The COVID-19 pandemic and nurses’ attitudes toward death*

Objective: to analyze nurses’ attitudes toward death in a hospital context after the critical period of the COVID-19 pandemic in Portugal. Method: this quantitative, descriptive, exploratory study was conducted in a university hospital and addressed 995 nurses. Revised Death Attitude Profile (DAP-R) was used to collect data, which were analyzed using analytical and inferential statistics. Results: the nurses most frequently agreed with the statements concerning the Neutral/Neutrality Acceptance and Fear. Age, marital status, profession, and unit of work influenced the nurses’ attitudes toward death. During the critical pandemic period, the nurses providing care to patients with COVID-19 presented the following means: Fear (28.89/±8.521) and Avoidance Acceptance (18.35/±7.116), which were higher than the mean obtained in the Escape Acceptance dimension, with significant differences (p=0.004). Conclusion: the nurses held Fear and Avoidance attitudes, revealing the need to qualify and support Nursing workers to cope with the death of those they provide care and manage pandemics and catastrophes.


Introduction
The COVID-19 pandemic changed our lives and brought about much uncertainty, changing the practice of workers, significantly altering the experiences and functioning of organizations (1)(2) . In February 2020, recognizing that the pandemic situation in Europe and worldwide was challenging, Portugal started preparing and organizing the hospital addressed in this study to deal with the disease (3) efficiently. Like other countries, decreasing the risk of infection and its spread were the primary objectives of this process (2) .
In the Portuguese context, the Directorate General and services (4) .
Even though these guidelines enabled standardizing procedures in all Portuguese hospitals, successfully responding to the growing number of COVID-19 cases also depended on preparing competent and differentiated health care (3) . In this context, the hospital addressed in this study implemented adaptations to meet the community's and workers' needs, the epidemiological profile of cases, beds occupation and clinical guidelines as they emerged.
Considering the predictable increased need for highly complex care, the first measures implemented in many countries included providing medical inputs and equipment essential for health workers in the services involved and create, approve and disseminate standards and procedures (3)(4)(5) . Concomitantly, the needs of people in the different professions were verified, especially those of nurses, operational assistants and diagnostic and therapeutic technicians (3) .
After the first months in which the disease was disseminated, COVID-19 was characterized as a global emergency given its capacity to produce new cases and because it is a potentially fatal disease, considered the major pandemic of the last 100 years (6) .
As recently reported in the international literature, nurses were and are vital workers in the care process during the COVID-19 pandemic (1,5,7) , and their role has been emphasized in the surveillance, prevention, control of the virus spread, care provided to patients, research addressing the COVID-19, guidance provided to the community (8) and in the reorganization of institutions.
The possibility of mobilizing nurses -many of whom were volunteers -from the services that decreased their activity to ensure care was provided to patients with COVID-19 was determinant to organize the hospital addressed in this study. The nurses' ability to adapt to new challenges, comply with protective measures and respond to increasingly intensified emerging needs, was another critical factor of the strategy implemented (3) .
The provision of nurses in the units assigned to patients with COVID-19 needed to be adjusted because safety demanded the teams to be reinforced. The fact is that dealing with complex care, assisting clinically unstable patients and frequently experiencing death situations culminate in workers becoming physically and mentally exhausted (8)(9) .
The growing number of deaths caused by COVID-19 and its impact on health workers has been reported worldwide (8)(9) . Even though death is an integral part of life (10) , this unknown virus and disease may elicit different responses from workers and it is essential to identify how health workers are coping with death. This is even more important among Nursing workers considering the long time these professionals spend with patients. Hence, the following question guided this study: what are the nurses' attitudes toward death and associated factors during the COVID-19 pandemic, in a hospital context?
The death-dying process permeates Nursing practices; however, studies seldom address this topic, and discussions during nurses' training are either restricted or fragmented (11)(12)(13) while there is a lack of investment to better qualify these workers, especially for critical situations.
In this context, this study, which is part of a more extensive investigation addressing the topic since 2017, is intended to analyze nurses' attitudes toward death in a hospital context after the critical period of the COVID-19 pandemic in Portugal.    (14) . This instrument was composed of 32 close-ended questions rated on a seven-point Likert scale, ranging from 1 (strongly disagree) to 7 (strongly agree). The 32 items cover five dimensions: fear of death (7 items); death avoidance (5 items); neutral acceptance (5 items); approach acceptance (10 items) and escape acceptance (5 items). The total score ranges from 32 to 224. The Approach Acceptance dimension includes items: 4 -I believe that I will be in heaven after I die; 8 -Death is an entrance to a place of ultimate satisfaction; 13 -I believe that heaven will be a much better place than this world; 15 -Death is a union with God and eternal bliss; Five (0.5%) of this group of participants did not report the unit where they worked, during the critical period of the COVID-19 pandemic.

