Abstract
Introduction
Death is a universal event that is the last stage of life. It is the phase in which the vital processes in living beings cease to come back (Cheong et al., 2020). Individuals often see death as an obstacle to be overcome. Therefore, death is removed from all areas of life and imprisoned in hospitals or nursing homes. Unfortunately, this puts all the emotional and physical burden of death on health professionals. However, like all people, health professionals can also feel fear and anxiety about the phenomenon of death (Arab et al., 2019; de Swardt & Fouché, 2017).
In hospitals, nurses have a much closer relationship with patients and their families than the rest of the healthcare team, especially with patients with chronic diseases. This situation imposes huge responsibilities on nurses who have to give palliative care to the individuals they provide nursing care for a long time and witness their separation from life (Cheong et al., 2020). While nurses care for the dying individual, they are also affected by the process both individually and professionally (Rahman et al., 2021; Sönmez Benli & Yıldırım, 2017). The person whose death is near or about to die imposes some feelings on the people around him while experiencing this difficult process. Therefore, it causes the people around them to experience strong fluctuations in their spiritual world. In the hospital environment, nurses who have the longest relationship with the patient experience these strong fluctuations much more intensely (Milligan & Almomani, 2020). In the literature, it has been stated that nurses who care for terminally ill patients experience emotions such as anger, helplessness, and blame, and do not want to work in units where dying patients are interned. They are afraid of being inadequate in the care of the patient (Jang et al., 2019).
It can be thought that nurses may manage these processes, as they frequently encounter the phenomenon of death, just like other health professionals. However, it is reported that long-term exposure to illness and death can trigger death anxiety (Arab et al., 2019; Jang et al., 2019). Furthermore, especially professionals such as nurses who establish a close and long-term relationship with the dying individual, due to the nature of their profession and maintain this relationship for 24 hours, may experience death anxiety (Sönmez Benli & Yıldırım, 2017; Zheng et al., 2021).
Caring for dying patients requires nurses to be knowledgeable and skilled in relevant areas. Therefore, nurses’ training on the concept of death and dying patient care and gaining insight into their own behavior are the basis of providing quality care to patients and families. For this reason, the meanings and perceptions of death attributed by nurses to the concept of death should be revealed. In addition, nurses need to be aware of their own feelings, behaviors, expectations, approaches, and natural attitudes regarding life, death, loss, and mourning processes. A nurse who does not have insight into all these issues and does not know herself will naturally find it difficult to achieve a certain qualification in providing service to the dying individual and their relatives (Sönmez Benli & Yıldırım, 2017; Milligan & Almomani, 2020; Jang et al., 2019).
This study aimed to adapt the Thanatophobia Scale developed by Merrill et al. (1998) into Turkish. With the scale planned to be adapted into Turkish, fear of death levels of nurses responsible for giving care to dying patients may be evaluated. Thus, a scientific basis will be provided for further research and improvements.
Methods
Design and participants
It is a methodological, cross-sectional survey study. The study was conducted in a research and practice hospital of a public university. The study population consisted of the nurses working in the inpatient wards of the hospital. Inclusion criteria were working in inpatient units for at least 1 year and agreeing to participate in the study. Exclusion criteria were working in inpatient units for less than 1 year, working in outpatient clinics or operating rooms, and not agreeing to participate in the study. Thus, 178 nurses were included in the study. Analyses were completed with 154 properly filled questionnaires.
Instruments
The data were collected using a personal information form and Thanatophobia Scale-Turkish Form.
The Personal Information Form
This form had seven questions about the nurses’ age, gender, marital status, level of education, workplace, hospital unit, and their institutional and professional experience.
Thanatophobia Scale
The Thanatophobia scale was developed by Merrill et al. (1998) to evaluate the fear of the death of healthcare workers. In the original study, the scale’s reliability coefficient was 87, while the factor loadings were between .57 and .77. The scale consists of seven items. Responses were in a seven-degree Likert type. The items were scored from 1 to 7, starting from the category “I absolutely disagree” toward the category “I absolutely agree.” As the average score obtained from the scale increases, the person’s fear of death increases.
Procedure
Linguistic Validity
At this stage, both researchers and professional translators translated the items from English to Turkish. Then, the translated statements were evaluated. Next, required adjustments were made according to a Turkish teacher’s recommendations. Then, the Turkish form was translated back into English by two academics, one of whom was working in the field of medicine and the other in the field of nursing, who knew both Turkish and English at a good level.
Content Validity
Researchers used the Davis technique to calculate the content validity ratios of the items and the content validity index of the whole scale (Almanasreh et al., 2019). In the Davis technique, expert opinions were graded in four categories (1 = not relevant, 2 = in need of revision, 3 = relevant but needs minor alteration, and 4 = quite relevant). The number of experts who chose options (3) and (4) was divided by the total number of experts to obtain the “Content Validity Ratio” of the item. In this study, 20 specialists who had expertise in nursing management, internal medicine, psychology, and experience in intensive care nursing, evaluated the items.
Data collection and analysis
The data were collected in between April 2018 - September 2018. One researcher visited the clinics, explained the aim of the research to the nurses, and collected the filled surveys. Content validity, construct validity, item analysis, Kaiser-Meyer-Olkin-Bartlett tests, confirmatory factor analyses, and Cronbach alpha reliability coefficient was calculated.
