Abstract
-
Purpose
This study aimed to examine the relationships among death anxiety, attitudes toward death, and burnout in nurses working in hemodialysis units.
-
Methods
A cross-sectional, self-report questionnaire-based survey was conducted. Eighty-six nurses, each with more than one year of experience in hemodialysis units across six general hospitals, participated. Data were collected from July to December 2021. Statistical analyses included Pearson correlation coefficients and multivariate linear regression.
-
Results
The mean death anxiety score was 2.71±0.73 out of 5. Among attitudes toward death, neutral acceptance was most prevalent, with a mean score of 5.48±1.07 out of 7. The average burnout score was 3.94±0.77 out of 7. Death anxiety showed a significant negative correlation with neutral acceptance of death (r=–.33, p=.002) and a significant positive correlation with fear of death attitudes (r=–.65, p<.001). Multiple regression analysis identified marital status (being married) (β=–.35, p=.005) and the death attitude of escape acceptance (β=.37, p=.002) as significant predictors of burnout, together explaining 22.3% of the variance (F=2.43, p=.005).
-
Conclusion
Attitudes toward death among hemodialysis nurses may be linked to burnout. Burnout management programs for nurses in hemodialysis units should provide opportunities for neutral discussions and emotional expression regarding death, and should address strategies to mitigate escape acceptance attitudes.
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Key Words: Attitude; Burnout, psychological; Death; Hemodialysis units, hospital; Nurses
INTRODUCTION
Hemodialysis nurses are specialized healthcare professionals responsible for caring for patients with end-stage renal disease in technically demanding environments that require the operation of dialysis machines. These nurses play a pivotal role in facilitating self-management and adaptation in maintenance hemodialysis patients by providing ongoing education and encouragement. Additionally, the operation of dialysis equipment and the delivery of patient care require substantial training and expertise. Even after comprehensive training, hemodialysis units are recognized as high-intensity workplaces due to their unique challenges, including the management of patients with multiple chronic comorbidities, rigorous infection control measures to prevent bloodborne exposures, and the rising prevalence of older hemodialysis patients [
1].
The unique and demanding responsibilities of a hemodialysis nurse extend well beyond the physical aspects of patient care. Notably, the cumulative exposure to patients’ disease progression and death within the context of dialysis can, over time, affect nurses’ emotional well-being, professional performance, and the overall quality of care delivered. Patients with end-stage renal disease often experience high mortality rates, primarily due to cardiovascular complications or infections, even after initiating dialysis [
2]. This elevated mortality among end-stage patients can be a significant source of emotional distress and trauma for healthcare workers, including nurses [
3]. Hemodialysis nurses face considerable psychological stress, manifesting as death anxiety, compassion fatigue, and ethical dilemmas stemming from the unique challenges of caring for this population [
4]. Conceptually and practically, death anxiety is closely related to death fear [
5], and emotional responses to the prospect of one’s own death or the death of others can detrimentally affect psychological health and overall quality of life [
6]. For nurses, managing patient death can become deeply personal, and their emotional responses are not always supportive—either for themselves or for their patients [
7].
According to Grandey’s emotional regulation model [
8], work environments or specific occupational events can evoke emotional responses such as anger, sadness, and anxiety in employees. Individuals then employ a variety of emotional regulation strategies to sustain job performance and adapt within their organizations. However, this process of emotional regulation can result in both positive and negative outcomes for nurses, including increased stress, the risk of burnout, or, conversely, enhanced job satisfaction [
9]. As death is an unavoidable aspect of life, death anxiety constitutes a normal emotional response to stress [
5]. Nevertheless, excessive death anxiety in nurses may foster negative attitudes toward end-of-life care, resulting in emotional distancing from patients and diminished patient relationships [
3]. In hemodialysis settings, death anxiety and fear of dying can undermine therapeutic interactions between nurses and patients, ultimately compromising job satisfaction and the quality of care provided [
10].
