Social Support Moderates the Relationship Between Death Anxiety and Psychological Distress Among Israeli Nurses

Abstract

Based on the stress-buffering model, the current study sought to examine the moderating role of perceived social support in the association between death anxiety and psychological distress among nurses. Select variables found in previous studies to correlate with psychological distress served in the current study as covariates to control for their relationship with psychological distress among nurses. These include gender, years of professional experience, self-rated health, self-efficacy, and self-defined burnout. Structured questionnaires were administered to a sample of 795 professionally active nurses in Israel. Psychological distress was assessed by the 6-item Kessler Psychological Distress Scale (K6), death anxiety was assessed by a single item scale designed by Abdel-Khalek, and perceived social support was assessed by the Multidimensional Scale of Perceived Social Support (MSPSS). The research findings show that higher levels of death anxiety were associated with higher levels of psychological distress only among nurses with lower levels of perceived social support. The study indicates that in order to reduce the level of distress experienced by nurses it is important to take action to reduce their death anxiety and enhance their social support mechanisms.

Keywords

Anxiety death psychological distress social support nurses

Introduction

Death anxiety is “multi-faceted and encompasses concerns related to the denial of death, the fear of death for oneself and for others, avoidance of death, and the reluctance to interact with persons who are dying” (Mallett et al., 1991, p. 1348). While death anxiety is a universal phenomenon (Lehto & Stein, 2009), its manifestations are largely associated with people's cultural, mental, and social background and might also be related to their professional field of occupation (Stein & Cropanzano, 2011). For example, as part of their work nurses are more likely to be exposed to people whose life is in danger and to death than most of the population and it might be harder for them to avoid various stimuli that arouse thoughts of death, including their own mortality (Adriaenssens et al., 2012; M. Dadfar et al., 2018; M. Dadfar & Lester, 2016, 2020). As the field of nursing is fundamentally occupied with the preservation of life (Meliones, 2000), the issue of life and death has an integral part in its professional discourse. Exposure to the issue of death in the workplace might result in a significantly higher prevalence of death anxiety among nurses than among the general population (Brady, 2015).

When people are exposed to chronic work-related stressors that provoke their sense of death anxiety, their coping resources become strained (Chan et al., 2009), consequently increasing their risk of developing psychological disorders such as loss of meaning in life, psychological distress, and depression (Austin et al., 2017; Maxfield et al., 2014). Among nurses, such implications may detract from their professional engagement and functioning, the quality of services provided to patients, and the ability to feel and express empathy. Some nurses might apply avoidant behaviors such as frequent absence from work to reduce encounters with death-related issues and their psychological effects (Biron & Bamberger, 2012; Lehto & Stein, 2009).

Studies repeatedly show that the levels of stress among caregiving personnel increase when social support is limited (Bourbonnais et al., 2005; Eriksen et al., 2006). According to the stress buffering model (Chan et al., 2009; Cohen & Wills, 1985), social support might interact with stressful events or conditions to reduce the effect of stress by contributing to people's sense of belonging to the social environment, improving their sense of confidence and self-image as well as their belief in their ability to cope with difficulties. Accordingly, social support may reduce or prevent the emergence of psychological distress (e.g., Chan et al., 2009; Santini et al., 2015).

Awareness of the stress buffering role of social support may help improve the ability of professionals such as psychologists and social workers, professional nurse supervisors, policy makers, and nursing educators, to help nurses by developing information, awareness, and intervention programs on support and death-related issues. Hence, the aim of the current study is to examine the buffering (moderating) role of perceived social support in the association between death anxiety and psychological distress among nurses.

Based on the stress buffering model, it was hypothesized that:

H₁1: Higher levels of death anxiety would be associated with higher levels of psychological distress.

H₁2: Higher levels of perceived social support would be associated with lower levels of psychological distress.

H₁3: The positive association between death anxiety and psychological distress would be moderated by perceived social support, such that death anxiety would be positively associated with psychological distress only for lower levels of perceived social support.

Methods

Research population and sample

The research population consisted of professionally active nurses registered in the Registry of Nurses managed by the Ministry of Health, employed in Israel's healthcare system and providing direct care to patients. For the purposes of the current study 795 nurses were sampled, including 80.4% women (n = 639) and 19.6% men (n = 156). The mean age of the respondents was 38.11 (SD = 11.12). Mean years of experience in the profession was 12.67 (SD = 11.31).

