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Journal of caring sciences. 13(1):20-26. doi: 10.34172/jcs.2024.33069

Original Article

The Investigation of Death Anxiety and Spiritual Well-Being Levels of Family Members of Patients Admitted to Intensive Care Unit

Selçuk Görücü Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Resources, Project administration, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing, 1, * ORCID logo
Gülşah Gürol Arslan Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Resources, Project administration, Supervision, Validation, Writing – original draft, 2 ORCID logo

Author information:
1Department of Nursing Fundamentals, Kumluca Faculty of Health Sciences, Akdeniz University, Antalya, Turkey
2Department of Nursing Fundamentals, Faculty of Nursing, Dokuz Eylül University, Izmir, Turkey

*Selçuk Görücü, Email: selcukgorucu@gmail.com selcukgorucu@gmail.com

Abstract

Introduction:

This study aimed to investigate the death anxiety (DA) and spiritual well-being (SWB) levels of first-degree family members of patients hospitalized in the intensive care unit (ICU).

Methods:

The data of this descriptive correlational type of study were collected through a faceto-face interview and survey with 308 family members who came to visit family members treated in the ICU of a public hospital in the western province of Turkey. Results were analyzed with SPSS software version 22.

Results:

The average Death Anxiety Scale (DAS) score of the family members is 7.99 (3.15), which is above the middle value (min/max; 0-15), and the average Spiritual Well-Being Scale (SWBS) score is 121.83 (12.91), which is relatively high (min/max; 29-145). A positive, weak, and significant correlation existed between DAS and SWBS mean scores (r=0.20; P<0.05).

Conclusion:

As a result, the DA levels of family members increase with the thought of losing their patients in the ICU. During this period, family members of patients need spirituality more than ever to cope with increasing DA. In this study, a positive and significant correlation was found between the DA levels and SWB levels of the family members. According to this result, as family members’ DA increases, their spiritual needs also increase.

Keywords: Intensive care unit, Family members, Anxiety, Spirituality, Nursing, Holistic nursing

Copyright and License Information

© 2024 The Author(s).
This work is published by Journal of Caring Sciences as an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by-nc/4.0/). Non-commercial uses of the work are permitted, provided the original work is properly cited.

Funding Statement

The study did not receive any financial support.

Introduction

The feeling of uncertainty affects the fear of death. Especially people who feel lonely in their lives and those who experience uncertainty are those who tend to have a fear of death. Fear of death can be triggered when a person loses or is in danger of losing someone dear to his or her life. While the individual receiving treatment in the intensive care unit struggles between life and death, her family members may experience fear of death and may need spiritual support to cope with it. It is known that the policy of prohibited or restricted visits in the intensive care unit (ICU) causes stress and anxiety in the patient and her family.1 Therefore, it is reported that the psychosocial and spiritual needs of ICU patients as well as their families should be met.2In a study conducted with 223 family members who visit the in the ICU, it was reported that family members experienced moderate and severe cardiac anxiety.3

Spirituality comes to the forefront in cases of crisis, such as disease, stress, and fear of death where individuals question the meaning of life.4Being a patient’s family member or undertaking the care of a family member may cause deterioration of life satisfaction, health, and stress. “Spiritual Distress” can occur in cases where the individual’s belief system is challenged such as stressful condition, and various life events causing crises and loses.5 Spiritual well-being (SWB) also involves seeking the meaning, purpose, and understanding of a higher power upon which life depends.6Although nurses have responsibilities that also concern the patient’s family members, only dealing with the patient and the disease increases the anxiety levels of family members.7 Because of this, it is crucial to ensure family members’ participation in the patient’s care. Encouraging practices that will include the welfare of the family members are important in terms of the patient’s and its family member’s well-being and holistic care. Supporting spiritual self-care for a patient’s family members could be one such practice. Healthcare research on spirituality has focused on patients. Less is known about the spiritual self-care of family members who support these patients in any challenging environment. Spiritual self-care is a vital component of achieving and maintaining SWB. Spiritual self-care encompasses practices and activities that nurture and support an individual’s SWB. Providing spiritual self-care support to family members can help reduce their stress, burnout, and fear.

