Attitude toward death and dying and resilience response among healthcare professionals in a tertiary care center, western Rajasthan, India

INTRODUCTION

Although society is known for being uncomfortable discussing death and dying in general, death is an inevitable component of life. Many caregivers feel somewhat burdened by the responsibilities involved in providing terminal care.^[1] This responsibility has many different aspects, such as handling medical duties, corresponding with providers, making decisions, and maybe preparing for the loss-related pain that lies ahead. In a similar vein, a large number of medical professionals from all specialties feel not ready to offer terminal care or speak with patients and relatives about the difficult subjects surrounding death and dying.^[2] They can explain this by pointing out that these subjects were either completely avoided or just briefly covered in formal education. This exercise goes over how to evaluate and manage death and dying as well as how interprofessional team members can work together to improve patient outcomes and provide well-coordinated care.^[3]

Palliative care in India was established in the 1980s, primarily in institutions.^[4] Before this movement, people in the end-of-life stages were cared for by family caregivers in traditional home care settings, according to their customs and rituals.^[5] However, in recent times, policymakers and various stakeholders have been setting benchmarks for the practice of palliative care, innovative models of care, training, and evidence-based guidelines for end-of-life care in India.^[6] According to the Annual Report on Vital Statistics of India based on CRS-2020, total deaths reported in India in the Year 2020 were 81,15,882, out of which 48,82,584 were male and 32,33,045 were female. About 57.7% of total deaths were from the rural population, and 42.3% were from the urban population. The total number of deaths in the State of Rajasthan in the year 2020 was 4,77,151 (5.88% of National deaths), out of which 61.5% were male and 38.5% were female.^[7]

Healthcare providers may also be impacted by the unexpected loss of their family members.^[8] Because they see these kinds of incidents regularly, nurses are more prone to experience suffering-related emotional, behavioral, or cognitive reactions, which are frequently manifested through secondary traumatic stress (STS) disorder.^[9] Furthermore, the healthcare providers who work in the palliative care area regularly see enough suffering for patients and their families, leading to elevated levels of stress and burnout. Therefore, identifying the means to alleviate the risk of developing stress and burnout among them is crucial.

Resilience in healthcare workers (HCWs) is vital for managing the stress and emotional demands of their profession, preventing burnout, and ensuring high-quality patient care.^[10] Enhancing resilience through training, supportive leadership, and mental health resources is essential for HCWs’ well-being and job performance. Burnout is a prevalent issue among medical professionals, but research on its impact on Palliative care clinicians is limited.^[11] It leads to medical errors, impaired decision-making, adverse events, and work dissatisfaction. It also affects patient compliance, trust, and care quality. Mitigating burnout risk is crucial. The area of studies that investigate interventions to prevent burnout and stress and promote resiliency among interdisciplinary palliative care teams is under-researched.^[12] Further studies are much needed to study the variables behind the phenomenon of burnout among interdisciplinary team members of palliative care (i.e., nurses, physicians, social workers, and physiotherapists) to understand the challenges and their coping mechanisms.

Therefore, the researcher felt the need to conduct a study that can assess the healthcare professionals’ attitudes toward the death and dying process in their institutional care while delivering end-of-life care. Understanding the caregiver’s attitude is important to address burnout, STS, and other psychological issues that can affect the performance of the care providers.^[13] The researcher also wanted to study the resilience level of professional care providers to gain insight into their grief management and meaning-making processes. The findings can address misconceptions about the end of life and suggest appropriate interventions to enhance the body of knowledge regarding the death process. Interventions regarding resilience and grief management can be suggested for HCWs.

The study can help researchers gain insight into the strain of caregivers and help in addressing the needs of health caregivers to an optimum level. There are abundant misperceptions among the public as well as the caregivers that can negatively affect the use of palliative care services.^[11] The misperceptions increase the burden and anxiety among the care providers of patients with life-limiting illnesses. To successfully deliver the available palliative care services, it is mandatory to provide the knowledge of the death and dying process to the patient, his family members, and the healthcare professionals as well.^[14]

MATERIALS AND METHODS

A cross-sectional study was conducted on 128 healthcare professionals (doctors, nurses, social workers, and physiotherapists) working in a tertiary care center in western Rajasthan, India. The respondents working in intensive care units (ICUs), emergency, palliative care, oncology and pediatrics departments were included in the study. A purposive sampling technique was used. After obtaining written informed consent, a self-reported questionnaire, which had two scales – Death Attitude Profile Revised (DAP-R) and Connor-Davidson Resilience Scale (CD-RISC-25) was administered. Respondents who were working in the departments mentioned above but not directly involved in patient care were excluded from the study. Both scales were translated into Hindi, back-translated to English and congruence was established.

