In turn, the results suggested neutral views on escape attitudes (mean scores
ranging from 4.04 to 4.33) for respondents working in psychiatry, extended care, critical care,
and outpatient, whereas attitudes tending toward moderately high escape views (mean scores
ranging from 4.56 to 5.31) for respondents in medical-surgical, education, maternal-child care,
and management. The responses on neutrality attitudes showed similar views across various
areas of work, representing a high level of neutrality (mean scores ranging from 5.60 to 5.92).
Table 1: Descriptive Statistics for Three Subscales of Nurses’ Attitudes Toward Death
Based on Demographic Variables
Group N Anxiety Escape Neutral
M SD M SD M SD
Overall 168 2.80 1.06 4.50 1.09 5.39 0.52
Gender
Male 14 3.02 1.35 4.24 1.13 5.29 0.50
Female 154 2.78 1.03 4.53 1.09 5.40 0.52
Ethnicity
Caucasian 134 2.80 1.03 4.47 1.10 5.40 0.53
non-Caucasian 34 2.80 1.15 4.62 1.05 5.34 0.50
State
New Jersey 152 2.82 1.07 4.51 1.05 5.39 0.53
Others 15 2.62 0.96 4.45 1.48 5.44 0.47
Area of Work
Management 16 2.83 1.23 5.31 0.59 5.54 0.38
Education 34 2.56 0.75 4.60 1.22 5.41 0.59
Outpatient 26 2.88 0.73 4.33 1.02 5.38 0.41
Psychiatry 10 2.58 1.23 4.04 0.90 5.18 0.64
Maternal/Child 12 3.26 1.35 4.76 1.38 5.50 0.51
Medical-Surgical 35 3.00 1.12 4.56 0.92 5.33 0.53
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Vognsen, J., Hernandez-Gantes, V. M., & Chen, Y.-H. (2024). Nurses’ Attitudes Toward Death and Associations with Background Characteristics.
British Journal of Healthcare and Medical Research, Vol - 11(6). 38-48.
URL: http://dx.doi.org/10.14738/bjhmr.116.17783.
Critical Care 17 2.71 1.05 4.30 0.95 5.47 0.42
Extended Care 18 2.65 1.36 4.05 1.30 5.34 0.69
Note. The 7-point Likert scale was used. The lowest score was 1 and the highest 7.
Impact of Background Variables
After establishing the nurses’ profiles of attitudes toward death, we examined the association
of each background variable with attitudes toward death. There was a high correlation (r = 0.83,
p < .001) between age and year of experience in nursing practice. The strong correlation
between nurses’ age and year of experience simply states an obvious expectation that nurses
would become more experienced as they get older. As such, the variable age was excluded in
subsequent analyses to avoid multicollinearity. Years of experience was selected for further
analyses, as it would be reasonable to infer that someone with more years of work experience
was older as well.
Multiple Regression Analyses:
Three multiple regression analyses were conducted for anxiety, escape, and neutrality
subscales of attitudes toward death. The predictors involved background variables, including
gender, ethnicity, year of experience as nurse, residence state, and practice area. Table 2
presents the overall F tests of three subscales of attitudes toward death for background
predictors.
Table 2: Overall F Test Outputs of Three Subscales of Attitudes Toward Death for
Background Predictors
Dependent Variable Source df Sum of Squares Mean Square F p R-square
Anxiety Model 11 14.15 1.29 1.16 0.32 0.08
Error 156 172.73 1.11
Escape Model 11 25.59 2.33 2.09 0.02 0.13
Error 156 173.44 1.11
Neutral Model 11 3.97 0.36 1.34 0.20 0.09
Error 156 41.90 0.27
As shown in Table 2, a set of background variables made a significant prediction for escape (p
< 0.05) but not for anxiety (p = 0.32) or nNeutrality (p = 0.21) with approximately 13% of
escape variances, 8% of anxiety variances, and 7% of neutrality variances explained by these
variables.
Table 3 shows the regression coefficients for a set of predictors for three subscales. Based on
the overall F test results, we focused on the full set of background variables for the Escape
subscale. For the Escape attitude, year of experience and practice area (Management versus
Extended Care) were significant predictors, after controlling for other variables. Year of
experience with a regression coefficient of 0.01 (p < 0.05) had a positive impact on the escape
attitude, indicating that every year increase in experience would result in an increase of 0.01 in
the escape attitude score. For practice area, nurses in the management area had a higher escape
attitude than those in the extended care (b = 1.13, p < 0.01). The escape mean scores for nurses
in management and extended care were 5.31 and 4.05, respectively (see Table 1), showing the
largest difference in the escape attitude among nursing practice areas.
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Although the overall F tests for the Anxiety and Neutrality attitudes did not show significant
results, year as nurse and race might be potential significant predictors (b = -0.01, p < 0.05 and
b = -0.21, p < 0.01), respectively. These indicated that more experienced nurses showed less
anxiety than less experienced nurses, and Caucasian nurses (M = 5.40) tended to have a slightly
higher neutrality attitude than other racial nurses (M = 5.34). After controlling for other
variables, gender and state of resilience did not show any influence on the three subscales of
attitudes toward death.
Table 3: Regression Coefficients of Multiple Regression for Three Subscales of Attitude
Toward Death
Anxiety Escape Neutrality
Gender (Male vs. Female) 0.153 -0.16 -0.10
Racial (Caucasian vs. Others) -0.153 -0.02 -0.21**
Year as nurse -0.01* 0.01* 0.00
State (New Jersey vs. Others) 0.16 0.27 -0.10
Management 0.39 1.13** 0.22
Education 0.14 0.29 0.05
Outpatient 0.42 0.07 0.06
Psychiatry 0.00 -0.09 -0.07
Maternal Child 0.69 0.60 0.10
Medical-Surgical 0.41 0.48 0.09
Critical Care 0.00 0.24 0.17
Extended Care - - -
Note 1. * indicates p < .05 and ** p < .01. Extended care is the reference group in this study.