Unfortunately, it is well known that patients’ family members experience high levels of distress and grief in response to the patient’s suffering. In the literature review, no study was found that evaluated the death anxiety (DA) and SWB levels of patients’ family members. Our study will create innovation in providing holistic nursing care on how the SWB and DA levels of the patient’s relatives are affected during the care and treatment process of the intensive care patient. In addition, by revealing how DA and SWB affect each other, our study will reveal innovation in terms of developing health policies in this field and increasing the quality of nursing care. The aim of this study is to investigate the levels of DA and SWB, the levels of family members of patients in intensive care, and the variables affecting these levels, and to analyze how DA and SWB affect each other.


Materials and Methods

This descriptive correlational study was conducted in the intensive care unit of a state hospital in Turkey between September 2018 and February 2019. A probabilistic sampling technique was used in the study. The sample size was calculated based on 0.80% power at a significance level of 0.05 in the G-Power 3.0 statistical program. Since there was no study on this subject before, the sample size calculated on the basis of low effect in a single group was determined as 199. The sample of the study consisted of the family members of the patients who met the inclusion criteria. In order to increase the power of the research, 308 family members were reached, and data were collected by face-to-face interview method.

Inclusion Criteria

18 years and over

being a first degree relative (mother, father, spouse, child) of the patient

Being a family member of a patient who received treatment in intensive care for at least 24 hours or more. Having visited his patient at least once.

Willingness to participate in the research.

Exclusion Criteria

Having a communication problem (not knowing Turkish).

Not being able to adequately answer the cognitive questions asked.

Data Collection Tools and Data Collection

Patient relative descriptive characteristics form: It consists of gender, age, marital status, having children, employment status, occupational distribution, monthly income status, educational level, previous loss of someone descriptive questions.

Templer’s Death Anxiety Scale (DAS): It is a 15-item, binary Likert-type scale developed by Templer (1970) and explains the anxiety expressions stemming from the individual’s perception of his own death process. The total score taken from the scale is 15. The DA level increases as the scores increase from 0 to 15. In the Turkish validity reliability study conducted by Akça and Köse8 the Cronbach’s alpha value was 0.79. It was calculated as 0.71 in this study.

Spiritual Well-Being Scale (SWBS): It is a 5-point Likert-type scale developed by Eksi and Kardas6 and consists of 29 items. Range of scores that can be obtained from the scale is 21-145. High scores indicate increased SWB levels. The Cronbach alpha value of the scale was calculated as 0.88 by Eksi and Kardas.6It was calculated as 0.85 in this study.

Statistical Analysis

The data were analyzed with SPSS 22.0 software package. Frequency, percentage, arithmetic mean, and Cronbach’s alpha reliability coefficient were calculated to interpret the data. Normal distributions were evaluated using Kolmogorov–Smirnov test. Since the distribution of the scale scores was found to be normal by the normality test, the parametric tests of student’s t test and one-way analysis of variance (ANOVA) were used. Pearson correlation analysis was used to analyze the correlation between the mean scores of the two scales and independent variables. The level of significance level was set at P<0.05.


Results

Total number of participants in this study was 308. The mean age of the participants was 49.07 (11.06). In our study, 107 (34.7) of the participants were men and 201 (65.3) were women. Most of the participants were married 261 (84.7). Moreover, most respondents had secondary school or lower 161 (52.2). Most of the participants were unemployed 186 (60.4). Additionally, most of the participants reported that they had experienced a grief process before 294 (69.5) (Table 1).

Distribution of DAS and SWB scores according to sociodemographic characteristics of family members are given in Tables 2 and 3 , respectively. The mean (SD) DAS score of the family members was 7.99 (3.15) (min/max: 0-15).


Table 1. Socio-demographic characteristics of family member (N=308)
Demographic features No. (%)
Age
20–45 years 120 (39.0)
46–59 years 132 (42.9)
>60 years 56 (18.2)
Gender
Famale 201 (65.3)
Male 107 (34.7)
Marital status
Married 261 (84.7)
Single 47 (15.3)
Having children
Yes 269 (87.3)
No 39 (12.7)
Employment status
Yes 122 (39.6)
No 186 (60.4)
Occupational distribution
Housewife 92 (29.9)
Retired 75 (24.4)
Employee 111 (36.0)
Officer 30 (9.7)
Monthly ıncome status
No income 94 (30.5)
Minimum wage and lower 132 (42.9)
More than minimum wage 82 (26.6)
Educational level
Secondary school or lower 161 (52.2)
High school 95 (30.8)
University or higher 52 (16.8)
Previous loss of someone
Yes 294 (69.5)
No 94 (30.5)

