Death anxiety in females with and without exposure to death and dying: differential dimensions

Exposure to traumatic events like death and dying is anxiety provoking. High anxiety can contribute to psychological breakdown of the individual. A study was conducted to examine the impact of exposure to death and dying on different dimensions of fear of death. Data were obtained from 100 females who were professionally exposed to death/dying and their 100 matched controls that were not exposed to death/ dying in the last two years, using a background questionnaire and Collett-Lester’s fear of death scale. All subjects exhibited varying degrees of death anxiety from low to high. Females who were professionally exposed to death/dying reported to have significantly higher fear of death, and fear of dying of self as compared to their counterparts who were not exposed to death/dying in last two years (t= 1.65, p < .05, t= 2.74, p < .01, respectively). While comparing the fear of death of self with fear of death of others; and fear of dying of self with fear of dying of others, the females in both the groups were more fearful about the death and dying of others as compared to self. In the group exposed to death, the fear of death of self/ fear of death of others exhibited significant differences with the scores being more for others as compared to self (t = 6.87, p < .01). The relationship of socio-demographic variables (age and religious background) with death anxiety has also been explored in this study. One dimension of death anxiety i.e. fear of death of others was found to be negatively and significantly correlated with age in Group 1 (professionally exposed to death/dying) as well as in Group 2 (not exposed to death/dying in last 2 years). The two main religious groups in this study i.e. Hindus and Sikhs were compared on all the dimensions of death anxiety and no significant difference was observed. The implications of the findings are discussed in the paper.


IntroDuctIon
Death represents dissolution of bodily life, a time of rest and peace, a supreme refuge from turmoil of life. It is the terminal event in the life of all living creatures. Dying is a process, the end point of which is death (Singh, 2002). The concept of non-being is very threatening as it goes against a strong and innate feeling that life should not be reduced to non-being. People think of death as the worst occurrence in life and do their best to avoid talking and thinking about death, especially their own (Kozier, 2004). The perception of death and dying differs from individual to individual and thus, the resulting behaviour when facing death is diverse and complex (Morgan, 2001). The awareness of human beings about the inevitability of death make them different from other living beings, and therefore, they fear about what will happen during the dying process and after death. Discussions on death and dying are neither encouraged nor welcomed in our society. Professionals like nurses who spend time with terminally ill patients are not immune to such attitudes. They are like all other human beings but their professional responsibilities make them accountable to take care of the dying and the bereaved. Professional caregivers including nurses may experience role strain due to repeated interactions with dying clients and their families (Kozier, 2004). Wong et al. (1994) have reported multidimensionality of death attitudes both positive and negative. The two negative attitudes towards death are death avoidance and fear of death. Death avoidance means when a person avoids thinking or talking about death in order to reduce death anxiety, and fear of death means the feeling evoked when confronting death. One of the negative attitudes, i.e. fear of death, is the main focus of the current study.
Fear and anxiety are among the terms most frequently used to characterise orientations towards death throughout the lifespan. Templer (1970) suggested that death anxiety involves both uneasiness about personal extinction and apprehension about the dying process. Tomer (1992) further elaborated this definition and said that death anxiety is caused by the anticipation of the advice. The Group 1 professionally exposed females were nurses and Group 2 females were engaged in other professions where exposure to death and dying did not occur on the job. The female nurses included in this study were working with critically ill patients in a tertiary care level hospital. According to exclusion criteria, the females who have witnessed the death of someone close to them in the preceding two years were not included. Sample characteristics are as shown in Table 1. Females with poor state of health were also excluded. As per the observations of the investigator during data collection, no study subject was comfortable in answering the questions related to death and dying. Most of subjects' initial response was why this topic has been taken for investigation? After explaining the importance of the study both for nursing professionals as well as for other females they could be convinced to fill the questionnaires. In the background questionnaire, exposure status to death/dying was ascertained. For this, subjects were asked about witnessing the death/dying of someone close to them in the preceding two years. The respondents who had witnessed the death or dying process of somebody close to them were quite distressed. During interaction with the investigator they expressed that after this experience they felt emotionally drained and were not having any strength to resume routine activities. Although exposure to death/dying in the preceding two years was an exclusion criteria for this study, above mentioned were the feelings of the subjects who had witnessed the death/dying process of someone close to them the preceding two years. While answering the statements related to fear of death and dying of others, state in which one is not alive, including aspects of fear of dying or the death of significant others. Neimeyer (1997) described death anxiety as a term encompassing a cluster of death attitudes, characterised by fear, threat, unease, discomfort and other negative emotional reactions, along with anxiety as a kind of diffused fear with no clear object (anxiety in psychodynamic sense). Fear of death "includes measures of the extent to which one experiences angst in reference to death" (Fortner & Neimeyer, 1999). Pollak (1980) in his extensive review of various empirical studies concluded that researchers use wide variety of means to study death anxiety and it is complex as well as multi-dimensional. He also pointed out that researchers often examine death anxiety on separate dimensions based on the assumption that it is a multidimensional construct. Collett & Lester's (1969) fear of death scale allows researchers to examine death anxiety along with its various dimensions. It is comprised of four sub scales and each subs cale can be used separately as all of them are independent of each other. The four sub scales are fear of death of self, fear of dying of self, fear of death of others and fear of dying of others. In present research terms 'fear of death' and 'death anxiety' are used interchangeably.
The aim of the present endeavour is to investigate how exposure to traumatic events like death and dying affect the different dimensions of death anxiety i.e. fear of death and dying of self; and fear of death and dying of others.
The current study examines the following hypotheses: • Fear of death would be more among females exposed to death/dying in their professional capacity as compared to females not exposed to death/dying. • Fear of death of self would be more as compared to fear of death of others.