DISCUSSION AND CONCLUSIONS
The increase in the elderly population brings a renewed focus on end-of-life care. Nurses are in
a unique position to assist those who are dying to experience a high quality of life to the end of
their lives (Dunn, Otten, & Stephens, 2005). Nurses are expected to have emotional insight into
their feelings about death and dying to support their patients through the dying process
adequately (Antičević, Ćurković, & Lušić Kalcina, 2024). This study, therefore, was intended to
investigate nurses’ anxiety, escape, and neutrality attitudes toward death and the impacts of
demographic variables on their attitudes.
This study found some interesting results that do or do not align with previous findings about
nurses’ attitudes toward death in the nurse population. A similar finding in this study with other
studies (e.g., Barnett, Reed, & Adams, 2021; Dunn, Otten, & Stephens, 2005) was that in general,
nurses was not afraid of death and did not avoid thinking about death; that is, there was a lower
score on the anxiety attitude toward death. Nurses also tended to have a consistently high
neutral acceptance attitude toward death. For instance, they considered death as a part of the
process of life and an unavoidable event. Nurses showed a moderate to high tendency of the
escape attitude toward death. These attitude tendencies were consistent across gender, state of
residence, ethnicity, years of nursing practice, and area of nursing practice, except for escape
across different years of nursing practice and between nurses in management and extended
care.
Dunn, Otten and Stephens (2005) and others (e.g., Deffner & Bell, 2005) found that nurses with
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Vognsen, J., Hernandez-Gantes, V. M., & Chen, Y.-H. (2024). Nurses’ Attitudes Toward Death and Associations with Background Characteristics.
British Journal of Healthcare and Medical Research, Vol - 11(6). 38-48.
URL: http://dx.doi.org/10.14738/bjhmr.116.17783.
more experience had more positive interactions with death than younger nurses. Similarly, this
study found that more years of practice nurses had a lower anxiety toward death. Langue and
colleagues (2008) indicated that this may be due to exposure to death reducing death anxiety
(Barnett, Reed, & Adams, 2021). In contrast, Black (2007) and others (e.g., Karkhah, et al., 2024)
indicated that old and more experienced nurses showed more fear of death attitudes than
young and less experienced nurses.
However, this study also found that nurses with more experience had a higher escape attitude
than less experienced nurses. The escape attitude was seen as a way to escape one’s troubles.
The nurse's attitude could depend on how much death and care of the dying the nurse
encountered throughout their career. A novice nurse would have much less exposure and be
less comfortable with death and the dying process than an experienced nurse working in
hospice (Gurdogan, et al., 2019). This may be a sign of burnout, as it appears to be the result of
work-related stress. Hochschild (1983) further reinforced this notion, stating that if an
employee was in an emotionally demanding job, then that employee might be at a higher risk
of burnout. To this end, one survey respondent stated, “...I started out in Critical Care, but found
the constant death too much to take in my twenties...so I switched to school nursing.”
Furthermore, this study found that nurses in management had higher escape attitude compared
to those in extended care. This finding might indicate that nurses with high escape attitudes
tend to choose the less stressed practice areas like management, whereas those with lower
escape attitudes feel more comfortable to work in more tensive areas such as extended care.
In this study, male nurses had about the same anxiety level across three types of attitudes
toward death as female nurses. However, Russac et al. (2007) found that death anxiety was
higher in women than in men. Incongruent results between this study and previous research
may be due to small samples of male nurses and different practice areas (Metallinou, Bardo,
Kitsonidou, & Sotiropoulou, 2023), warranting further research with large-scale samples
including more male nurses.
Implications, Limitations, and Future Research
Based on the findings in this study, potential implications for nursing practice were identified.
Study results suggested that nurses with more years of experience had less anxiety towards
death. Patients should not have to wait for their nurse to gain years of experience in end-of-life
care. Nursing programs must consider covering related issues more adequately as part of
undergraduate programs. End-of-life education after graduation also needs to integrate
medical knowledge as well as personal knowledge of death and dying signs, symptoms, and
personal viewpoints. The format of on-the-job education and training could have an impact on
the nurses as well, as many educational opportunities in healthcare settings now rely on self- study and/or online tutorials. These types of end-of-life education and training do not support
personal interaction and instead may contribute to emotional labor as suggested above. On the
other hand, experiential education such as self-reflection exercises, role-playing scenarios on
dying, and journaling with discussion groups could lead to less personal anxiety toward death
and a decrease in nurses’ emotional labor.
Some limitations need to be acknowledged in this study, along with some opportunities for
further research. First, even though the survey was emailed to all state nurses’ associations in
the US, most respondents in this study were from New Jersey, heavily female, and Caucasian.
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Thus, further research should target a broader sample to enhance the geographical
representation of participants. Second, the original DAP-R survey included five attitudinal
categories and was revised to include only three categories (i.e., anxiety, escape, and neutrality)
for the purpose of the study. As such, another consideration for additional research may involve
duplicating the compressed categories or administering the survey in its original form of five
subsets to validate the results. In addition, further research using different modes for survey
administration may contribute to more accurate reporting of related attitudes.
In conclusion, the nurses surveyed in the study had a high mean score in the Neutrality attitude
toward death, followed by the Escape attitude, and lowest for the Anxiety attitude. To this end,
the research results confirmed some assumptions regarding nurses’ attitudes. Female and male
nurses rated relatively the same regarding the three types of attitudes toward death. The
Escape attitude was higher in nurses with more nursing experience and nurses in management.
In turn, the results showed that experienced nurses were the most comfortable with death.
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