Method
Note that 91 (9.1%), out of the total participants, were on leave during March and April 2020: As for the reasons for absence 30 (3.0%) were complying with the quarantine/prophylactic isolation, 19 (1.9%) were absent due to other diseases, 19 (1.9%) were providing family support, 17 (1.7%) had a COVID-19 diagnosis, four (0.4%) were on maternity leave while two (0.2%) participants were on vacation. Table 1 presents the results to support the analysis of nurses' attitudes toward death in the context of the COVID-19 pandemic.   Then, attitudes about death and sociodemographic variables were analyzed, showing significant associations in Table 2.   (Table 4). In this sense, the nurses working in these contexts obtained the lowest mean in the Escape Acceptance. Acceptance means obtained by the individuals aged between 46 and 55 were higher than the means obtained by those younger than 25 years of age, while the Escape average obtained by participants 56 years old or older was also higher than that obtained by those younger than 25 years old.

Nurses' attitudes toward death
Analysis of the nurses' unit of work (medical, surgical, or intensive care unit) using the Kruskal-Wallis test for independent samples revealed significant differences between the scale's dimensions and the participants' units of work (Table 5). considerably high mortality rates worldwide in a very short time. It is essential to identify attitudes toward death of the primary professionals working in the front line fighting the pandemic in this context. One study (15) warned about the importance of understanding how working tasks and conditions contribute to disseminating the pathology and monitoring the strategies established. In addition to these aspects, these findings also show the importance of understanding how workers cope with the disease's repercussions and what are the resources available.
Death was and still is one outcome of this disease with which health workers providing care have to deal (16)(17) . This aspect enables understanding the results may be more resilient with the challenges imposed (1,5) .
Participants 56+ years old, in turn, obtained the highest median in the Escape Acceptance dimension, that is, they consider death an end to suffering, considering that older patients are more likely to die due to the novel coronavirus. Additionally, attitudes may be associated with experiences and personal and professional knowledge when facing rapid and severe changes that may affect the general condition of individuals with the disease (5) .
Working with the care provided to patients with COVID-19 and witnessing suffering among those with the disease led nurses to experience tension and anguish (1) .
The Escape Acceptance dimension was less evident among those who worked between March and April in the units providing care to patients with COVID-19 than among those who did not work in these units. Perhaps, because the disease progresses rapidly and the media regularly and widely disseminated news indicating the growing number of contaminated and dead individuals, the participants not always saw death as an end to suffering, which was often of short duration.
Studies (18)(19)(20) sought to understand the multiple impacts of the pandemic on people and health workers' lives. Among the aspects observed, some studies have debated the mental health of these workers, which indicates the difficulty of preparing to face the problem.
Still, regarding attitudes toward death, Fear of death was significant among married participants or those living in a stable union. It is believed that the risk of being a carrier of the disease with the potential to transmit it to family members was a daily concern of crucial importance in the lives of these professionals. For this reason, many of them adopted measures to protect themselves and their families, leaving their homes, for instance, and staying in hotels (1,7) . In this critical period, the challenge was to provide care to individuals with COVID-19 and remain healthy to care for their families without contaminating them, so many opted for preventive isolation (1,7) , something unusual among the various challenges nurses experience.
Additionally, many nurses witnessed patients dying without the presence of their families and often mediated the contact, or farewell of severe patients with their families using a mobile phone or tablet, as it happened in different countries (21)(22)(23) , which impacted most participants in terms of the Fear dimension, but potentially more severely impacted those with a spouse or partner.
Psychological support became, even, more crucial as In this study, specialist nurses stood out because they most frequently hold an Approach Acceptance attitude. Additionally, the nurses' skills and knowledge are elements that promote different attitudes in care practice, resulting in positive strategies and behavior to deal with the disease (25) .
The probability of experiencing a large number of deaths is directly proportional to the number of people with COVID-19 to whom one provides care, consequently, a higher likelihood of dealing with death or the severe clinical condition of patients (7) . and death became closer (7) , leading to the emergence of an Escape attitude.
Note that the front line workers have dealt with work overload given the intense demand for care, exacerbated by precautionary measures necessary to prevent the disease's spread and avoid self-contagion. Furthermore, even in this challenging context, these workers provide emotional support to those hospitalized (23) . Additionally, the growing number of deaths leads to exhaustion and may also change attitudes and perceptions toward death.
One study (17) reports that the process of mourning, death, and dying are unique experiences of each individual and cannot be standardized so that the signification of loss in times of pandemic is something complex and subject to change. Studies addressing this topic outside the unique context imposed by the COVID-19 have already warned that all elements in the professional context may influence the way nurses cope with death and how well this relationship can be explained (16) .
These results, especially those related to terminality, death, and mourning processes, are relevant for other countries recording even a more significant number of deaths, considering the possibility that the number of cases may increase again in the future and the potential occurrence of new pandemics (18)(19) . These findings are also relevant for managers and institutions considering support measures to implement among workers dealing with death in health services and to guide personalized monitoring and support to nurses.
The fact that Fear and death Avoidance is more evidenced in a pandemic context reinforces the need to invest in the qualification of Nursing workers to cope with the death of those they provide care to, simultaneously minimizing the adverse effects these experiences may cause. Additionally, it is essential to ensure workers have specialized assistance to minimize the psychological distress to which they are exposed, aggravated by the This study's results can support institutions regarding coping strategies when facing pandemic and catastrophic events, in which strategies are needed to prepare workers to cope with death. These findings also provide information about the health of Nursing workers, considering that the pandemic impacts the physical health of workers and has repercussions on their attitudes and psychological aspects.