EVALUATION OF THE DEATH ATTITUDE PROFILE-REVISED: A STUDY WITH HEALTH SCIENCE UNDERGRADUATE STUDENTS¹

ABSTRACT

Objective

to identify the profile of attitudes towards death in undergraduate students from in the health science area.

Method

a cross-sectional study performed with undergraduates from six healthcare courses of a public university in the Federal District. The Death Attitude Profile Assessment Scale and a sociodemographic questionnaire were applied.

Results

a total of 1,005 students participated in the study. The neutral acceptance attitude obtained higher average scores among the undergraduate students, higher averages in the fear of death dimension are presented in younger students and lower means of avoidance of death in older students, who attended the first semester of the undergraduate course. The acceptance and approach acceptance dimensions obtained higher averages in male undergraduate students. It was observed that 59.9% of the participants had no prior experience of loss and 75.4% reported not having participated in any discussions about death or dying.

Conclusion:

based on the results found in the research, the need for discussions on the subject of death and dying beginning in the first semesters in undergraduate courses is reinforced, this is in order to provide a positive attitude towards death and future health professionals exercise their care in a more qualified manner

DESCRIPTORS:
Attitude towards death; Death; Thanatology; Grief; Students of health sciences

RESUMO

Objetivo:

identificar o perfil de atitudes frente à morte pelos graduandos da área de saúde.

Método:

estudo transversal realizado com graduandos de seis cursos de saúde de uma universidade pública do Distrito Federal. Aplicou-se a Escala de Avaliação do Perfil de Atitudes Acerca da Morte e um questionário sociodemográfico.

Resultados:

participaram da pesquisa 1.005 estudantes. A atitude de aceitação neutra obteve maiores médias dentre os graduandos da amostra, médias mais elevadas na dimensão medo da morte apresentam-se em graduandos mais jovens e médias mais baixas de evitamento da morte em graduandos com maior idade, que cursavam os primeiros semestres da graduação. As dimensões aceitação de escape e religiosa obtiveram médias mais elevadas nos graduandos do sexo masculino. Observou-se que 59,9% dos participantes não tiveram experiência prévia de perda e 75,4% referiram não ter participado de discussões acerca da morte e do morrer.

Conclusão:

com base nos resultados encontrados na pesquisa, reforça-se a necessidade de discussões sobre a temática da morte e do morrer desde os primeiros semestres na graduação, com a finalidade de oportunizar uma atitude positiva frente à morte e o exercício de um cuidado mais qualificado entre os futuros profissionais de saúde.

DESCRITORES:
Atitude frente à morte; Morte; Tanatologia; Pesar; Estudantes de ciências da saúde

RESUMEN

Objetivo:

identificar el perfil de actitudes frente a la muerte por los graduandos del área de salud.

Método:

estudio transversal realizado con graduandos de seis cursos de salud de una universidad pública del Distrito Federal. Se aplicó la Escala de Evaluación del Perfil de Actitudes Acerca de la Muerte y un cuestionario sociodemográfico.

Resultados:

participaron de la investigación 1005 estudiantes. La actitud de aceptación neutra obtuvo mayores promedios entre los graduandos de la muestra, las medias más elevadas en la dimensión miedo a la muerte se presentan en graduandos más jóvenes y medias más bajas de evitación de la muerte en graduandos con mayor edad, que cursaban los primeros semestres de la graduación. Las dimensiones aceptadas de escape y religiosa obtuvieron promedios más altos en los graduandos del sexo masculino. Se observó que el 59,9% de los participantes no tuvieron experiencia previa de pérdida y el 75,4% dijo que no había participado en discusiones sobre la muerte y el morir.

Conclusión:

con base en los resultados encontrados en la investigación, se refuerza la necesidad de discusiones sobre la temática de la muerte y del morir desde los primeros semestres en la graduación, con la finalidad de proveer una actitud positiva frente a la muerte y el ejercicio de un cuidado más calificado entre los futuros profesionales de la salud.