Nonetheless, attitudes toward death can be influenced by existential perspectives [
11]. Individuals may develop a coexistence-oriented attitude toward death, shaped by their personal meanings of life and death, leading either to despair and fear or, alternatively, to acceptance. Within this context, as a strategy to support the sustainability of the nursing workforce for hemodialysis patients with severe chronic illnesses, it is crucial to investigate and identify emotional burdens that may often be overlooked, such as death anxiety and attitudes toward death. In cultures or environments where open discussion of death is challenging, these attitudes may further impact both the quality of care for hemodialysis patients and nurses’ job satisfaction [
4,
7]. Thus, addressing accumulated experiences of loss and negative attitudes toward death within hemodialysis units could serve as a strategic approach to improving both patient outcomes and job satisfaction among nurses.
Hemodialysis nurses are especially vulnerable to burnout due to their recurrent exposure to patient suffering, end-of-life care, and frequent patient deaths. This heightened vulnerability may result in lower job satisfaction and declining standards of nursing care. Although death-related attitudes and anxiety are likely to substantially affect nurses’ well-being and the quality of care they provide, these factors have not been sufficiently explored within the context of hemodialysis nursing. This gap in the literature underscores the need for further empirical investigation. Therefore, the present study aimed to assess the levels of death anxiety, attitudes toward death, and burnout among nurses caring for hemodialysis patients, as well as to explore the relationships among these variables.
METHODS
1. Study Design
This study employed a cross-sectional design.
2. Setting and Samples
Participants were nurses working in hemodialysis units at hospitals located in Seoul and Gyeonggi-do, South Korea, each with over one year of experience in their current role. Data were collected using a convenience sampling method from six hemodialysis units. Each hospital employed 12 to 17 hemodialysis nurses, and most participated in the survey. Using G*Power 3.1.9.7, the required sample size was calculated to be 84 participants, based on a significance level of .05, a statistical power of 0.80, and a medium effect size of 0.30. To allow for an anticipated 10% dropout rate, 93 nurses were recruited. After excluding individuals with missing data, 86 participants were included in the final analysis.
The methods for estimating effect size and calculating sample size, as recommended by Cohen [
12], include: 1) estimation based on existing similar studies; 2) conducting a pilot study if no similar studies are available; and 3) when neither is feasible, predicting the effect size as large, medium, or small and applying the corresponding value. Previous studies have reported correlations between nurses’ anxiety and attitudes toward death ranging from 0.126 to 0.315 [
13], and hazard ratios for the effect of nurses’ death anxiety on burnout ranging from 0.96 to 1.05 [
14]. Therefore, a medium effect size was assumed for this study’s sample size calculation.
1) General characteristics
The formal survey questionnaire consisted of four sections: general characteristics, death anxiety, attitudes toward death, and burnout, comprising a total of 70 items. The general characteristics section included 11 items such as sex, age, educational background, religion, marital status, total nursing experience, years working in a hemodialysis unit, and experience with patient deaths within the past year.
2) Death anxiety
Death anxiety refers to emotional reactions such as discomfort, worry, anxiety, and fear experienced when thinking about or anticipating aspects of death [
15]. In this study, death anxiety was measured using a scale developed to reflect South Korean culture and based on Templer’s Death Anxiety Scale [
16]. The scale comprises 14 items: 8 items assess anxiety about one’s own death, three items assess anxiety regarding God and afterlife judgment, and three items assess anxiety concerning surviving family members. Responses are measured on a 5-point scale (1=not at all, 5=strongly agree), with a total possible score ranging from 14 to 90. Higher scores indicate greater death anxiety. Cronbach’s α was .88 at the time of scale development [
16], and .90 in the current study.
3) Death attitudes
Attitudes toward death were measured using the Korean-adapted version [
17] of the Multidimensional Attitudes Toward Death Scale developed by Wong et al. [
11]. The scale includes 32 items rated on a 7-point scale (1=not at all, 7=very strongly agree) and is organized into five dimensions: fear of death, avoidance of death, approach acceptance, escape acceptance, and neutral acceptance. These dimensions are broadly classified into two categories of attitudes toward death: negative and accepting. The negative attitude component includes 7 items assessing fear of death and five items assessing avoidance as a defense mechanism. The accepting attitude component includes 10 items reflecting the view of death as a gateway to a happy afterlife, five items reflecting death as an escape from a painful existence, and five items reflecting the view of death as a natural reality that is neither feared nor welcomed. Higher scores reflect stronger endorsement of each death attitude. For the Korean version, Cronbach’s α ranged from .81 to .90 across the five dimensions [
17], and from .85 to .95 in this study.