DAP-R contains 32 items 7-point Likert scale was used to measure respondents’ attitudes toward death. The scale has five domains (a) fear of death (FD) measures the level of anxiety and fear an individual has about death, (b) death avoidance (DA) assesses the extent to which a person avoids thinking about or confronting death, (c) neutral acceptance (NA) reflects a person’s recognition of death as a natural part of life, neither fearing nor welcoming it, (d) approach acceptance (AA) indicates a positive outlook toward death, often tied to beliefs in an afterlife or a better existence post-death, and (e) escape acceptance (EA) measures the extent to which individuals see death as an escape from a painful or difficult life. The scale assesses both positive and negative attitudes, providing insights into psychological and emotional responses to mortality.^[15] Scores for all items were from 1 to 7 (Total score ranges from 32 to 224) in the direction of strongly disagree (1) to strongly agree (7). The DAP-R scale is widely used in research to understand how different attitudes toward death are associated with psychological outcomes, coping mechanisms, and behaviors. It can provide valuable insights into clinical settings, particularly in areas such as palliative care, mental health, and counseling.^[16]

CD-RISC-25 is a 25-item structured self-administered scale to measure resilience in participants. Each item is rated on a 5-point scale, ranging from 0 (“not true at all”) to 4 (“true nearly all the time”). The total score can range from 0 to 100, with higher scores indicating greater resilience. The scale’s psychometric properties have been well-established, demonstrating good reliability and validity across diverse populations and settings.^[17] The CD-RISC-25 is used in both clinical and research settings to assess resilience levels among various populations, including individuals experiencing stress, trauma, and mental health challenges.^[18]

The ethical clearance was obtained vide IEC certificate Reference Number AIIMS/IEC/2024/5090 dated April 16, 2024. Written permission was obtained from the concerned authority of the hospital for data collection. Individual informed consent was obtained from the participants by providing them with the participant information sheet in both Hindi and English.

Data were collected from the participants during May and June 2024. Data were analyzed with the IBM Statistical Package for the Social Sciences Statistics Version 27. The normality tests were done using the Kolmogorov–Smirnov test to ensure the normal distribution of the data. Descriptive analysis including frequency, proportion, mean, and standard deviation (SD) was computed. A Pearson correlation and univariate F-test were used to define the relationship among measured factors of death attitude and resilience along with demographic variables.

RESULTS

The demographic attributes of the participants [Table 1] presents that the sample predominantly consisted of relatively young healthcare professionals whose ages ranged from 23 to 49 years, with a mean age of 30 (4.1) years. The gender distribution reflected a higher proportion of males (64.6%) compared to females (35.4%). The healthcare professionals were grouped into two levels (a) doctors and (b) nurses and allied health workers (social workers and physiotherapists). The nurses and allied health care workers constitute most of the sample (57.5%). The majority of participants have between 1 and 10 years of total work experience, with a substantial proportion having relatively limited experience in palliative care (<1 year). This may impact their attitudes and resilience, as less experience could correlate with less exposure to end-of-life situations.^[19] Participants work across various hospital units, with the ICU, pediatric, oncology, and emergency units being the most common. These settings often involve high-stress situations and exposure to critical care and end-of-life issues, which may shape attitudes toward death and resilience.^[20] A notable proportion of the participants have not received formal training in palliative care (65.4%). Among those who have, the training types vary, with most having only brief or introductory courses. About one-third of participants have experienced the death of someone close within the past 6 months, and a smaller portion has been involved in caregiving at the time of death. These experiences can profoundly affect attitudes toward death and coping mechanisms.

The observed data from Table 2 revealed a moderate level of FD and avoidance behaviors, coupled with a high acceptance of death as a natural event. Regarding resilience, the scores across various domains suggest that while participants generally possess moderate resilience skills, areas such as optimism and adaptability show room for improvement. The variation in responses across both DAP-R and CD-RISC-25 domains highlights the participant group’s diverse attitudes and resilience capabilities.