Table 2. Distribution of mean death anxiety scale score by sociodemographic characteristics of family members
Mean score of death anxiety Mean (SD) P
Gender
Female 8.36 (3.11) t: 2.91
P: 0.00*
Male 7.28 (3.12)
Age (y)
20–45 8.36 (3.13) F: 3.19
P: 0.04*
46–59 7.46 (2.91)
>60 8.41 (3.58)
Marital status
Married 8.07 (3.08) t: 1.13
P: 0.25
Single 7.51 (3.48)
Having children
Yes 8.05 (3.07) t: 1.01
P: 0.31
No 7.51 (3.66)
Employment status
Yes 7.42 (2.94) t: -2.56
P: 0.01*
No 8.36 (3.23)
Occupational distribution
Housewife 9.34 (2.82) F: 8.71
P: 0.00*
Retired 7.37 (3.49)
Employee 7.43 (3.04)
Officer 7.43 (2.38)
Monthly income status
No income 9.19 (2.97) F: 11.05
P: 0.00*
Minimum wage and lower 7.64 (3.10)
More than minimum wage 7.17 (3.07)
Educational level
Secondary school or lower 8.04 (3.01) F: 1.60
P: 0.20
High school 8.26 (3.44)
University or higher 7.30 (2.98)
Previous loss of someone
Yes 7.66 (3.16) t: ­2.73
P: 0.00*
No 8.72 (3.01)

SD: Standard deviation; t: t-test; F: One-way ANOVA test. *Statistically significant (P<0.05).


Table 3. Distribution of mean spiritual well-being scale score by sociodemographic characteristics of family members
Mean score of spiritual well-being Mean (SD) P
Gender
Female 122.39 (13.00) t: 1.04
P: 0.29
Male 120.78 (12.75)
Age (y)
20–45 years 121.43 (13.18) F: 0.57
P: 0.56
46–59 years 121.49 (13.04)
>60 years 123.51 (12.09)
Having children
Yes 122.49 (12.33) t: 2.37
P: 0.01*
No 117.28 (15.81)
Occupational distribution
Housewife 125.47 (10.09) F: 7.81
P: 0.00*
Retired 120.86 (12.77)
Employee 121.88 (12.48)
Officer 112.93 (17.67)
Monthly income status
No income 125.73 (10.41) F: 16.56
P: 0.00*
Minimum wage and lower 123.06 (11.96)
More than minimum wage 115.40 (14.64)
Marital status
Married 122.97 (11.69) t: 3.71
P: 0.00*
Single 115.53 (17.09)
Previous loss of someone
Yes 122.01 (12.67) t: 0.36
P: 0.71
No 121.43 (13.50)
Employment status
Yes 119.74 (14.25) t: -2.31
P: 0.02*
No 123.20 (11.80)
Educational level
Secondary school or lower 124.42 (10.69) F: 18.58
P: 0.00*
High school 122.50 (12.13)
University or higher 112.59 (16.28)

SD: Standard deviation; t: t-test; F: One-way ANOVA test;*Statistically significant (P<0.05).

In the study, it was determined that the mean DAS score of females 8.36 (3.11) was statistically significantly higher (P<0.05). It was found that the mean DAS score of the participants in the middle age group (46-59 years) was statistically significantly lower (P < 0.05). No statistically significant differences were found in the mean DAS score of the family members according to marital status, status of having children, and educational level (P > 0.05). The mean DAS score of the unemployed individuals was statistically significantly higher compared to the employed participants (P<0.05). In this present study, occupational distribution was found to have a statistically significant effect on the mean DAS score (P<0.05). The mean DAS score of the patient relatives without any income was statistically significantly higher (P<0.05). It was seen that the mean DAS score 8.72 (3.01) of the family members who did not previously lose someone was higher and that the experience of loss of someone statistically significantly affected the mean DAS score (P<0.05) (Table 2).

In the study, the mean (SD) SWBS score of the family members was 121.83 (12.91) (min/max: 21-145).