4) Burnout
Burnout is a syndrome characterized by emotional exhaustion and cynicism, commonly observed in service-oriented professions [
18]. Burnout was assessed using the Maslach Burnout Inventory™ (MBI), which evaluates three domains: emotional exhaustion, reduced personal accomplishment, and depersonalization. Emotional exhaustion, the core aspect of burnout, refers to feelings of being emotionally drained and overwhelmed. Reduced personal accomplishment involves negative self-evaluation of work performance and achievements. Depersonalization is characterized by negative, cynical, or excessively detached attitudes toward those being cared for [
19]. These subcomponents function independently; depersonalization, in particular, is not simply the inverse of emotional exhaustion or reduced personal accomplishment [
20]. The MBI comprises 22 items rated on a 7-point scale (1=not at all, 7=very strongly agree), with higher scores indicating greater burnout. The Cronbach’s α was .82 for the Korean version used with nurses [
20], and .92 in this study.
This research was approved by the Research Ethics Committee of Namseoul University (No. 1041479-HR-202105-002) prior to data collection. Approval was obtained from the head of the nursing department before recruiting participants. The principal investigator visited each hemodialysis unit to explain the study’s purpose, procedures, the voluntary nature of participation, and confidentiality assurances. Only nurses who provided written informed consent were included in the study and were offered a $10 coffee voucher as compensation. All data were anonymized and will be destroyed after three years. Data collection took place from July to December 2021.
5. Data Analysis
Data were analyzed using IBM SPSS Win 21.0 (IBM Corp., Armonk, NY, USA). General characteristics of participants were summarized as frequencies (percentages) and means (standard deviations). The reliability of each measurement tool was assessed using Cronbach’s α. Differences in burnout according to general characteristics were examined using the independent t-test and analysis of variance (ANOVA), with the Bonferroni post-hoc test as appropriate. Relationships among death anxiety, death attitudes, and burnout were analyzed using Pearson’s correlation coefficients. Additionally, multiple regression analysis (simultaneous entry method) was performed to evaluate the unique contribution of each predictor variable to the dependent variable.
RESULTS
1. Differences in Burnout According to General Characteristics
There were no significant differences in burnout based on any general characteristics. All 86 participants were female, with a mean age of 35.4±9.07 years. Among the participants, 54 (62.8%) had less than 5 years of overall nursing experience, and 78 (90.7%) had less than 5 years of dialysis-specific experience. Sixty-eight participants (79.1%) had experienced the death of a dialysis patient within the past year, yet only 27 (31.4%) had received formal education on death (
Table 1).
The mean death anxiety score among participants was 2.71±0.73. Attitudes toward death were ranked in the following order: neutral acceptance, escape acceptance, fear of death, death avoidance, and approach acceptance. The mean burnout score was 3.94±0.77. Of the burnout subscales, emotional exhaustion had the highest mean score, followed by reduced personal accomplishment and depersonalization (
Table 2).
Death anxiety was found to correlate with specific attitudes toward death. There was a significant positive correlation between death anxiety and both fear of death (r=.65, p<.001) and death avoidance (r=.35, p=.001). In contrast, death anxiety demonstrated a significant negative correlation with the neutral acceptance attitude toward death (r=–.33, p=.002).
Additionally, certain attitudes toward death were significantly associated with burnout. Specifically, higher levels of escape acceptance were associated with increased emotional exhaustion (r=.36,
p=.001) and reduced personal accomplishment (r=.37,
p<.001). Conversely, as neutral acceptance of death increased, levels of depersonalization decreased (r=–.24,
p=.027) (
Table 3).