Table 3 presents the Pearson correlation coefficients between the various domains of the DAP-R. These coefficients indicate the strength and direction of the relationships between different attitudes toward death. A moderate positive correlation (0.416) between FD and DA is observed, suggesting that individuals who are more fearful of death are also more likely to avoid thinking or talking about it, whereas there is a moderate negative correlation (−0.245) between FD and NA, indicating that those who have an NA of death tend to have lower levels of fear regarding death. FD was found to have a moderate positive correlation (0.278) with AA, showing that individuals who believe in a positive afterlife or view death as a transition tend to have higher levels of FD. The most notable correlations are between FD and both DA (0.416) and AA (0.278), indicating that FD significantly influences these attitudes. A moderate positive correlation (0.369) between AA and EA demonstrates that those who believe in a positive afterlife or see death as a transition are also more likely to view death as an escape from suffering or a positive transformation.

Table 3 also provides correlations between the DAP-R domains and the CD-RISC-25, a measure of resilience. There is a weak negative correlation (−0.155) between FD and resilience, suggesting that higher FD is slightly associated with lower resilience. This could indicate that individuals who are more fearful of death may struggle more with resilience in the face of challenges. There is a weak positive correlation, which is statistically significant (0.177), between NA and resilience. This suggests that individuals who accept death neutrally tend to have slightly higher resilience. It may imply that a balanced, neutral view of death can contribute to greater psychological strength and adaptability.^[21] The correlation is weak and negative, suggesting a slight tendency for individuals who view death as an escape from suffering to have lower resilience. This could reflect a potential link between viewing death as a means of escape and lower coping mechanisms or resilience. The overall correlations between the DAP-R domains and resilience (CD-RISC-25) are generally weak, indicating that while there are some associations, they are not particularly strong. This suggests that attitudes toward death are not major determinants of resilience but may still play a role.

Table 4 reflects that most domains of the DAP-R show no significant differences across age groups, indicating that attitudes toward death are relatively stable regardless of age. The only significant difference among the age groups is in the EA domain. Older participants (36 and above) have the highest mean score of 3.86 (1.1), suggesting a stronger tendency to view death as an escape from a painful existence. This could reflect differences in life experiences or perspectives on suffering and mortality. Female participants exhibit a significantly higher FD (3.97) compared to their counterpart males (3.27). This may reflect gender differences in emotional responses, cultural norms, or coping mechanisms related to death and dying. This also suggests that females may experience greater anxiety or concern about death. The lack of significant differences in other domains such as DA, NA, AA, and EA indicates similar attitudes toward these aspects of death between genders. The most notable finding is the significant difference in the FD domain, where doctors score higher than nurses and allied health workers. Doctors exhibit a significantly higher FD (3.80) compared to nurses and allied HW (3.31), indicating that doctors may have greater anxiety or concern related to death.

However, the CDRISC-25 scale measures the different aspects of resilience through its various domains as listed in Table 2, along with their mean scores and SDs, but the authors of the scale do not recommend the method of scoring according to subscales or domains.^[20] For the CD-RISC-25 in participants (n = 127), the mean score was 75.18 (13.11), with Q1, Q2, Q3, and Q4 being 0–67, 68–77, 78–84, and 85–100. The range between the 25^th percentile (67.00) and the 75^th percentile (84.00) provides a measure of the spread of the middle 50% of scores. This indicates that there is a moderate spread in resilience scores among the respondents. The majority of HCWs (47.2%) fall into the intermediate resilient category, suggesting a generally moderate level of resilience among the workforce. A significant portion, 29.1%, is in the least resilient category, indicating a need for targeted interventions to enhance their resilience and coping strategies.^[22] The highest resilient group, comprising 23.6% of the respondents, represents an asset in the healthcare setting, likely contributing positively to team dynamics and patient care.

Table 4 indicates that there are no meaningful differences in resilience scores across different age groups and both genders. The F value of 9.391 with p = 0.003 indicates a statistically significant difference in resilience scores between different occupational groups. The results suggest that nurses and allied health workers have significantly higher mean resilience scores which are 78.99 (SD = 11.2) compared to doctors whose mean score is 70.04 (SD = 13.8). The difference in mean scores indicates that the occupational role may influence the resilience levels of healthcare professionals, possibly due to differences in job responsibilities, work environment, or coping strategies employed by these groups.