Procedure

Ethical approval for the current study was received from the institutional ethics committee for nonclinical research in humans at the university with which the researcher is affiliated. The research assistants directly approached nurses at community-based clinics and hospitals, as well as at educational institutions where professionally active nurses expand their training and professional specialization. The response rate using this method was approximately 80%. Moreover, the research assistants also approached nurses through online means such as Facebook and in Israeli nurse forums. In this case, it was not possible to assess the response rate, as it is not known how many nurses were exposed to these appeals. Respondents whom the research assistants approached in person completed structured questionnaires manually. Once the questionnaires had been completed, the research assistants sealed them in opaque envelopes. Respondents who were contacted online accessed a link to online questionnaires using the Google Forms program. All research participants signed an informed consent form before completing the questionnaires.

Measurements

Research variables

Death anxiety (Abdel-Khalek, 1998) was assessed by a single item scale, where the participants were requested to respond to the statement: “I am afraid of death”. The items were rated on a seven-point Likert scale, ranging from 1 (strongly disagree) to 7 (strongly agree). According to Abdel-Khalek (1998), “the reliability of the multi-item psychometric instruments of death anxiety vis-a-vis the single item ranged from .67 to .94 for the multi-item scales and .82 for the single item” (p. 770). Consequently, the reliability of the single item scale is within the reliability limits of the multi item measures. Furthermore, since the one item death anxiety scale can be reliable across time, and was moderately correlated with multi-item scales, it demonstrated a moderate emergent validity (i.e., Abdel-Khalek, 1998; Thorson & Powell, 1992).

Perceived social support was assessed by the Multidimensional Scale of Perceived Social Support (MSPSS) (Zimet et al., 1988). This instrument examines one's subjective perception of the social support at one's disposal from three sources: family, friends, and significant others. The items were rated on a seven-point Likert scale, ranging from 1 (low perceived social support) to 7 (high perceived social support). A systematic review of the psychometric properties of the cross-cultural translations and adaptations of the MSPSS from 70 studies (Dambi et al., 2018) suggests that most of the studies failed to provide robust proof of a three subscale model, resulting in an only one or two factor structure. Hence, in the current study a mean score was calculated for all 12 items in the MSPSS, with higher scores indicating a higher level of perceived social support. Cronbach’s alpha for this scale in the current study was 0.95. Previous studies displayed a Cronbach’s alpha of at least 0.70 and demonstrated adequate test-re test stability over time, with strong correlations between the two administrations of the MSPSS, ranging from .72 to .85, and established moderate levels of divergent and convergent validity (Dambi et al., 2018; Hardan-Khalil & Mayo, 2015; Wongpakaran et al., 2011; Zimet et al., 1988, 1990).

Psychological distress was assessed by the 6-item Kessler Psychological Distress Scale (K6) (Revised) (Kessler et al., 2003). It examines nervousness, hopelessness, irritability, negative affect, fatigue, and worthlessness experienced over the past 30 days. The items were rated on a five-point Likert scale, ranging from 0 (absence of the symptom) to 4 (highest level of the symptom). Calculating a total score for the six items of the scale results in a score ranging from 0 to 24, with a higher score indicating a higher level of psychological distress. Cornelius et al. (2013) argued that the K6 is a reliable and valid screening scale for DSM-IV psychiatric disorders. The optimal cutoff point of the K6 scale in their study was 14, and their finding indicated a positive predictive value of 0.51 and a negative predictive value of 0.87 for the optimal cutoff score. Arnaud et al. (2010) reported cutoff score of 10 for the K6, with sensitivity of 0.92 and specificity of 0.62. Similarly, Lace et al. (2018) concluded that for the total K6, the optimal cutoff score appears to be 10, yielding a sensitivity of .64, a specificity of .73, and total classification accuracy of 71%.

The current study refers to a cutoff point of 13, as originally offered by the K6 developers (Kessler et al., 2003) who clinically validated the K6 and suggested that a cutoff point of 13 has a sensitivity of 0.36, specificity of 0.96, and total classification accuracy of 92% (Kessler et al., 2003). Based on diagnostic criteria of the DSM-IV, the K6 cutoff point of 13 allows discernment of serious mental illness cases in population based surveys (Furukawa et al., 2003; Kessler et al., 2003; Veldhuizen et al., 2007).

According to Kessler et al. (2003), the K6 is sensitive to the upper tenth of the population distribution of mental distress. Cronbach’s alpha of .80 for this scale in the current study was quite similar to that reported in previous studies, which also demonstrated adequate test-retest reliability of 0.80 (M. A. Dadfar et al., 2016) and 0.79 (Kang et al., 2015).

Covariates

Selected variables found in previous studies to correlate with psychological distress served in the current study as covariates for controlling for their relationship with this variable. These included years of professional experience in the role of nurse, self-rated health (Idler & Benyamini, 1997), self-efficacy (Chen et al., 2001; Pisanti et al., 2015), self-defined burnout (Schmoldt et al., 1994), and gender (Kagan et al., 2018; Kagan et al., 2017; Evans et al., 2006). For the distribution of the research variables see Table 1.