DESCRIPTORES:
Actitud frente a la muerte; Muerte; Tanatología; Pesar; Estudiantes de ciencias de la salud

INTRODUCTION

Death, like birth, is inherent in life, it is a natural episode in human existence and depending on cultural, ethnic or religious beliefs, and it helps to shape one’s attitude toward the process of death and dying. Reflections on the meaning of life, the existence of the soul and the possibility of the afterlife are beliefs that anchor the attitude towards death in the human being.¹

Thus, in this context, attitudes toward death, whether positive or negative, can be perceived and defined through different perspectives. Positive attitudes are classified as the acceptance of death, while negative attitudes denote fear and avoidance of death. With regard to the acceptance of death, it is possible to identify three distinct types of attitudes: neutral, approach, and escape. Neutral acceptance is characterized as the understanding that death is a normal and natural part of life. Approach acceptance is marked by a belief in a happy life after death and escape acceptance can be understood from the assumption that when one lives in certain circumstances that lead to pain and suffering, death becomes an alternative to the termination of these.^2-3

Negative attitudes such as fear and avoidance of death are identified. The fear of death is characterized by dreading it, and avoidance with the attitude of doing what is possible not to think or talk about it. These five attitudes are part of the Death Attitude Profile- Revised (DAP-R), an instrument that measures attitudes toward death, created by researchers Wong, Reker, and Gesser.^2-4

Although death is part of the human experience and its discussion has a transverse character, it is understood that identifying attitudes of health professionals towards death is quite important as they experience the phenomenon on a daily basis, a fact that influences their care to palliative patients, as well as to their relatives. Studies on nurses’ attitudes towards death have revealed that caring for terminal patients and their families arouse negative emotions, such as: feelings of helplessness, fear, anxiety, which can have a negative impact on the quality of care provided to patients and their families.^5-8

Thus, nurses’ attitudes towards death can influence the quality, care, and behavior of the patient.^9-10 Depending on the nurse’s perspective of this context, the nurse will be less able to adopt a positive attitude of care with a palliative patient, which may impair the quality of the professional-patient relationship.¹⁰ Studies indicate that undergraduates students educated on the subject of death and dying had more positive attitudes towards caring for palliative patients than those who did not receive teaching on the subject.^7-11

Therefore, it is understood that knowing the attitude profile of the health sciences undergraduate students towards death can support strategies to be more adequately prepare these future professionals. The basic question of this study was: what is the attitude profile of undergraduate students in the area of health towards death?

In view of the above, the objective of this study was to identify the attitudes profile of undergraduate students in the health area towards death. Attempts were also made to characterize attitudes towards students’ deaths and to verify the existence of a relationship between these attitudes and the experiences of personal and professional loss experienced by undergraduates.

METHOD

A descriptive and cross-sectional study which was performed at a public university in Brasilia with undergraduate students from six health courses, including: nursing, pharmacy, physiotherapy, speech therapy, public health and occupational therapy. At the time of data collection, 2,040 regularly enrolled graduates who constituted the research universe. Considering that the flow of disciplines is organized in semesters and that in the last semesters the students have classes during the clinical experience in the hospital, the following aspects were defined as inclusion criteria: being present in the classroom at the time of data collection and accepting to participate in the survey.

Two instruments were used for data collection: 1) a sociodemographic questionnaire, consisting of open and closed questions, including variables such as: age, gender, marital status, course, experience of loss due to death of close significant person (father, mother , brother, cousin, uncle, grandparents, great-grandparents or others), experience of loss due to death of patients during the clinical experience. The participants were also asked if they had participated in discussions about death and dying in disciplines during their training (a description of the subject’s name was requested and the classification in compulsory discipline of the basic cycle, specific compulsory discipline of the course, or optional discipline); 2) Death Attitude Profile Assessment Scale (EAPAM).²

EAPAM is the translated and adapted DAP-R scale for Portuguese, the original version is available at: http://www.drpaulwong.com/documents/wong-scales/death-attitude-profile-revised-scale.pdf. It is an instrument that was developed from the conceptual analysis of the acceptance of death, considered as the last stage of the dying process. It measures a wide range of attitudes toward death, consisting of 32 items divided into five dimensions: fear (7 items), avoidance of death (5 items), natural acceptance / neutrality (5 items), acceptance as transcendence / religious 10 items) and escape acceptance (5 items). Each item is evaluated according to a Likert agreement scale, from 1(completely disagree) to 7 (completely agree) points.^2-4

Data were collected from September to October 2014. The days of collection were previously scheduled with the coordinator of the undergraduate course and with the teachers of the specific disciplines of the course. Graduates who were present in the classroom on the day of data collection were invited to participate in the study. After clarifying the research objectives, those who agreed to participate in the study, signed the Term of Free and Informed Consent and then received the questionnaires to fill out.