MEtHoDS
Purposive sampling method was used to select a sample of 200 females, which comprised of 100 females professionally exposed to death/dying (Group 1) and 100 females not exposed to death/dying for last 2 years (Group 2). All the subjects were in the age group of 25-45 years, were married, having minimum qualification up to graduation level and none of them was suffering from any chronic illness. To rule out the presence of any medical/mental illness, the respondents were asked to specify their health condition at present as well as in the past for which they may or may not have sought medical some of the subjects expressed that they want nothing wrong should happen to their family members, especially their children. While responding to the questions on fear of death/dying of self, most of the subjects were worried who would look after their children if they die. All the subjects expressed their desire to be in good state of health and to live long.
Tools used for the study are enlisted below:

Background questionnaire
Background questionnaire was developed to collect information about socio-demographic characteristics of the subjects and to ascertain the status of exposure to death and dying in last two years. The questionnaire comprised of eight questions. Four questions were about socio-demographic profile of the respondents and two about their exposure to death and dying in the preceding two years. Under socio-demographic characteristics, information about age, marital status, educational qualification and religion was obtained. Exposure to death and dying status of the participants was assessed by asking two questions, i.e. have you witnessed the death of someone close to you in the last two years? And if yes, mention the relationship to the deceased. Subjects' self-reported measures were used to ascertain the health status and presence of any illness. Subjects were asked to report their health status as good, fair or bad. If health status is bad, the underlying cause for which they have sought or not sought any medical help was asked to be specified. Females suffering from any chronic illness either medical or psychological, with bad state of heath were not included in the sample.

The revised Collett-Lester fear of death and dying scale (Lester, 1990)
The revised scale used in this study has four subscales, i.e. fear of death of self, fear of dying of self, fear of death of others and fear of dying of others. For fear of death and dying of self, the respondents were asked to report their discomfort level on questions like: the isolation of death, the disintegration of your body after you die and the suffering involved in dying. In the other two subscales, i.e. fear of death of others and fear of dying of others, the subjects were asked to report their discomfort level to items like: the loss of someone close to you, to see their dead body and to be with someone who is dying. Each subscale comprises of 8 items and scoring is based on a 5 point Likert scale ranging from not disturbed (1) to extremely disturbed (5). The scale also provides different levels of fear of death related to the obtained scores; namely, low (8 to 20), moderate (21-30) and high (31-40), respectively. The test-retest reliability using Pearson correlations for various sub-scales were adequate; specifically these were 0.85 for death of self, 0.79 for dying of self, 0.86 for death of others, and 0.83 for dying of others.

