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    Death Anxiety and Caregiver Burnout

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    The nature of working in healthcare entails exposure to death. Death anxiety, according to Doenges (2016) is a nursing diagnosis defined as a “Vague uneasy feeling of discomfort or dread generated by perceptions of a real or imagined threat to one’s existence” (p 219-222). Lee & King (2014) add that “Caregivers who experience death anxiety have anxious thoughts or feelings when thinking about or talking about death and/or the dying process, or when interacting with someone who is dying (p 480).” Healthcare workers, including nurses, report feeling unconfident in their ability to talk about death, much less to provide talk therapy to dying patients, and are at greater risk of experiencing burnout (Lee & King, 2014, p 480). As this writer struggles with work-related death anxiety, with respect to self and patients, an article (Exploring Death Anxiety and Burnout Among Staff Members Who Work In Outpatient Hemodialysis Units) on the subject of death anxiety specific to nurses was located in the ProQuest database. The article was analyzed so that possible solutions for death anxiety might be undertaken to prevent death anxiety-induced burnout.


    Lee and King (2014), the authors of the article, assert that caregiver death anxiety is positively correlated with burnout. They hypothesize that education on EOL care might serve as a treatment for death anxiety and burnout. They point out that both death anxiety and burnout can negatively impact the quality of care that caregivers provide, as well as their job satisfaction and increases job turnover (p 479-480). They found numerous studies that validate their assertions: that patient mortality is positively correlated with unresolved grieving (Gerow et al., 2010, as cited in Lee & King, 2014), that these can lead to “frustration, moral distress, compassion fatigue, depression, and burnout” (Ashker, Penprase, & Salman, 2012; Dermody & Bennett, 2008; Hayes & Bonner, 2010, as cited in Lee & King, 2014), that turnover was positively correlated with psychological stress (Argentero, Dell’Olivio, & Ferretti, 2008; Hayes & Bonner, 2010, as cited in Lee & King, 2014) and many more; a total of 33 scholarly resources were cited by the authors to validate their points.

    To test their hypothesis, they sampled fifteen nurses working in hemodialysis units and provided four classes on EOL care, each two hours long and one week apart from the others. To assess the efficacy of their program, they used the Revised Collet-Lester Fear of Death and Dying Scale and the Maslach’s Burnout Inventory; both tools were administered before the program and after. The conclusion of the program was that it was successful, but with several limitations. All of the participants were female, the sample size was small, and not all of the participants finished the program. Because of these limitations, the authors admitted that “results may not be generalizable to other [hemodialysis] units.” In spite of this, the authors do not make any recommendations for further study or research. (Lee & King, 2014, p 479-486)


    Lee & King (2014) write in a clear and logical manner: they begin with an overview of the environment in which they plan to draw participants, their motives studying the topic chosen, their hypothesis and exactly how their experiment will test their hypothesis. They explain the study in appropriate detail and provide more than enough of evidence for their foundational claims. The important terms (death anxiety, burnout, unresolved grieving, hemodialysis, end-of-life care) were all defined by the second page of the article. The article made clear that the impact of death anxiety on caregivers was more extensive than this writer had thought; for example, the psychological strain created by death anxiety can lead to compassion fatigue (p 479-480).

    The article was submitted to the Nephrology Nursing Journal and is appropriate for their audience (nurses, especially those who work in the field of nephrology) as the topic is directly relevant to their field and explores solutions for a common problem that such nurses deal with (Lee & King, 2014, p 479). Lee & King appear to have a confirmation bias: the experiment they conducted had, at its end, only eleven participants and at no point did they establish a control group; yet they still concluded that their experiment was a success and made no mention of the placebo effect in their discussion of experimental limitations (Lee & King, 2014, p 483-484). While this is the only error they have made, it is a rather serious error given that it is the culmination of the article and casts doubt on all of the primary research done by Lee & King in this study. The only arguments that effectively support their main point lie in evidence drawn from other sources. The authors make no mention of an opposing viewpoint, further illuminating their confirmation bias. These flaws invalidate their limited conclusion.