Statistical analysis

Statistical analysis was conducted using SPSS-22 software. A three-step hierarchical multiple regression was performed to predict psychological distress among nurses (see Table 3). The covariates (gender, years of professional experience, self-rated health, self-efficacy, and self-defined burnout) were entered in the first step of the regression. Death anxiety and perceived social support were entered in the second step. In the final, third step, the interaction between death anxiety and perceived social support was added. The multicollinearity assumption was rejected, with the maximal VIF measure being 1.12. For correlations between the research variables see Table 2.

Table 1.

Descriptive statistics of the research variables.

Sample of nurses (n = 795)
	Statistics
Variables	Mean	Sd	N	%
Gender			Male-156Female-639	19.680.4
Years of professional experience	12.67	11.31
Self-rated health^a	3.23	.55
Self-efficacy^b	21.15	2.97
Self-defined burnout^c	2.09	.85
Death anxiety^d	4.15	1.76
Perceived social support^e	5.69	1.28
Psychological distress^f	4.66	3.6

^aScores on this item range from 1 to 4, with higher scores indicating higher levels of self-rated health.

^bScores on this item range from 8 to 24, with higher scores indicating higher levels of self-efficacy.

^cScores on this item range from 1 to 5, with higher scores indicating higher levels of burnout.

^dScores on this item range from 1 to 7, with higher scores indicating higher levels of death anxiety.

^eScores on this item range from 1 to 7, with higher scores indicating a higher levels of perceived social support.

^fScores on this item range from 0 to 24, with higher scores indicating higher levels of psychological distress.

Table 2.

Correlations between research variables (n = 795).

	1	2	3	4	5	6	7
1. Gender	–
2. Years of professionalexperience	.014
3. Self-rated health	−.012	−.171**
4. Self-efficacy	−.011	.022	.151***
5. Self-defined burnout	.026	.057	−.251***	−.151***
6. Death anxiety	−.030	−.044	−.059	−.101**	.047
7. Perceived social support	−.043	−.041	.141***	.191**	−.207***	−.030
8. Psychological distress	.046	−.027	−.185**	−.193**	.348***	.129***	−.406***

Note. Gender (dummy): 0 – male, 1 – female **p < .01, ***p < .001.

Table 3.

Summary of the hierarchical regression analysis for variables predicting psychological distress among nurses (n = 795).

Variables	B	Std. Error	Beta	T	Adj.R²	ΔR²	F
Step 1					.145	.151	F_(5,749)= 27.64***
Gender	.345	.310	.038	1.12
Years of professional experience	−.022	.011	−.068	−1.99*
Self-rated health	−.723	.234	−.110	−3.09**
Self-efficacy	−.153	.042	−.124	−3.62***
Self-defined burnout	1.275	.151	.298	8.46***
Step 2					.253	.109	F_(7,747)= 37.57***
Gender	.245	.290	.027	.84
Years of professional experience	−.022	.010	−.066	−2.07*
Self-rated health	−.536	.220	−.081	−2.44*
Self-efficacy	−.080	.040	−.065	−1.99*
Self-defined burnout	1.031	.143	.241	7.23***
Death anxiety	.189	.066	.091	2.86**
Perceived social support	−.945	.093	−.331	−10.12***
Step 3					.263	.010	F_(8,746)= 34.64***
Gender	.214	.289	.023	.740
Years of professional experience	−.022	.010	−.068	−2.14*
Self-rated health	−.570	.219	−.086	−2.61**
Self-efficacy	−.091	.040	−.074	−2.27*
Self-defined burnout	1.020	.142	.238	7.19***
Death anxiety	.186	.065	.089	2.84**
Perceived social support	−.910	.093	−.319	−9.74***
Death anxiety × Perceived social support	−.360	.110	−.104	−3.28**

Note. Gender (dummy): 0 – male, 1 – female *p < .05, **p < .01, ***p < .001.

Results

The final (third) step of the hierarchical multiple regression model (F_(8,746) = 34.64, p < .001, ΔR² = .01) demonstrates that nurses who had more years of professional experience (β = -0.068, p < .05), reported better subjective health (β = −0.086, p < .01), had higher self-efficacy (β = −0.074, p < .05) and higher levels of perceived social support (β = -0.319, p < .001), attested to lower levels of psychological distress. However, higher levels of burnout (β = 0.238, p < .001) and of death anxiety (β = 0.089, p < .05) were associated with reports of higher psychological distress and no association was found between gender and psychological distress (p > .05) (see Table 3).