The collected data were entered and stored in the Epi-Info 3.5.1 Program. In order to characterize the sample, descriptive statistics were used during the analysis, calculating frequencies and percentages, as well as determining means and standard deviations, considering the variables involved. The ANOVA and Mann-Whithney tests were used in order to verify the effect of age, marital status, sex, experience of death of significant people, participation in discussions about death and dying, experience of death of patients in undergraduate activities in the dimensions of attitude towards death. The Pearson Correlation Test was applied to the variables that presented a statistically significant relationship.

The study complied with the formal requirements contained in national and international standards for research involving human subjects and was approved by the Research Ethics Committee of the Faculty of Health Sciences of the Universidade de Brasília, under opinion n. 493,459 and CAAE: 19869813.8.0000.0030.

RESULTS

A total of 1,005 graduates from six courses participated in the study. Table 1 presents data regarding age, marital status, death experience of significant people, participation of discussions about the subject and experiences of loss of patients in undergraduate clinical experience. In relation to age, there was a predominance of the age group ranging from 16 to 20 years of age (60.8%). It was observed that 946 undergraduates (94.1%) were single; 602 (59.9%) had not experienced situations of loss involving significant people; 758 (75.4%) had not participated in a discussion on the subject of death and dying in the graduation process at time of data collection; and 875 (87.1%) of the participants had not reported experiences of patient death during the undergraduate clinical experiences at the time of data collection.

Table 1
Distribution of undergraduate students according to sociodemographic variables, experiences of loss and discussion about death and dying. Brasília, DF, Brazil, 2014. (n=1,005)

Variables	n	%
Age
16-20	611	60.8
21-30	364	36.2
31-40	18	1.8
41-50	8	0.8
51-55	4	0.4
Civil status
Unmarried	946	94.1
Married	41	4.1
Divorced	4	0.4
Widowed	1	0.1
Unanswered	13	1.3
Sex	811	81
Female
Male
Experience of death of significant person	194	19
Yes	376	37.4
Father	19	1.9
Mother	11	1.1
Sibling	7	0.7
Cousin	27	2.7
Uncle/Aunt	77	7.7
Grandparents	135	13.4
Great Grandparents	18	1.8
Friend	50	5.0
Girlfriend/Boyfriend	2	0.2
Mother -in-law/ Father -in-law	1	0.1
Other	24	2.4
Unanswered	5	0.5
No	602	59.9
Unanswered	27	2.7
Participation in discussions about death and dying
Yes	228	22.7
Obligatory discipline of the basic cycle	30	3.0
Required discipline specific course	138	13.7
Optional discipline	47	4,7
Unanswered	13	1.3
No	758	75.4
Unanswered	19	1.89
Experience of patient death in undergraduate activities
Yes	111	11
No	875	87.1
Unanswered	19	1.9

Table 2 shows the relationship between the EAPAM dimensions and the undergraduate health science courses. The analysis of the scores of the attitude scale towards death revealed that the neutral dimension presented the highest average among undergraduate health science students, followed by the dimensions of approach acceptance, escape acceptance, fear of death and avoidance of death. The dimensions of fear of death and avoidance of death obtained higher averages among the public health undergraduate students. High averages were observed in speech-therapy undergraduate students in the approach acceptance and escape acceptance dimensions. The highest average in the neutral acceptance dimension was obtained by the nursing undergraduate students.

Table 2
Scores of the dimensions from the Attitude Towards Death Assessment Scale, according to the undergraduate course. Brasília, DF, Brazil, 2014. (n=1,005)

Course	Attitudes (n=1005)
	Fear of death		Avoidance of death		Approach acceptance		Escape Acceptance		Neutral Acceptance
	*	S†	X	S	X	S	X	S	X	S
Nursing	3,97	1,30	3,57	1,39	4,69	1,18	3,96	1,40	5,40	0,73
Pharmacy	3,74	1,27	3,80	1,39	4,54	1,30	3,81	1,43	5,34	0,91
Physiotherapy	3,85	1,23	3,77	1,48	4,66	1,15	3,94	1,33	5,38	0,67
Speech Therapy	3,82	1,21	3,64	1,59	4,83	1,13	4,46	1,42	5,31	0,96
Public Heath	4,02	1,30	3,84	1,33	4,67	1,23	3,86	1,44	5,19	0,92
Occupational Therapy	3,79	1,27	3,59	1,42	4,66	1,12	3,73	1,36	5,33	0,79
All courses	3,87	1,28	3,71	1,42	4,66	1,20	3,90	1,40	5,34	0,81

• ^*
  arithmetic mean;
• ^†
  S: standard deviation; applied ANOVA and Mann-Whithney tests.