    Lee & King (2014) promised to demonstrate a connection between death anxiety and burnout in the nursing profession, (p 479-481), and a cursory review of the article appears to offer a genuine solution to both. However, their experiment does not hold up to a critical and scientific analysis. The greatest feeling that this writer experienced while reading the article was a feeling of alienation as Lee & King (2014) point out that one of the risk factors of psychological stress is being “an unmarried male” (p 481) and then proceed to conduct an experiment with only female participants. To be clear, even if the authors had made a concerted effort to recruit male participants it may have still proven impossible given the gender ratio in nursing; further, the advantages of being (an unmarried) male are legion; the same cannot be said for women (Kellet, et al, 2014, p 82-86). Knowing this does not alleviate the feeling of alienation, but given that the focus of the paper was on hemodialysis and caregiver death anxiety (and not, for example, on how gender impacts the care provided by a caregiver), the authors are under no obligation to address this.

    In spite of its flaws, this article is still useful to a nurse struggling with death anxiety in relation to their work. The article confirms that death anxiety is not only common among caregivers, but that it is also worth treating. The authors make it clear that the tendency of nurses (and other caregivers) to avoid talking about death anxiety is problematic. They also point out the relationship death anxiety has with unresolved grieving, which suggests that death anxiety on the part of the caregiver might be alleviated by finding healthier ways to grieve for deceased patients that are still compatible with the professional and ethical expectations of the nursing profession, and may even improve the ability of a nurse to engage in therapeutic conversation with patients receiving EOL care (Lee & King, 2014, p 480-481).


    This writer still struggles with death anxiety, but the act of reading the article have eased the symptoms. Lee & King (2014) did explore death anxiety and burnout in the healthcare field (specifically hemodialysis) and included an experiment to test the efficacy of education on death anxiety. The experiment failed to include a large simple random sample, had no control, and ultimately did a better job of proving the authors’ confirmation bias than illuminate any actual solution for death anxiety. In spite of this, the authors’ diligence in their preliminary research (p 479-485) still made this paper a valuable resource for caregivers struggling with death anxiety.


    1. Argentero, P., Dell’Olivo, B., & Ferretti, M.S., (2008). Staff burnout and patient satisfaction with the quality of dialysis care. American Journal of Kidney Diseases, 51(1), 80-92.doi:10.1053/j.ajkd.2007.09.011
    2. Ashker, V.E., Penprase, B., & Salman, A. (2012). Work-related emotional stressors and coping strategies that affect the well-being of nurses working in hemodialysis units. Nephrology Nursing Journal, 39(3), 231-236.
    3. Dermody, K., & Bennett, P.N. (2008). Nurse stress in hospital and satellite haemodialysis units. Journal of Renal Care, 34(1), 28-32. doi:10.1111/j.1755-6686.2008.00007.x
    4. Doenges, M., Moorhouse, M., Murr, A. (2016). Nurse’s Pocket Guide (14th ed.). Philadephia, PA: F. A. Davis Company
    5. Gerow, L., Conejo, P., Alonzo, A., Davis, N., Rodgers, S., & Domian, E.W. (2010). Creating a curtain of protection: Nurses’ experiences of grief following patient death. Journal of Nursing Scholarship, 42(2), 122-129.doi:10.1111/j.1547-5069.2010.01343.x
    6. Hayes, B., & Bonner, A. (2010). Job satisfaction, stress, and burnout associated with haemodialysis nursing: A review of the literature. Journal of Renal Care, 36(4), 174-179. doi:10.1111/j.1755-6686.2010.00194.x
    7. Kellett, P., Gregory, D. M., & Evans, J. (2014). Patriarchal paradox: Gender performance and men’s nursing careers. Gender in Management, 29(2), 77-90. doi:
    8. Lee, V. L., & King, A. H. (2014). Exploring death anxiety and burnout among staff members who work in outpatient hemodialysis units. Nephrology Nursing Journal, 41(5), 479-485,518,486. Retrieved from

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