In the study, no statistically significant differences were found in mean SWBS scores between different groups of gender, age, and status of previous loss of someone when SWBS was analyzed according to the sociodemographic characteristics of the family members (P>0.05). The mean SWBS score of the individuals who were married had children and were unemployed was statistically significantly higher (P<0.05). The monthly income status and occupational distribution of the family members had a statistically significant effect on the mean SWBS score (P<0.05). The mean SWBS score of the individuals with a low educational level was statistically significantly higher (P<0.05) (Table 3).

A positive weak, and significant (r=0.20; P<0.05) correlation was found between the DAS and SWBS score averages of family members (Table 4).


Table 4. Correlation between death anxiety scales and spiritual well-being scales according to descriptive characteristics of family members
Descriptive Characteristics of Family Members
Scales Age Gender Employment status Occupational distribution Monthly income status Marital status Status of having children Educational level Previous loss of someone
Death Anxiety Scale r:­0.03
P:0.59
r:­0.16
P:0.00*
r:0.14
P:0.01*
r:­0.22
P:0.00*
r:­0.24
P:0.00*
r:­0.06
P:0.25
r:­0.05
P:0.31
r:­0.06
P:0.28
r:0.15
P:0.00*
Spiritual Well-Being Scale r:0.04
P:0.38
r:­0.06
P:0.29
r:0.13
P:0.02*
r:­0.21
P:0.00*
r:­0.29
P:0.00*
r:­0.20
P:0.00*
r:­0.13
P:0.01*
r:­0.30
P:0.00*
r:­0.02
P:0.71
Interscale Correlation
Death Anxiety Scale Mean Score

Spiritual Well-Being Scale
Mean Score
r=0.200
P=0.000*

*Statistically significant (P<0.05). r: Pearson correlation analysis.

In the study, mean DAS score of the family members had a negative (r=0.16; P<0.05), weak and significant correlation with the independent variable of gender, a positive (r=0.14; P<0.05), weak and significant correlation with employment status, a negative (r=0.22; P<0.05) significant correlation with occupational distribution and a negative (r=0.24; P<0.05) significant correlation with monthly income status. A positive significant correlation was found between the experience of the loss of someone and the mean score DAS score of the family members (r=0.15; P<0.05) (Table 4).

In the study, the mean SWBS score of the family members had a positive weak, and significant correlation with employment status (r=0.13; P<0.05), a negative and significant correlation with occupational distribution (r=0.21; P<0.05), a negative significant correlation with monthly income distributions (r=0.29; P<0.05), a negative significant correlation with marital status (r=0.20; P<0.05), a negative significant correlation with the status of having children (r=0.13; P<0.05) and a negative significant correlation with educational level (r=0.30; P<0.05) (Table 4).


Discussion

This present study investigated the DA and SWB levels and the correlation between these levels of 308 first-degree family members of patients treated in ICU. A positive weak, and significant (r=0.20; P<0.05) correlation was found between the DAS and SWBS score averages of family members. The mean (SD) DAS score of the family members was 7.99 (3.15) which is above the intermediate value. In this present study, in which the majority of participants (65.3%) were females, the mean DAS score of females was significantly higher compared to males, consistent with the literature.9,10The various roles imposed on males and females by society can significantly affect the expression of DA by causing both genders to express their fear and anxiety in different ways.11 In a field study, Russac et al12reported that DA increases with increasing age, while in our study, low DA was detected in the middle age group, while DA levels were found to be significantly higher in the young and older age groups. In this study, the mean DAS score of those in the middle-aged group (46-59 years) was significantly high. Although the DA levels of the married family members in this present study were higher than that of the singles, this difference was not statistically significant. There are also studies reporting that there is no correlation between marital status and DA level.13 In our study, no significant difference was found between the education level of the family members and the DAS score averages. It was found that DA decreased as the education level increased. In a study, similar to our findings, it was reported that DA decreased as the education level increased.14In our study, the DAS score average of individuals who did not work and did not have any income was significantly higher. Our study finding is consistent with Şahin and Demirkıran15study finding that lower income leads to higher DA levels. It was found that the mean DAS score of the individuals who had no previous experience with the loss of someone was higher. This result is consistent with the theory of Lester and Templer16who suggested that individuals who have no previous experience or have little experience associated with death would have a higher DA. Likewise, in the study by Florian and Mikulincer,17 it was reported that the DA levels of individuals who had recently lost their family members were significantly higher compared to those who have never experienced any loss or those who had many years passed over their loss.

