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International Journal of Nursing Practice 2013; 19: 8–13
RESEARCH PAPER
Paediatric nurses’ experience with death: The effect of empathic tendency on their anxiety levels Sevinç Polat PhD Assistant Professor, Department of Paediatric Nursing, School of Health, Bozok University, Yozgat, Turkey
Dilek Küçük Alemdar MSc Lecturer, Department of Paediatric Nursing, Faculty of Health Sciences, Giresun University, Giresun, Turkey
Ays¸e Gürol PhD Assistant Professor, Health Services Vocational School, Atatürk University, Erzurum, Turkey
Accepted for publication May 2012 Polat S, Küçük Alemdar D, Gürol A. International Journal of Nursing Practice 2013; 19: 8–13 Paediatric nurses’ experience with death: The effect of empathic tendency on their anxiety levels The purpose of this descriptive and analytic study is to investigate the effect on anxiety levels of nurses’ empathic tendency after experiencing death of patients in the paediatric intensive care unit. No sampling method was used in this study, and all 58 nurses working in the paediatric intensive care unit that agreed to participate in the study were included. The score mean of Empathic Tendency Scale for nurses was 77.43 ⫾ 4.55, their score mean of trait anxiety inventory was 39.82 ⫾ 5.53 and their score mean of state anxiety inventory was 48.03 ⫾ 6.80. This study concluded that nurses had a mild trait anxiety level under normal conditions and experienced moderate anxiety levels when faced with death. This study concluded that the empathic tendency of nurses working in the paediatric intensive care unit had no effect on their anxiety levels when faced with death; however, the anxiety level of nurses decreased as their empathic trends increased. Key words: anxiety, death, empathy, nurse.
INTRODUCTION Knowing, living, accepting and coping with the fact that a child is about to die is difficult. The health-care personnel’s professional support for parents during this process is extremely important in helping them accept death and overcome the shock and trauma they experience. However, parents experience more difficulties, especially
Correspondence: Dilek Küçük Alemdar, Department of Paediatric Nursing, Giresun University Faculty of Health Sciences, 28340 Piraziz-Giresun, Turkey. Email:
[email protected] © 2013 Wiley Publishing Asia Pty Ltd
when faced with death, if nurses do not empathize adequately and subsequently do not handle the situation professionally.1 Empathy is the most important dimension of supportive (therapeutic) relations. Nurses require an empathic approach in order to determine the needs and reactions of patients and their families within every communication situation. The quality of health services is negatively affected when nurses have inadequate levels of empathic skills when communicating with patients.2 The attitude towards death reflects a personal reaction about death and is defined as a sense of threat, fear and doi:10.1111/ijn.12023
Paediatric nurses’ empathic tendency
discomfort. Death of patients is something nurses do not enjoy experiencing, and anxiety towards death is usually an expected result. However, when nurses lack understanding of what is going on around them their level of anxiety increases; as a result, nurses often portray physical and emotional discomfort. The attitude nurses have towards death has a significant effect on the care they provide for their terminally ill patients. In his study, Ünsal stated that nurses were afraid of coming face-to-face with terminally ill patients and death and would prefer to work in units that did not have terminally ill patients.3 Death is an even more traumatic event for nurses who work in neonatal intensive care units and paediatric clinics, interact extensively with newborns and take on the primary care of newborns. There are no studies available in Turkey that investigate the effect of nurses’ empathic trends on their anxiety levels after facing death. In the literature, there are limited studies that individually investigate the empathic trends of nurses and their anxiety levels towards death.4–6 Future studies related to this subject are extremely important as they will help determine the reactions nurses experience when faced with death, provide them with support and professional help as required and increase the quality of patient care.
METHODS Participants and procedure This descriptive study was conducted between March 2008 and January 2011 with a group of 58 nurses in Samsun, Turkey. No sampling method was used in this study; all 58 nurses working at the paediatric intensive care unit who agreed to participate in this study were included in the study. A questionnaire form, the State–Trait Anxiety Inventory (STAI) and the Empathic Tendency Scale (ETS) were used to collect data. The self-administered questionnaire included demographic information (age, education, etc.) and questions about death and took 15–20 min to complete. The semi-structured questionnaire form was developed specifically for this study, using questionnaires from previously published studies as a guide. Researchers determined the face validity of the questionnaire. The questionnaire form, the STAI and the ETS were conducted on nurses during their first interview. The STAI was conducted on nurses immediately after they were faced with the death of a patient. Previous resources referred to in the literature were used due to the lack of studies conducted on the subject.