It is observed in table 3 that the fear and avoidance dimensions of death presented a statistically significant relationship with age. When we applied Pearson’s correlation test we observed a weak negative linear correlation between fear of death (r=-0.10 and p=0.03) and age, as well as between avoidance of death (r=-0.11 and p=0.00) and age, inferring that higher averages in the fear of death dimension are presented in younger students, and that lower average in the avoidance dimension of death are found in older students.

Table 3
Significance test between the dimensions of the Attitude Towards Death Assessment Scale and the sociodemographic and experience of loss variables. Brasília, DF, Brazil, 2014. (n=1,005)

	Attitudes
	Fear of death	Avoidance of death	Approach Acceptance	Escape Acceptance	Neutral Acceptance
Age	0.03*	0.00*	0.08	0.40	0.21
Civil Status	0.72	0.54	0.34	0.73	0.17
Sex	0.17	0.06	0.02*	0.03*	0.73
Experience of death of significant person	0.53	0.76	0.93	0.94	0.93
Participation in discussions about death and dying	0.82	0.82	0.93	0.06	0.77
Patient death experience in undergraduate activities	0.51	0.57	0.47	0.99	0.59

• ^*
  Significant value (p <0.05); applied Pearson's Correlation Test

The escape acceptance and approach acceptance dimensions presented a statistically significant relationship with the sex variable (r=-0.02 and p=0.03, r=-0.12 and p=0.02, respectively), observing higher averages in these dimensions in male undergraduate students.

DISCUSSION

In general, the analysis of attitudes towards death revealed the prevalence of neutral acceptance, which comprises the phenomenon of death as one of many other factors of life, or as an integrative part of it, this was followed by approach acceptance, which implies the imaginary of a happy life after death, in which religious beliefs and religion include the notion that death can bring peace and harmony with God. These results corroborate findings from a study of 110 students in Iran.¹¹ In other studies, unlike the study conducted in the present study and in Iran, the average for the fear of death was found to be higher than the other attitudes.^10,12

It was observed that the undergraduate students of the public health course obtained higher averages in the dimensions of fear of death, which is characterized by a certain anxiety caused by thoughts and feelings about death and the dying process; and avoidance of death, which is related to detachment, either through speech or contact with death, in order to reduce fear and anxiety, since they impel the individual to attribute meaning to life. A study with 147 nurses found a positive correlation between fear of death and avoidance of death and approach acceptance, explaining that nurses who are more fearful of death and avoidant of death present fewer positive attitudes towards the care of palliative patients.¹²

Among the undergraduate students of the Speech Therapy course, the highest averages were seen in the approach acceptance dimensions, which implies the existence of a belief in the happy continuity of life beyond death; and the escape acceptance which may be a response of the individual to the difficulties of life, where death can be perceived as an exit from the suffering experienced. A study conducted with Israeli nurses found a positive correlation between approach acceptance and avoidance of death and escape acceptance and also found that nurses with higher averages of approach acceptance had fewer positive attitudes toward palliative care of patients, which may be related with culture and practiced religion.¹²

The highest average of the neutral acceptance dimension was highlighted in the nursing cours. This result ratifies a study with 360 nurses from different areas (palliative, medical, hematological and oncologic) who also obtained higher means of neutral acceptance, but the palliative nurses obtained a greater neutral acceptance and found a positive significance with the fact that they have greater contact with the patient.¹³ A survey of nurses in Iran showed that those who perceive death as a natural part of life were more capable of caring for end-of-life patients, which can be explained by the fact that nurses interact positively with end-of-life patients and talk honestly about death with them.¹⁴

Concerning fear of death, it was observed that the younger the age, the greater the fear, in an inversely proportional relationship, confirming the study findings with young adults, who also found higher scores in the fear of death dimension, suggesting that young people perceive death as a catastrophic interference in their lives, preventing them from reaching important goals in professional and emotional spheres.¹⁵ The analysis of the age range of most students in the study (16 to 20 years) indicates that high levels of fear of death may be related to the fact that at this stage the young person has to make several choices, the consequences of which will continue for many years, and the eventual early death would prevent them from doing them.(¹⁵) Another possible cause would be a lack of experience in the area, therefore, more mature students may have a greater experience in the area of health, where they would have learned to face the fear of death.¹⁶