rESultS anD DIScuSSIon
Keeping in view the aims of the study, the descriptive and inferential statistical tests were used. The mean and standard deviation were worked out in respect of age as shown in Table 2. The mean age of the subjects in Group 1 (females exposed to death/dying) and Group 2 (females not exposed to death/dying in last two years) was 31.65 and 32.37 respectively. The sample thus had comparable age in the two groups studied.  Table 3 reveals the distribution of subjects according to levels of death anxiety. In Group 1, 46% subjects expressed high fear of dying of self. About death and dying of others 60% and 53% subjects expressed high fear respectively. In Group 2 moderate level of fear of death and dying of self was exhibited by maximum number of subjects, i.e. 43% and 58% respectively. For fear of death and dying of others maximum subjects were in high category, i.e. 51% and 47% respectively. Table 3 that all the study subjects had varying degrees of death anxiety and among all the study subjects nobody was found to be free from it. Findings are supportive of Becker's (1973) and Kubler -Ross's (1969) views on fear of death, that fear of death is the universal fear that all human beings experience. Kastenbaum (2003) also reported that individual differences on self control exist when it comes to death-related anxiety, disallowing it from disrupting their day-to-day lives, but no one has the ability to completely quell underlying feelings of threat. Presence of varying degrees of fear of death and dying among study subjects is suggestive of individual differences in the present study. Another interesting finding from Table 3 is that in Group 1 (females exposed to death/ dying) 46% of the subjects reported high fear related to the dying process of self as compared to those who were not exposed to death/dying in the last two years, i.e. in Group 2 only 24% of the subjects were highly anxious about the dying process of self. In this context it can be said that witnessing death of others or seeing others going through that pain and sufferings at the time of death definitely influences the death anxiety related to self. It is not the fear of death of self but the fear of process of dying that is greatly influenced. That means exposure to such events enforces the individual to think about his/her own death.  Table 4 shows the difference between Group 1 and Group 2 on death anxiety. It is evident that out of the four death anxiety dimensions, for two dimensions, i.e. fear of death of self and fear of dying of self, significant differences existed. Significantly high fear of death of self and dying of self was exhibited by the females who were exposed to death/dying (Group 1) as compared to those who were not exposed to death and dying (Group 2) (t = 1.65, p< .05 and t = 2.74, p< .01) respectively. The findings indicate that exposure to traumatic events like death and dying increases the death anxiety. The results support the findings of Lees & Ellis (1990), that contact processes accompanying the death of others make us conscious of our own mortality, giving rise to anxiety and unease. The results are also in accordance with the findings of Chuen et al. (2006) who compared 53 experienced, 49 non-experienced nursing students and 50 non-nursing students on death anxiety. Both experienced and non-experienced nursing students reported more fear of unknown than controls which is again in consonance with the findings of the current study.