As hypothesized, aside from the main effects found for death anxiety and perceived social support, a significant interaction was found between these variables (β = −0.104, p < .01). The interaction was probed using PROCESS (Hayes, 2013). Simple slopes for the association between death anxiety and psychological distress were tested for low (−1 SD below the mean) and high (+1 SD above the mean) levels of perceived social support (see Figure 1). Higher levels of death anxiety were found to be associated with higher levels of psychological distress only among nurses with lower levels of perceived social support (β = 0.386, p < 0.001), yet no association was found between these variables (p > 0.05) among nurses with higher levels of perceived social support. The total regression model accounted for 26.3% of the variance in psychological distress. Based on diagnostic criteria of the DSM-IV that allow discernment of serious mental illness cases, in the current study only 3.4% of the nurses received a score ≥13, implying that a sufficient proportion of them do not experience a severe level of mental distress (Furukawa et al., 2003; Kessler et al., 2003; Veldhuizen et al., 2007). A cutoff point of ten would imply that 9.8% of the nurses have a severe level of mental distress (Lace et al., 2018; Arnaud et al., 2010).

Figure 1.

The two-way interaction between death anxiety and perceived social support predicting psychological distress among nurses.

Discussion and conclusions

The current study revealed that higher levels of death anxiety were found to be associated with higher levels of psychological distress only among nurses with lower levels of perceived social support. This finding emphasizes the importance of perceived social support as a stress buffering mechanism (Bourbonnais et al., 2005; Eriksen et al., 2006; Payne et al., 1998). Hence, it is important to consider the issue of social support among nurses on both the policy and practical level. It is important to act to improve support mechanisms at the workplace and to promote informational and educational efforts aimed at increasing the awareness of professional managers, the nurses themselves, and their families, regarding the issue of support. It is important to stress interpersonal communication skills in order to facilitate coordination of expectations between the nurses and their social environment with regard to the type of support they need versus that received in practice. This might improve nurses' ability to convey their needs to their surroundings and to seek support and help when necessary (Bourbonnais et al., 2005; Eriksen et al., 2006; Kagan et al., 2017).

The findings also indicate that in order to reduce the level of psychological distress experienced by nurses it is important to act to reduce their death anxiety. This issue must be considered when socializing nurses into the profession in self-awareness courses or workshops within training institutions as well as at workplaces. Furthermore, nurses should be exposed to more information on the subject, as it is evident from previous studies that although they are exposed to death at a higher frequency than most other professions, they do not have more knowledge or tools for coping with this subject (Adriaenssens et al., 2012).

Finally, it can be concluded that since the issue of death is an inseparable part of the nurses’ professional context and death anxiety has implications manifested, among other things, in high levels of psychological distress, beyond dealing with thoughts of death and the associated anxiety it is very important to recognize and implement stress buffering mechanisms such as social support capable of reducing nurses’ level of psychological distress and, accordingly, improving their professional and personal quality of life.

Research limitations and recommendations for further research

Several limitations must be taken into consideration with regard to the current study. First, as the information containing contact details for all professionally active nurses in Israel is confidential, a convenience sample was employed. This might affect the representativeness of the sample. Furthermore, the study did not distinguish between nurses’ types of occupation. The different types of occupation might be associated with death anxiety and psychological distress and therefore must be considered in future studies. In addition, the current study controlled for select research variables found related to psychological distress in previous studies. Nevertheless, other issues such as personality traits of nurses, their attitudes toward death, as well as characteristics related to their work such as number of work hours, job satisfaction, and sense of professional gratification, should also be considered in future studies. Furthermore, it is suggested that in future studies a distinction be made between the different types of support (for example, actual versus perceived support) and between support provided by professionals and nonprofessional support and its sources (for instance, family, friends, therapists, colleagues, and superiors).

Another limitation has to do with possible concern regarding use of a single-item scale to assess death anxiety (Abdel-Khalek, 1998). There is a wide range of theoretical and methodological approaches to the measurement of death anxiety (e.g., Mallett et al., 1991; Templer, 1970; Tomer & Eliason, 1996; Wong et al., 1994). Nonetheless, Abdel-Khalek (1998, p. 770) argues that the “single-item death anxiety scale correlates moderately with multi-item instruments, therefore, it has moderate emergent validity. Furthermore, using a single item scale to measure death anxiety may minimize the subjective distress associated with longer questionnaires related to this issue among the study participants”. In future studies it would be recommended to use several different scales to assess death anxiety in order to examine whether they operate similarly when investigating the interaction between death anxiety and social support to explain psychological distress.

Footnotes

Author Biographies

Maya Kagan, PhD, is a researcher and a senior lecturer at the School of Social Work at Ariel University since 2004. She received her PhD from the Department of Sociology and Anthropology at Haifa University. Her ongoing research focuses on psychological, personal, and environmental factors associated with the professional work of nurses and social workers.

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.

ORCID iD

Maya Kagan

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