The avoidance of death dimension presented lower scores among older students. Studies suggest that older nurses may have greater acceptance of death as an escape attitude for suffering and pain and have more positive attitudes toward death compared to younger nurses.^13,17

The high scores in approach acceptance and escape acceptance among male undergraduates was considered an interesting finding in this research. This result contradicts the literature that highlights women as having the most positive attitudes towards death when compared to men.^13,17 In this perspective, studies indicate that women in general fear death on a larger scale, perhaps due to the fact that they express their emotions more easily than men.¹⁵

It was not possible to verify the existence of a relationship between the attitudes towards death and the experiences of personal and professional loss experienced by undergraduates, but negative attitudes towards death may be related to the lack of preparation during the educational process in undergraduate studies.^7-8,18 As evidenced in the present study, 758 (75.4%) students did not participate in any discussion on the subject of death and dying during the undergraduate course, which may impact the way care is performed.^10,13,17-18 A literature review¹⁸ clarifies the need for professional training on the subject of death and dying, as well as previous training programs from the beginning of professional practice as part of the education of nurses

A study performed with two different groups of nurses observed that, after a group received training on the subject of death, the attitudes towards the death of these nurses became positive, while the other group, who did not have access to the same training, did not obtain significant changes.¹⁹ Those educated about death and dying are better able to care for people who are dying.(¹¹) Most of the students interviewed in the study by Grubb and Arthur¹⁷ expressed a strong desire for an education in palliative care and subjects related to death to be included in the nursing graduation course.

Faced with the emotional problems caused by the death of their patients, professionals need to develop skills and competencies to deal with these problems.¹⁰ Research performed with different students and health professionals showed that: nurses with education in palliative care had less difficulty talk about death and did not refer to fearing death;²⁰ human service students who had contact with an education about death presented a reduction in anxiety when faced with death compared to students who had no education on the subject;²¹ pharmacy students, who had access to education about death through simulation in clinical skills laboratories , demonstrated a significant improvement in their attitudes towards death compared to pre-simulation and declared themselves more competent to care for patients in the process of death; and that the study of death for undergraduate pharmacy student had been of real importance and had led to curricular improvement.^22-23 Considering the cited studies, the importance of an education regarding the subject of death and dying, so that the professional is prepared to exercise his profession with quality is considered justified.

It is important to emphasize that fear or avoidance of death is a defense of the ego against suffering, but that too much can impoverish the understanding of the present moment, reflecting in the understanding of the meaning of life. In this line of reasoning, understanding death can enrich life, giving meaning and the encouragement to live a well lived life.²⁴

The time available which the students had to answer the questionnaire, and the selection of the same, since the choice followed accessibility criteria are included as study limitations. As a study strength, the participation of undergraduates from six health courses is outstanding, as it is observed that most of the studies available in the literature refer to studies conducted with only one course.

CONCLUSION

The study revealed that the neutral dimension presented higher averages among undergraduate students from all courses. Higher means in the dimension of fear of death were presented in younger students and avoidance of death in older students. Higher averages in terms of escape acceptance and approach acceptance were found in male undergraduates.

A significant number of undergraduate students did not participate in discussions on the subject of death and dying. It was observed that the negative perception of death, expressed in the dimensions of fear of death and avoidance of death, was present among the youngest students.

These results reinforce the need to include the theme of death and dying in healthcare courses from the first semesters. It is necessary to create spaces which allows students to explain, listen and accept suffering, helping them to deal with losses of all kinds in a better way by using different pedagogical strategies. Although pedagogical and therapeutic scenarios cannot be confused, it should not be denied that a psychopedagogical approach can mitigate the impact that the experience of death can have on the personal and academic lives of these young people. From this point of view, the discussion about the subject at the very beginning of the training, can favor a more comprehensive preparation of the undergraduate students, enabling them to practice their profession, not only in the perspective of healing, but also of caring.

• 1
  Article from the Undergraduate Nursing Thesis - Perfil de atitude frente à morte em graduandos da área de saúde, presented to Universidade de Brasília (UnB), Faculdade de Ceilândia, in 2014.

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Publication Dates

• Publication in this collection
  2017

History

• Received
  25 Aug 2016
• Accepted
  22 May 2017