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Instrument STAI Anxiety was assessed using the STAI, which consists of 40 items: 20 designed to assess state anxiety (STAI-S), and another 20 aimed at evaluating trait anxiety (STAI-T). The STAI requires the individual to describe feelings at a certain moment and under a certain situation; in other words, he/she has to describe feelings caused by the current situation he/she is in. The STAI-S assesses how respondents feel ‘right now, at this moment’. The STAI-T evaluates how people ‘generally feel’. The STAI measures how a person feels at the present moment as scored on a 4-point Likert scale. The questionnaire consists of 40 items with answer choices of 1, ‘not at all/almost never’; 2, ‘somewhat/sometimes’; 3, ‘moderately so/often’; and 4, ‘very much so/almost always’. The STAI is a selfevaluation questionnaire that consists of short responses. According to responses given to ranked items, expressed feelings and behaviours are marked according to their intensity as: (i) ‘never’; (ii) ‘some’; (iii) ‘much’; and (iv) ‘completely’. Scores range from 20 to 80, with a high score indicating a high level of anxiety and a low score indicating a low level of anxiety. The STAI scores increase in response to stress, and decrease in relaxing conditions. The STAI has adequate concurrent validity and internal consistency. The STAI consists of two types of expressions: direct expressions that express negative feelings, and reverse expressions that express positive feelings. In state anxiety inventory items, 1, 2, 5, 8, 10, 11, 15, 16, 19 and 20 are reverse expressions. Reverse expressions in the trait anxiety inventory are items 21, 26, 27, 30, 33, 36 and 39. After calculating the total intensity of direct and reverse expressions separately, the total intensity value of the reverse expressions is subtracted from the total intensity value of direct expressions. The STAI developed by Spielberger et al.,7 measures individual’s trait anxiety levels. The validity and reliability study of the inventory in Turkey was conducted by Öner and Le Compte.8 The validity of the state anxiety inventory is between 0.83 and 0.87, and test–retest reliability is between 0.71 and 0.86. The Cronbach’s alpha value for the state anxiety scale within the study was determined as 0.87. Spielberger et al. stated that a score between 0 and 19 was ‘not anxiety’, a score between 20 and 39 was a ‘slight anxiety level’, a score between 40 and 59 was a ‘moderate anxiety level’, a score between 60 and 79 was a ‘high anxiety level’ and individuals with a score 60 and above should seek professional help.8 © 2013 Wiley Publishing Asia Pty Ltd
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ETS
Dökmen9 developed the ETS in order to measure the empathy trends of individuals in daily life. The 20-item scale is a 5-point Likert-type scale ranging from ‘strongly disagree’ to ‘strongly agree’. Nurses in this study were asked to choose a number from 1 to 5 for each item, in order to describe how much they agreed with the statement referred to in the item. Nearly half the items (questions 3, 6, 7, 8, 11, 12, 13 and 15) were negative statements to stop individuals from answering ‘Yes’, and were scored reversely. The highest score obtainable from the scale is 100, and the lowest is 20. High scores obtained from the ETS indicate the high empathy capacity of the individual. The Cronbach’s alpha coefficient of the ETS for this study was 0.72.
Data analysis SPSS version 15.0 (SPSS Inc., Chicago, IL, USA), was used to conduct data analysis. Percentages and means are used to illustrate the descriptive properties of demographic characteristics. Bivariate correlate tests were used to compare STAI-S, STAI-T and EST. The confidence interval was 95%; P < 0.05 was considered to be statistically significant.
Ethical considerations Permission to undertake this study was obtained from the Research Ethics Committee at 19 Mayis University hospitals, and informed consent was obtained from each participant. Prior to this study, the nurses were informed of the purpose of the research. Nurses were assured of their right to refuse to participate, or to withdraw from the study at any stage.
