A comparison of the level of fear of death among students and nursing professionals in Mexico

OBJECTIVE: to compare the level of fear of death in nursing students and professionals. METHOD: this was a comparative-transversal study examining 643 nursing students and professionals from a third-level institution. A random sampling method was employed, and the sample size was calculated by power analysis. The study was developed during three stages: the first stage consisted of the application of a pilot test, the second stage involved the recruitment of the participants, and the third stage measured the participants' responses on the Collett-Lester Fear of Death Scale. RESULTS: the average fear of death was moderate-high (-X=3.19±0.55), and the highest score was observed for the fear of the death of others (-X=3.52±0.20). Significant differences in the perceptions of fear of death were observed among the students of the first three years (p<.05). However, no significant differences were observed among the first- and fourth-year students and professionals (p>.05). CONCLUSIONS: it is possible that first-year students exhibit a reduced fear of death because they have not had the experience of hospital practice. Students in their second and third year may have a greater fear of death because they have cared for terminal patients. However, it appears that greater confidence is acquired over time, and thus fourth-year students and professionals exhibit less fear of death than second- and third-year students (p<.05).


Introduction
Talking about death necessarily implies talking about life; a man begins the process of death from the very moment he is born. Life-death processes are integrated in a universal rhythm; life is an impulse, it is the engine that keeps us going, it is the condition that allows action and interaction (1) .
Death and dying constitute concerns that deeply oppress the subject rooted in human life; thus, thinking about death can sometimes provide a motive for reflection but can also generate fear. In Mexican culture, the feelings about death are to frequent it, mock it, cherish it, sleep with it, and celebrate it; it is one of the favorite playthings in Mexican culture and the most steadfast love of many Mexicans (2) . People often end up evading the conversation when death is spoken of, until it becomes classified as an alien, impersonal and distant event. Although most individuals do not want to, many put up protective barriers to avoid confronting it (1) .
Preparing to experience one's own death and the death of others with human sensitivity within the framework of care in the nursing discipline is a taboo subject in units where death is present. However, death can be, and often is, a motive for reflection, but it can also generate fear and anxiety when facing concerns about the termination and fragility of human life.
The death of a sick person while being provided healthcare services, be it in the emergency room, the intensive care unit or the internal medicine department (to name a few), is assumed by nursing personnel as a failure. Consequently, many professionals pray "that s/ he does not die on my rotation" and thereby alleviate fear, worry, suffering, pain, sayings, misfortunes and sensations of failure within the practice of nursing (1) .
Mexican nurses have been known to tease their colleagues by calling them "jinxed," which means that patients frequently "will die" on his or her work rotation. A nursing professional should be able to resolve his or her own fears, beliefs and convictions when facing death, especially given that death is a part of nursing care. However, some nurses have to fight internally against the sense of failure that is associated with death, and all have to live or experience the sensation of seeing their patients die. In many cases, nurses have to handle death with limited psychological knowledge, little institutional support and a lack of awareness regarding the therapeutic techniques and strategies for confrontation and self-help that they should have acquired in their professional training.
An ideal curriculum for nursing programs would include learning units that relate to managing one's own death and the deaths of others, which would make professionals more efficient. Therefore, it is important to know the extent of the fear of death that nursing students and professionals have. This knowledge could contribute to understanding how nurses are actually being prepared to attend, understand, accompany, help and care for any human being in the difficult moments that precede their own death or the death of others. Using the Collet-Lester The literature regarding this phenomenon shows that the average fear of death score in Spanish and Chilean nursing students is moderate-high. The thought that students exhibit the least fear of is one's own death, and the highest level of fear corresponds to fearing the death of others (3)(4)(5)(6)(7)(8) . Outside of these Latin American

Methods
This study was descriptive and comparative, and it featured a cross-sectional design. The participants were nursing students from the Meritorious Autonomous University of Puebla (Mexico) and nursing professionals from a third-level institution. Random sampling was performed, and the sample size was calculated by power analysis at 0.99 with an effect size of 0.25 and a level of significance of 0.05, which produced a required n of 589 participants.
To counteract the effects of attrition (5) , 10% was added, resulting in a target study population of n = 643.
The study was developed during three stages. The

Instrument
The adapted Spanish version of the Collet-Lester

Ethical considerations
This research was conducted according to the regulations of the General Health Law of Mexico (6) . It relied Based on these findings, analysis of variance (ANOVA) was used to perform the statistical comparisons.

Study hypothesis
If the level of fear of death is associated with the level of academic training and the experience of nursing students and professionals, then the comparisons will reveal significant differences in the fear of death among nursing students and professionals of different academic status.

Results
The sample consisted of 643 participants, 558 of whom were women (91%). The average age was

Analysis of variance (ANOVA)
The following steps were performed in the ANOVA: 1) to describe each of the groups to be compared, 2) to perform the analysis of variance and then apply Tukey's HSD test, 3) to interpret the tests of the multiple comparisons and 4) to observe the differences in the groups in graphical form. Additional details for all of these steps are shown below.
The sample data matrix shows five groups corresponding to the first-, second-, third-, and fourth- year students and the nursing professionals. The study variable is the level of fear of death for a total of 643 participants.
When describing the arithmetic averages of the groups (first-, second-, third-, and fourth-year nursing students and nursing professionals), statistically significant differences were observed, p = 0.17.
However, Tukey's HSD tests revealed that there were no significant group differences among the second-, thirdand fourth-year students and nursing professionals (p = 0.79). (Table 3). In the multiple comparison test comparing each group to the first-year students (Table 4), statistically significant differences were observed for the secondand third-year students (p< .05). However, no significant differences were observed between the first-year students and the fourth-year students or the professional nurses (p > 0.05).

Discussion
The  (3)(4)(5)(6)(7)(8) . However, in these participants, the fear of one's own death is less worrisome than the fear of the death of others (patients and family), which includes the loss of a loved one, having to see a dead body, regretting not getting along better with the person when he or she was still alive and feeling guilty regarding the relief provoked by his or her death. Alternatively, it can be interpreted that for nursing students, the greatest difficulty occurs during the development of the grieving process that is produced by the loss of a family member or a patient. In a hospital setting, the loss of a patient generates greater anxiety given that there is a preamble of accompanying and caring for the dying patient, which is a specific component of nursing care for terminally ill patients. The majority of students have not yet been prepared for these types of situations, but it has also been shown that these types of situations generate fear even in professionals, despite their experience.
The results of this investigation should be taken with some reservations due to the following study limitations.
First, despite being a sample of a pre-calculated size, the sample size is considered to be small and may not be generalizable to other populations. However, given the methodological rigor with which this research was conducted, the results should be considered reliable.
The current results suggest that it may be useful to evaluate the perceptions of fear of death in nursing professionals from other levels of health care and to determine their academic level and years of experience to assess whether the tendency that was demonstrated in this work is also observed in other groups.

Conclusions
It can be concluded that students at lower academic levels and professionals with greater clinical experience exhibit a reduced fear of death. However, second-and third-year students report a greater fear of death when compared to the extreme groups (i.e., first-year students, fourth-year students and nursing professionals).