Ethical considerations
First, a formal permission was asked to Joseph M. Merrill via email. She also confirmed that the scale was not adapted Turkish before. Then, an ethical approval of a clinical research ethics committee was obtained (Date: 15.03.2018, Number: 92). A formal permission was obtained from the hospital management. The nurses were informed about the aim of the study, and the ones who agreed to participate in filled the surveys.
Results
Participants’ characteristics
The mean age of the participants was 30.08 (SD = 5.90). Thus, 75.3% of the nurses were 26 years or older, 81.8% were women, and 76.6% had a bachelor’s degree. In addition, it was found that they mostly worked in internal medical units (46.1%), had 6 years and more (62.3%) professional experience, 5 years or less (53.2%) institutional experience, and worked in staff positions (92.99%).
Content Validity
Content validity ratios of the items and content validity indices of the scale.
aCVR: content validity ratio.
Item Total Score Correlations
Item total point correlation values of the items.
Confirmatory Factor Analysis
Confirmatory factor analysis results.
Thanatophobia scale-confirmatory factor analyses.
Internal Consistency Analysis
The Cronbach alpha internal consistency coefficient of the Turkish version of the Thanatophobia Scale was found to be .854.
Discussion
It is a fact that nurses are affected by the heavy emotional state they experience due to witnessing the death of the individuals they care for and the anxiety, stress, and workload created on them by the environment they work in (Jang et al., 2019; Nia et al., 2016). For this reason, it is important to investigate the thoughts and attitudes of nurses about the fear of death and determine the situation on the subject (Moudi et al., 2017; Ifdil et al., 2020). However, when the literature is evaluated, it is seen that there is a limited number of valid and reliable data collection tools that deal with the concept of fear of death. And this is an indication that standardized measurement tools are needed to carry out qualified studies on the subject with nurses.
The scales should be tested in terms of “validity,” which is considered as an indicator of the degree of accurately measuring the feature it aims to measure without confusing it with any other feature, and “reliability,” which is considered as an indicator of the consistency of the measurement values (Çapık et al., 2018). In studies conducted with scales whose validity and reliability are not at the desired level, the power of statistical tests decreases, and erroneous decisions may occur as a result of the measurements (Polit & Beck, 2017).
Validity of the Thanatophobia Scale
It is essential to translate the expressions correctly from the original language during translation. The translation of the statements of the Thanatophobia scale, which was developed to determine the fear-anxiety about a phenomenon such as death, should have similar meanings in the adapted culture. In this study, the steps regarding the translation suggested in the literature were followed (Çapık et al., 2018; Morgado et al., 2017; Polit & Beck, 2017), and it was seen that the experts mostly evaluated the items as “quite appropriate.” Only two specialists scored 1 the items of “Managing dying patients traumatizes me.” (four numbered item) and “I don't look forward to being the personal physician of a dying patient.” (six numbered item). After making revisions on these items, further analyses were made.
Evaluation of the item total score correlations
The literature stated that the correlation value, which can indicate the consistency of an item with the whole test, should be at least 0.30 (Buyukozturk et al., 2018). In this study, item-total score correlation analyzes were performed to evaluate the compatibility of the items with each other and with the scale. As a result, it was evaluated that each item correlated to the other ones and the whole scale. In other words, the claim of measuring the same phenomenon was sufficient.
Construct Validity
Confirmatory factor analysis was used to evaluate the construct validity of the scale. Validity indices of confirmatory factor analysis were above the goodness-of-fit indices determined as the lower limit in the literature. In addition, the suitability of the measurement model of the whole scale was evaluated with the chi-square/degree of freedom value. This value was below 2, which was an indicator of a good fit (Watkins, 2018).
Internal Consistency
In the study, it was determined that the Thanatophobia Scale had a high internal consistency. Furthermore, looking at the literature, it was stated that the lower limit for the Cronbach alpha coefficient that measurement tools should have should be 0.70 (Buyukozturk et al., 2018). Therefore, these results showed that the scale was reliable.
Limitations
• Study findings are limited to the research sample. Therefore, it is recommended to be used in different samples. • Since the stability of the tool was not evaluated in the study, researchers should consider this limitation before using the tool.
Conclusion
In the study, the Thanatophobia scale developed by Merrill et al. and published in 1998 was found to be valid and reliable in Turkish.
Implications for nursing practice
The scale is a valid and reliable tool for assessing fear of death in the nurse sample. Therefore, it is recommended to be tested in different studies and different sample groups.
Footnotes
Author Note
*The abstract was presented in Good Nursing Research Congress, seventh International Multidisciplinary Congress on Good Medical and Clinical Research (Virtual), 24–31 October 2020.
Acknowledgments
The authors would like to thank the nurses who participated in the study and the administrators who gave permission for data collection.
Author Contributions
ZYC and AKHS designed the study.
ZYC were responsible for data collection.
AKHS analyzed and interpreted the data.
ZYC wrote the first draft of the manuscript.
AKHS made critical revisions to the manuscript for important intellectual content.
Ethical Approval
Ethical approval was obtained (Date and number: 15.03.2018–92)
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