Table 1 The demographic characteristics of nurses (n = 58) Age (mean ⫾ SD) STAI-S STAI-T ETS Marital status Married Single Do they have children?† Yes No Education level Associate degree University degree Years of experience in NICU < 1 year 1–5 years 6–10 years > 11 years Previous death experience Yes No What they felt when faced with death Helpless Unsuccessful Sorrow How often did they think about their own death Frequently From time to time Never
27.55 ⫾ 3.72 48.03 ⫾ 6.80 39.82 ⫾ 5.53 77.43 ⫾ 4.55 22 (37.9) 36 (62.1) 16 (27.6) 42 (72.4) 8 (13.8) 50 (86.2) 8 26 14 10
(13.8) (44.8) (24.1) (17.2)
54 (93.1) 4 (6.9) 14 (24.1) 4 (6.9) 40 (69.0) 14 (24.1) 36 (62.1) 8 (13.8)
†
Nurses with children were included in the study. ETS, Empathic Tendency Scale; NICU, Neonatal Intensive Care Unit; STAI-S, State Anxiety Inventory; STAI-T, Trait Anxiety Inventory.
RESULTS The average age of nurses that participated in this study was 27.54 ⫾ 3.72, 37.9% of nurses were married, 86.2% of nurses were university graduates, all nurses were female and 44.8% of nurses had 1–5 years work experience. Table 1 illustrates the demographic characteristics of nurses. This study concluded that 93.1% of nurses had previously experienced death, 24.1% felt helpless when faced with death, 69% felt sorrow when faced with death and 62.1% thought about their own death from time to time. The score mean of the ETS for nurses was 77.43 ⫾ 4.55, their score mean of STAI-T was 39.82 ⫾ 5.53 and their score mean of STAI-S was 48.03 ⫾ 6.80. The empathic © 2013 Wiley Publishing Asia Pty Ltd
tendency scores of nurses participating in this study were good; this indicates that nurses had a mild constant anxiety level under normal conditions, and experienced moderate anxiety levels when faced with death. Table 2 illustrates the relationship between the score means of the ETS, the STAI-S and the STAI-T for nurses participating in the study. This study concluded that the anxiety level of nurses decreased as their empathic tendency increased. There was no statistically significant relationship between the score means of ETS of nurses and their score means of STAI-S and STAI-T; however, there was an inverse relationship between variables.
Paediatric nurses’ empathic tendency
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Table 2 The comparison of Empathic Tendency Scale and State– Trait Anxiety Inventory ETS
STAI-S STAI-T
r
P
-0.119 -0.098
0.466 0.374
This study concluded that there was a significant relationship between the education level of nurses, whether they were mothers and their ETS score mean (P < 0.05); university graduate nurses with children had a higher ETS score. The STAI-S scores of married nurses with children was significantly high (P < 0.05). The was no statistically significant relationship between the ETS, STAI-S and STAI-T marks based on the years of experience nurses had and based on previous death experiences.
DISCUSSION Understanding the patient and their family is a difficult task for a nurse. A nurse’s job becomes more difficult before and after death, a period when extensive anxiety is experienced.2 A nurse will feel that they have not done their job properly if they cannot establish effective communication and empathize with the patient and their family; this situation is one of the fundamental reasons that causes exhaustion.10–13 This study concluded that nurses had a good level of ETS score means, and their level of anxiety decreased as their empathic tendency increased (P > 0.05). In his study, Inel Manav stated that the mean score of ETS for nurses was 72.07 ⫾ 8.26.4 Conducted studies prove that the emotional exhaustion and desensitization score of nurses decreases as their empathic tendency scores increase, and there is an inverse relationship between empathy and desensitization.14–16 These results support our study. This study concluded that the STAI-T score mean for nurses was 39.82 ⫾ 5.53, and their STAI-S score mean was 48.03 ⫾ 6.80; nurses had a mild constant anxiety level under normal conditions and experienced moderate anxiety levels when faced with death. S¸ahin17 reported that nurses had a STAI-T score mean of 42.773 under normal conditions, and an STAI-S score mean of 52.720 after death (t = 14.64, P < 0.05). This result proves that, in general, nurses’ levels of anxiety increase when faced with death.