Assumptions of homoscedasticity and normality of residuals were tested and confirmed prior to regression analysis. To identify factors influencing burnout, multiple regression analysis was performed, including general characteristics—such as age, educational background, religion, marital status, length of nursing career, experience in hemodialysis units, and experience with patient deaths within the past year—as well as death anxiety and the five attitudes toward death. All tolerance values were ≥0.1 (range=.41–.80), and all variance inflation factor values were below 10 (range=1.28–2.43), indicating no multicollinearity. The Durbin-Watson statistic was 1.71, close to the ideal value of 2, confirming the absence of autocorrelation. The overall regression model was statistically significant. The regression equation was as follows: Y=3.02–0.68X1+0.23 X2 (Y=burnout; X1=marital status [married]; X2=escape acceptance attitude toward death).
This multiple regression analysis revealed that marital status (being married) (β=–.35,
p=.005) and the escape acceptance attitude toward death (β=.37,
p=.002) were significant predictors of burnout. Being married was associated with lower levels of burnout, whereas higher levels of escape acceptance were associated with increased burnout (
Table 4).
DISCUSSION
This study examined whether burnout was associated with death anxiety or attitudes toward death among nurses working in hemodialysis units. Significant correlations were observed between death anxiety, attitudes toward death, and burnout. Due to fear or avoidance of death, some clinical nurses distance themselves from patients or avoid forming close relationships [
7]. These behaviors can contribute to feelings of helplessness and emotional projection [
21], which in turn may lead to decreased job performance, increased stress, deteriorating health, and higher turnover rates [
14]. Nurses are healthcare professionals who frequently encounter death in clinical practice. The present findings are particularly important because negative perceptions or attitudes toward death among nurses caring for patients with chronic and severe conditions, such as those undergoing hemodialysis, may affect both their job satisfaction and the quality of nursing care provided.
In this study, participants reported the highest scores for neutral acceptance of death (5.48±1.07), which was negatively associated with death anxiety. Consistent with these findings, previous research in Turkey has similarly demonstrated that nurses tend to exhibit a high level of neutral acceptance (5.14±0.76), especially those who have received education on death [
13]. Neutral acceptance refers to recognizing death as a natural part of life [
22]. This attitude helps mitigate fear and avoidance of death by encouraging individuals to accept life’s finiteness, acknowledge personal limitations, and transcend existential boundaries [
23]. While it remains unclear whether neutral acceptance is the most desirable attitude, it may be suggested as one potential approach to reducing death-related burnout in nurses.
Similarly, Greek nurses showed the highest levels of neutral acceptance of death (5.25±0.89), which was significantly associated with burnout, including emotional exhaustion [
24]. Taipei nurses exhibited the highest levels of death acceptance through approach attitudes, which were linked to Christian beliefs emphasizing a positive view of the afterlife [
14]. Perceptions of death are influenced by sociocultural experiences and may evolve over time [
25]. Therefore, the relationship between nurses’ neutral acceptance of death and death anxiety in hemodialysis settings may reflect unique characteristics shaped by Korean cultural contexts.
The results of this study also indicated that the death attitude of escape acceptance was a key factor associated with burnout among hemodialysis nurses. Escape acceptance views death as a desirable means of relief from pain and suffering [
22]. Because this attitude is grounded in life’s hardships rather than the value of death itself, it may emerge when individuals are unable to effectively cope with pain and existential challenges [
11]. Nursing is founded on the ethical obligation to uphold the dignity and integrity of individuals and to provide holistic patient care [
26]. Hemodialysis nurses, acutely aware of their patients’ suffering, may experience feelings of guilt due to their inability to fully relieve this suffering. This can lead to a sense of inadequacy or helplessness when responding to patients’ emotions, hopes, and expectations. While caring for patients with end-stage renal disease who require complex treatment, nurses may experience illness subjectively and adopt escape acceptance attitudes toward death as an existential reflection on serving the patient’s best interests.
A concern highlighted by these results is that as the tendency to view death as an escape from suffering increased, so did emotional exhaustion. Nurses who strongly fear death or see it as an escape from pain were more likely to experience heightened emotional exhaustion, depersonalization, and reduced personal accomplishment [
27]. Depersonalization, a core component of burnout, is characterized by emotional detachment, indifference, and a sense of coldness toward patients. It can also be understood as cynicism, which is linked to job satisfaction and professional commitment [
28]. A significant portion of nursing work involves direct patient interaction, and emotional exhaustion resulting from depersonalization or cynicism can exacerbate burnout, lower job satisfaction, worsen mental health, and increase turnover intentions [
29]. However, burnout itself may also influence the development of an escape acceptance attitude toward death. Thus, further research is needed to examine how burnout may alter nurses’ emotional responses and interactions with patients.