Another study finding was that the mean score of the SWB scale of family members was high. İn this study, there was no statistically significant difference between the mean SWBS score and the gender of the family members. Consistent with the literature, Osarrodi et al18study on nurses and Rabow & Knish19 reported that there was no difference in SWB scores according to gender in their studies on cancer patients. On the other hand, SWB levels of females were reported to be significantly higher in the studies by Frost et al20and Lewis et al.21 These findings suggest that it may be due to the intercultural role differences that society imposes on gender. Spirituality has been reported to be used to provide hope in despair and anxiety in the literature.22In the studies by Tate and Forchheimer23and Peterman et al,24 it was reported that the SWB levels of elderly patients were higher. In the present study, the SWBS score was higher in the age group of above 60 years, however, no significant difference was found between the age groups. The mean SWBS score of the individuals who were married and had children was statistically significantly higher than that of the singles. Similarly, in the study by Ercan et al,25 it was reported that married individuals had a higher perception of SWB. According to these results, being married and having children can be considered important in terms of providing strong social support. In this present study, the mean SWBS score of the unemployed individuals was significantly higher than that of the employed ones. This result is considered due to the fact that 49.4% of the unemployed individuals were housewives and their mean SWBS score was higher than that of all participants.

On the other hand, the SWB level of employed individuals was found to be higher in a study by Amirmohamadi et al26 in cancer patients. The mean SWBS score of those without any income was significantly higher than that of the participants with minimum wage or a higher income. However, no effect of income status could be demonstrated on the mean score of SWBS in a study by Park and Cho.27On the other hand, a high-income level was found to be associated with a higher level of SWB in a study by Amirmohamadi et al26 in cancer patients. In this present study, the mean SWBS score of the individuals with a lower educational level was higher. Similarly, SWB levels of participants with a low educational level were found to be high in the study by Peterman et al.24The idea of losing a family member causes uncertainty, hopelessness, anxiety, and emotional, cognitive, and social stress in individuals.28The correlation between DAS and SWBS was analyzed. There was a positive, weak, and significant correlation between the scales (r=20; P<0.05). SWBS scores of the family members can be suggested to increase as DAS scores increase. In the study by Moetamedi et al29spirituality was found to create positive mental thinking, joy, and hope for reducing anxiety about death, as well as developing a sense of a purpose for living and self-efficacy in individuals. In line with these results, it is considered that family members adhere to spiritual emotions more to cope with increasing DA.


Conclusions and Recommendations

As a result, family members’ DA levels increase at the thought of losing their patient in intensive care. During this period, family members need spirituality more than ever to cope with increasing DA. In this study, a positive and significant relationship was found between family members’ DA levels and SWB levels. This finding is new and important in terms of developing health policies. It is thought that our study findings provide a perspective to the literature in terms of strengthening holistic care and integrating it into health policies.


Acknowledgements

The authors thank the family members of the patients who participated in this study.


Competing Interests

The authors report no actual or potential conflicts of interest.


Data Availability Statement

The datasets are available from the corresponding author on reasonable request.


Ethical Approval

The approval for our study was obtained from the Non-Interventional Research Ethics Committee of Dokuz Eylul University (Decision date: 27.09.2018, Decision No: 2018/23–27). All participants filled out written informed consent forms.


Research Highlights

What is the current knowledge?

  • DA is a stressful anxiety that needs to be dealt with.

  • Intensive care units are life-threatening, stressful care environments.

  • Being a family member is as difficult as being treated in intensive care.

  • Holistic care is important for family members.

What is new here?

  • The DA levels of patient family members increase with the thought of losing their patients in the ICU.

  • A positive correlation was found between the DA levels and SWB levels of the family members of patients in the ICU.

  • As family members’ DA increases, the need for spiritual support increases.

  • Regular communication and information should be provided to the family members of patients who have family members in the intensive care unit.

  • Holistic care should be provided to the patient and family.


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Submitted: 07 Jul 2023
Accepted: 12 Dec 2023
First published online: 05 Feb 2024
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