This study concluded that the ETS score mean for university graduate nurses was significantly higher than the ETS score mean for associate graduate nurses (P < 0.05, Table 3). Numerous studies state that university graduate nurses have a higher empathic tendency in comparison with vocational high school graduate nurses and associate graduate nurses18–22 In their studies, Pınar23 and Aydın24 stated that there was no relationship between the empathic skills of nurses and their level of education. There was no significant relationship between the STAI-S and STAI-T scores of nurses and their level of education – a similar result reported to that of Ünsal.3 There was no statistically significant relationship between the ETS scores of nurses and their marital status. Numerous studies state that the marital status of midwives and nurses does not affect their level of empathic skills.19,22,23 The marital status of nurses did not affect their trait anxiety levels; however, married nurses had a higher state anxiety level in comparison with single nurses – the relationship between them was significant (P < 0.05). In the study of Ünsal,3 she identified that there was no difference between the state anxiety level of nurses based on their marital status; however, she stated that the trait anxiety level of single nurses was significantly high in comparison to the trait anxiety level of married nurses. The ETS score and state anxiety level of nurses with children was higher in comparison with the ETS score and state anxiety level of nurses without children, and the relationship was statistically significant (P < 0.05, Table 3). This might be due to the fact that, under the circumstances, the maternal instinct of nurses with children increases, which enables them to empathize more, and this is reflected in their state anxiety level. Similar results have been obtained in numerous other studies conducted regarding the subject.4,13,18,20,25–27 There was no statistically significant relationship between the ETS, STAI-S and STAI-T scores of nurses and whether or not they had previously experienced death (P > 0.05). Ünsal3 stated that the state and trait anxiety level of nurses who had experienced 1–5 deaths was significantly high (P < 0.05). This result leads us to believe that as opposed to previous death experiences, nurses focus on the present death.
CONCLUSION This study concluded that nurses working at the paediatric intensive care unit had a slight trait anxiety level under © 2013 Wiley Publishing Asia Pty Ltd
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Table 3 The distribution of scores obtained from the Empathic Tendency Scale and the State–Trait Anxiety Inventory according to the demographic characteristics of nurses
Marital status Married Single MW-U; P Do they have children? Yes No MW-U; P Education level Associate degree University degree MW-U; P Years of experience A year and below 1–5 years 6–10 years 11 years and above KW; P Previous death experience Yes No MW-U; P
ETS
STAI-S
STAI-T
76.81 ⫾ 4.31 76.94 ⫾ 4.51 -0.773; P > 0.05
41.33 ⫾ 5.26 37.36 ⫾ 5.16 -2.609; P < 0.05
48.09 ⫾ 4.86 48.00 ⫾ 7.82 -0.774; P > 0.05
77.25 ⫾ 4.58 73.76 ⫾ 4.38 -1.629; P < 0.05
41.33 ⫾ 5.08 35.87 ⫾ 4.77 -3.182; P < 0.05
46.25 ⫾ 4.05 48.71 ⫾ 7.52 -0.911; P > 0.05
74.25 ⫾ 1.38 77.32 ⫾ 4.57 -2.629; P < 0.05
37.25 ⫾ 3.05 40.24 ⫾ 5.75 -1.133; P > 0.05
45.00 ⫾ 3.62 48.52 ⫾ 7.09 -1.498; P > 0.05
77.41 ⫾ 1.13 77.22 ⫾ 4.17 74.73 ⫾ 4.25 73.36 ⫾ 4.12 5.21; P > 0.05
40.38 ⫾ 5.08 39.57 ⫾ 4.77 37.25 ⫾ 3.05 36.24 ⫾ 5.82 4.78; P > 0.05
46.34 ⫾ 5.45 48.91 ⫾ 7.29 47.00 ⫾ 3.52 45.82 ⫾ 6.17 4.57; P > 0.05
76.15 ⫾ 4.70 78.20 ⫾ 2.52 -1.850; P > 0.05
40.20 ⫾ 5.76 42.00 ⫾ 4.61 -0.864; P > 0.05
49.60 ⫾ 6.60 46.20 ⫾ 7.67 -0.124; P > 0.05
KW, Kruskal Wallis test; MW-U; Mann-Whitney U test.
normal conditions and experienced moderate anxiety levels when faced with death. The empathic tendency of nurses had no effect on their anxiety levels when faced with death; however, the anxiety level of nurses decreased as their empathic trends increased. Taking this result into consideration, we recommend that in an effort to increase nurses’ empathic skills and to support nurses that have a high anxiety level when faced with death, which affects the quality of nursing care, future studies on the subject should be more comprehensive.
ACKNOWLEDGEMENT The authors received no financial support for this study.
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