Although hemodialysis nurses recognize the importance of discussing end-of-life issues with patients early in the course of maintenance hemodialysis [
30], they often lack knowledge in the psychosocial, spiritual, and philosophical aspects of end-of-life care [
31]. In this study, only 31.4% of participants had received formal education about death, highlighting the need to expand educational programs that support nurses in developing appropriate attitudes toward death. Death education aims to foster a deeper understanding of death, promote open discussion, and encourage individuals to appreciate and make the most of their remaining life [
32]. For hemodialysis nurses, education on death preparation may help reduce anxiety and fear of death, establish healthier attitudes toward death, and ultimately prevent burnout [
33]. As marital status was found to be associated with reduced burnout, death education programs should consider demographic characteristics. Given that most participants had less than 5 years of hemodialysis experience, it is necessary to tailor educational content to address diverse cultural and religious perspectives and to reflect on death according to nurses’ levels of experience.
Cultural background and corresponding perceptions of death—whether positive or negative—may shape nurses’ professional roles and the broader organizational context. Negative attitudes toward death have been associated with reluctance among nurses to provide end-of-life care [
34]. In Korean society, death and dying are sometimes viewed as failures or are otherwise negatively perceived; however, the extent to which Korean culture influences the development of neutral attitudes toward death remains unclear. Nevertheless, the strength of this study lies in its ongoing exploration of death-related factors among hemodialysis nurses. By investigating the relationships among death anxiety, negative attitudes toward death, and burnout, this study proposes the development of educational programs aimed at reducing death anxiety and negative attitudes. Such systems might include regular death-related education, emotional labor management programs, peer support networks, stress management workshops, and counseling services tailored for hemodialysis nurses. Future research should strive to include more diverse samples, such as male nurses, those working in rural or smaller healthcare settings, and individuals from varied sociocultural backgrounds. In addition, future studies should employ intervention research (e.g., death acceptance training, burnout prevention programs) and qualitative investigations to further explore nurses’ in-depth experiences and to guide the creation of evidence-based support strategies.
It is important to note, however, that the data for this study were collected during the coronavirus disease 2019 pandemic, which may limit the generalizability of findings regarding death anxiety, attitudes toward death, and burnout among hemodialysis nurses. Furthermore, the sample consisted entirely of female nurses—most with less than 5 years of dialysis experience—selected via convenience sampling, which may introduce selection bias. Statistically, fear of death and death avoidance are often highly correlated and may jointly reflect negative attitudes toward death. As a result, their unique contributions to explanatory models may be diminished, potentially leading to their exclusion from the regression analysis in this study. Therefore, interpretations of these results should also take into account the limitations of self-reported data and the potential for overfitting in the statistical analyses.
CONCLUSION
In clinical environments such as hemodialysis units, where life and death are closely intertwined, ethical and professional decision-making is required continuously. To sustain a highly trained hemodialysis nursing workforce and ensure high-quality care, it is essential to establish organizational support systems that go beyond individual efforts to acknowledge personal feelings about death and to cultivate appropriate attitudes toward it. To address death-related burnout among hemodialysis nurses, it may be effective to reduce negative attitudes toward death and to create opportunities for open, neutral discussions and emotional expression about death, both among nurses themselves and with patients and their families.
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CONFLICTS OF INTEREST
The authors declared no conflict of interest.
-
AUTHORSHIP
Study conception and/or design acquisition - SK; analysis - SK; interpretation of the data - SK and KK; and drafting or critical revision of the manuscript for important intellectual content - SK and KK.
-
FUNDING
This work was supported by the National Research Foundation of Korea (NRF-2021R1G1A1003370).
-
ACKNOWLEDGEMENT
None.
-
DATA AVAILABILITY STATEMENT
The data can be obtained from the corresponding authors.