It is evident from the findings in
Based on the observations in Table 4 it can be concluded that fear of death is more internalised in females who are professionally exposed to death and dying (Group 1) as compared to other females who are not exposed to death and dying in the preceeding two years (Group 2). 'Ignorance is bliss' will be the right term to use here for females in Group 2 as they do not have the same opportunity like their counterparts to observe and care for people suffering at the end stage of life. On the other hand, female nurses in Group 1 (professionally exposed to death and dying) are directly involved as well as professionally accountable for providing care to terminally ill patients with an empathetic attitude, hence, being forced to think about their own death and dying process. Thus this fear of death of self especially of the dying process, affects their inner-being.
Table 4 also depicts that for the last two dimensions of death anxiety, i.e. fear of death of others and fear of dying of others, no significant difference exists in Group 1 (females professionally exposed to death/ dying) and Group 2 (females not exposed to death/ dying). It is an important and positive finding, especially in context to those females who are professionally providing services to human beings when they are on death bed. Results presented here indicate that emotional involvement while providing care to others is under control. If excessive emotional involvement would have been present in these subjects, i.e. Group 1 (females exposed to death/dying), the services provided by them to the ailing humanity would have suffered because of the personalised traumatic stress. These findings also emphasise the importance of professionals being more effective in objective care if they are not closely related to the patient. Table 5 describes the comparison of fear of death/ dying of self with fear of death/ dying of others. It can be observed that in Group 1 while comparing the fear related to self and others, the subjects reported significantly high fear about the death of others (t = 6.87, p< .01). Whereas, the females in Group 2 exhibited significantly high fear of death as well as of dying of others as compared to fear of death and dying of self (t = 7.92, p< .01 & t = 5.23, p < .01) respectively. Death anxiety in females with and without exposure to death and dying: differential dimensions It can be concluded from the above findings that in both the groups the subjects were more open in exhibiting fear related to death and dying process of others as compared to self. In Group 1 (females exposed to death/ dying) the subjects have not shown any significant difference between fear of dying of self and others. This may be related to the fact that the measure used for assessment was a questionnaire with the items being obvious in their content. The females in this group are thought to be preoccupied with the thoughts of sufferings during the dying process. Their anxiety related to dying of self and others is almost in par with each other, professional exposure to traumatic events like death and dying can be held responsible for this. Becker's (1973) existential view supports the current findings that much of our daily behaviour consists of attempts to deny death and thereby keep death anxiety under control. Terror management theory (Greenberg et al., 1997) also stresses that people use distinct modes of defense to deal with the problems of death. The direct rational, threat focused defenses reduce the individual perception of his or her vulnerability to life threatening conditions, thus pushing the problem of death into a vague and distant future. Here, in the present study, it may be the denial which has been used by the subjects as defense in managing self-related fear of death and dying.
Under socio-demographic variables, the relationship of age with all the dimensions of death anxiety was explored. In Table 6 correlation analysis of age with all the dimensions of death anxiety is shown. In the total study sample fear of death of others showed negative and significant correlation with age (r = -0.249, p< .01). Fear of dying of self and others reflected a negative relationship with age but it was not significant. Age has shown positive relationship with fear of death of self. Females in Group 1 also showed negative and significant relationship of age with fear of death of others. The relationship of fear of death of self with age was positive but insignificant in Group 1. In Group 2, again fear of death of others was found to be negatively and significantly correlated with age (r = -0.245, p < .05). Age has shown a significant and negative relationship with fear of death of others in the total sample as well as in Group 1 and Group 2. With all other dimensions of death anxiety against age showed a negative relationship although not significant, except for fear of death of self in Group 1, as well as in the sample as a whole. The current findings suggest that fear of death of others significantly decreases with advancing age. Number of studies have been done in this field, but still no conclusive findings are present on the nature of relationship between age and death anxiety. Tang et al. (2002) while comparing younger with older students and women with men, concluded that younger and women subjects were more anxious as compared to their counterparts. Rasmussen and Brems (1996) are of the view that instead of age, psychosocial maturity and life satisfaction are better predictors of death anxiety. According to these authors, as the psychosocial maturity and age increases, death anxiety decreases. The subjects recruited for the present study were healthy, economically independent, married and living with their families. The above mentioned characteristics of the sample subjects might be acting as a source for feelings of love and belongingness, improved self-esteem and life satisfaction which in return might be buffering death anxiety. Thus, it can be said that for decrease in fear of death with advancing age, age does not seem to be the only factor responsible for the negative relationship in this study, but the above studied traits of the study sample have definitely contributed for reducing death anxiety.
Another socio-demographic variable studied was religion. Most of the subjects in this study belonged to two religious groups, i.e. Hindu and Sikh. Both these groups were compared on all the four dimensions of death anxiety as shown in Table 7. From the findings depicted in Table 7, it is evident that on the basis of religious background of the study subjects there is no significant difference on death anxiety. The reason that can be cited here for these results is that the basic philosophy of both these religion is same. Hindus believe in the continuity of life after death, but still they are not able to overcome the fear of death. The possible reason for this may be their inability to see that continuity. In the doctrine of Karma, one's deeds play an important role. Bhagavad Gita (1962) says that actions performed, Nishkam, gradually lead people to a stage when they will not be born again but will be merged with 'Brahma', the Almighty and be freed from this world and finally attain Moksha. According to Sikhism, human life is the most important gift given by God to unite with the ultimate reality. It is up to the mortal to end the continuing journey of births and deaths by meditating on the name of God (Sikh Missionary, 2004). Therefore, it can be concluded that the fact of universality of death anxiety is supported by this study. Degree of death anxiety varies from individual to individual depending upon the situation. Present study also emphasises that exposure to death and dying definitely influence the fear of death or death anxiety. As yielded from the results of this study, the females who were professionally exposed to death/dying were significantly high on fear of death and dying of self. To minimise the mental effects of recurrent exposure to traumatic events like death/dying, need based guidance and counseling services at organisational level, and a mutually supportive environment are suggested by the findings. Regular interactive group discussions with professionals and psychologists are also recommended which may provide opportunities for ventilating the fears, so that these fears may be rationally accepted and handled rather than denied. This would go a long way towards increasing the mental health of the nursing staff and subsequently their professional efficiency.