DISCUSSION

The mean age of the sample was 30 ± 4.1 years, which suggests that it is a relatively young population and the majority of domains in the DAP-R do not show significant differences across age groups, suggesting that attitudes toward death remain relatively stable regardless of age. The older participants have a stronger tendency to view death as an escape from a painful existence. This finding may reflect differences in life experiences or perspectives on suffering and mortality. Older individuals may be more inclined to see death as a release from suffering, possibly due to increased exposure to life challenges or health issues. Females exhibited a higher FD compared to males, likely due to various factors. Cultural and social conditioning often emphasize caregiving roles for women, making them more sensitive to death’s impact.^[23] Women are generally more encouraged to express emotions, leading to higher reported fears. Perceived vulnerability and different health-related anxieties also contribute to this heightened fear. In addition, inherent psychological differences may influence how fear and anxiety about death are experienced and reported by women.^[24]

Nurses and allied health workers (social workers and physiotherapists) expressed less FD due to frequent exposure to end-of-life care, training in palliative care, and a supportive team environment. Their roles often emphasize comfort and acceptance, fostering a more positive attitude toward death. These factors collectively reduce their FD compared to doctors. Further analysis could explore why doctors have a higher FD, potentially considering factors such as specific medical responsibilities, patient outcomes, or personal beliefs. In addition, qualitative data could provide deeper insights into these attitudes and their implications for healthcare practice. A significant number of the participants (65.4%) have not undergone formal training in palliative care. Among those who have, most have only brief or introductory courses. Approximately one-third of the participants have recently experienced the death of someone close in the past 6 months, and a smaller portion have been involved in caregiving at the time of death. These experiences can significantly impact attitudes toward death and coping mechanisms.

The study population comprises individuals with varied origins and varying degrees of palliative care experience, which may account for variations in attitudes toward death as indicated by the DAP-R categories.^[25] Other things to think about are looking into cultural, social, or psychological aspects that could lead to a greater fear of dying in women; designing supportive interventions to meet the unique needs of various gender groups in the healthcare setting, especially end-of-life care and emotional support;^[26] and examining how attitudes influence professional behavior, decision-making, and patient interactions, with implications for educators and healthcare professionals. Subsequent qualitative investigations may be conducted to investigate the causes of the greater acceptability of flight among the elderly population, considering variables such as life satisfaction, health, and existential beliefs.^[27] This highlights the importance of taking occupational role-specific factors into account when discussing resilience in healthcare settings. It may be necessary to provide tailored interventions and support systems to improve resilience across various professional groups, especially for doctors who exhibit lower resilience scores in this study. While a significant number of HCWs have moderate to high resilience, targeted interventions may be required to help those with lower resilience improve their ability to manage stress and maintain well-being in demanding healthcare environments.^[28] The highest resilience level, 85 or higher, is represented by 23.6% of participants, indicating a smaller group with strong resilience. This suggests the importance of considering both professional roles and personal experiences in understanding and supporting resilience among HCWs.^[29] The limitations of the study involve its focus on a single center, reliance on self-reported data that may introduce bias, and a cross-sectional design that restricts causal inferences. It concentrated specifically on attitudes toward death and resilience, leaving out other relevant factors. Besides, cultural sensitivity and language interpretation challenges could have impacted responses, thereby affecting the reliability and broader applicability of the results.

CONCLUSION

Since occupation and cumulative experiences have an impact on resilience, healthcare organizations may create specially designed programs to help physicians and others who have experienced considerable loss and caring feel more resilient. Future programs might include gender-specific therapies targeted at lowering anxiety associated with mortality and enhancing coping strategies, given the higher recorded FD among women. Training programs for palliative care providers should be improved to better meet the unique psychological and emotional needs of healthcare professionals. This could lessen workers’ fear of dying and increase their general resilience. Further multi-centric, longitudinal, and qualitative research should explore the psychological, social, and cultural factors that affect resilience and attitudes toward death. Including variables such as coping styles, burnout, and institutional support can enhance understanding. Intervention-based and comparative studies across healthcare roles can help create targeted strategies to improve resilience and attitudes toward dying. The results may have an impact on healthcare institutions’ policies by highlighting the necessity of continual training, occupationally specific interventions, and comprehensive mental health assistance to retain a resilient workforce. The goal of these results is to improve patient care and the personal and professional well-being of healthcare professionals by fostering a more supportive work environment.