Table 1.Differences in Burnout According to General Characteristics (N=86)
|
Characteristics |
Categories |
n (%) |
Burnout t or F (p) |
|
Sex |
Female |
86 (100.0) |
- |
|
Age (year) |
20s |
30 (34.9) |
87.89 |
|
30s |
32 (37.2) |
(.658) |
|
Over 40s |
24 (27.9) |
|
|
Education |
College |
71 (82.6) |
53.59 |
|
Graduate school |
15 (17.4) |
(.236) |
|
Religion |
Yes |
39 (45.4) |
54.26 |
|
No |
47 (54.6) |
(.216) |
|
Marital status |
Married |
37 (43.1) |
53.23 |
|
Unmarried |
49 (56.9) |
(.247) |
|
Nurse career (year) |
<5 |
54 (62.8) |
38.37 |
|
≥5 |
32 (37.2) |
(.811) |
|
Hemodialysis unit career (year) |
<5 |
78 (90.7) |
42.15 |
|
≥5 |
8 (9.3) |
(.673) |
|
Patients’ death within a year |
Yes |
68 (79.1) |
40.88 |
|
No |
18 (20.9) |
(.723) |
|
Family/friends’ death within a year |
Yes |
32 (37.2) |
43.41 |
|
No |
54 (62.8) |
(.622) |
|
Experience of death education |
Yes |
27 (31.4) |
47.08 |
|
No |
59 (68.6) |
(.469) |
|
Intention to participate in death education |
Yes |
20 (23.3) |
99.09 |
|
Unsure |
41 (47.7) |
(.075) |
|
No |
25 (29.0) |
|
Table 2.Scores for Death Anxiety, Death Attitudes, and Burnout
|
Variables |
Possible range |
M±SD |
Cronbach’s α |
|
Death anxiety |
1–5 |
2.71±0.73 |
.90 |
|
Death attitudes |
1–7 |
|
|
|
Neutral acceptance |
5.48±1.07 |
.85 |
|
Escape acceptance |
3.09±1.58 |
.95 |
|
Fear of death |
3.05±.1.41 |
.92 |
|
Death avoidance |
2.99±1.34 |
.86 |
|
Approach acceptance |
2.84±1.52 |
.95 |
|
Burnout |
1–7 |
3.94±0.77 |
.92 |
|
Emotional exhaustion |
4.01±1.42 |
.94 |
|
Reduced personal accomplishment |
3.28±1.21 |
.90 |
|
Depersonalization |
2.59±1.21 |
.77 |
Table 3.Relationships among Death Anxiety, Death Attitudes, and Burnout
|
Variables |
Death anxiety |
Burnout |
Subdomain of burnout |
|
EE |
PA |
DP |
|
r (p) |
|
Death attitudes |
|
|
|
|
|
|
Fear of death |
.65 |
.02 |
.02 |
–.06 |
.08 |
|
(<.001) |
(.891) |
(.878) |
(.581) |
(.485) |
|
Avoidance of death |
.35 |
.05 |
.08 |
–.06 |
.08 |
|
(.001) |
(.640) |
(.449) |
(.611) |
(.457) |
|
Neutral acceptance |
–.33 |
–.16 |
–.02 |
–.13 |
–.24 |
|
(.002) |
(.144) |
(.881) |
(.251) |
(.027) |
|
Escape acceptance |
.09 |
.41 |
.36 |
.37 |
.19 |
|
(.402) |
(<.001) |
(.001) |
(<.001) |
(.073) |
|
Approach acceptance |
.16 |
–.13 |
–.14 |
–.10 |
–.06 |
|
(.144) |
(.223) |
(.206) |
(.369) |
(.585) |
Table 4.Factors Affecting Burnout in Nurses Caring for Hemodialysis Patients
|
Variables |
B |
SE |
β |
t |
p
|
|
Constant |
3.02 |
1.08 |
|
2.79 |
.007 |
|
Marital status (married) |
–0.68 |
0.24 |
–.35 |
–2.88 |
.005 |
|
Death attitudes (escape acceptance) |
0.23 |
0.07 |
.37 |
3.28 |
.002 |
|
Adjusted R2=.22, F=2.43, p=.005 |
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