Exploring Death Anxiety and Burnout

Among Staff Members Who Work Continuing Nursing

Education

In Outpatient Hemodialysis Units

Valerie L. Lee
Anita H. King

he outpatient hemodialysis

T
Copyright 2014 American Nephrology Nurses’ Association
(HD) unit is a fast-paced, tech-
nological environment that Lee, V.L., & King, A.H. (2014). Exploring death anxiety and burnout among staff mem-
requires healthcare workers to bers who work in outpatient hemodialysis units. Nephrology Nursing Journal, 41(5), 479-
receive special training for the devel- 485, 518.
opment of a unique set of skills.
Patients who receive HD treatments Outpatient hemodialysis unit staff members are at risk for psychological stress, including
have been diagnosed with end stage death anxiety, unresolved grieving, and burnout, due to frequent interactions with chron-
renal disease (ESRD), are in a pro- ically ill patients who have a high mortality rate. Experiencing death anxiety and
gressively declining state of health, burnout may impair the ability to build interpersonal relationships, decrease job satis-
and have an average life expectancy faction, and impact quality of patient care. A quantitative study to evaluate the effect of
of 6.2 years (United States Renal Data educational classes on the level of death anxiety and burnout among hemodialysis care-
System [USRDS], 2013). Registered givers revealed a decrease in participants’ level of death anxiety and a decrease in emo-
nurses, patient care technicians, social tional exhaustion in one area that was directly related to the work environment.
workers, dietitians, and other staff Information from the study can be used to decrease psychological stress through educa-
members who work in HD units and tion and support for staff members who work in the hemodialysis unit environment.
provide life-supporting treatments
Key Words: Death anxiety, burnout, unresolved grieving, hemodialysis, end-of-
three to four times per week over a life care.
period of months or years often
develop close relationships with their Goal
patients. The intensity of work To provide an overview of the impact unresolved psychological stress, primarily death
required to prolong life in this patient anxiety and burnout, has on nephrology nurses and other staff members working in out-
population can cause frustration, patient hemodialysis units.
moral distress, compassion fatigue,
depression, and burnout in caregivers Objectives
1. Explore the effect of an educational intervention on the level of death anxiety and
burnout in caregivers who work in the outpatient HD environment.
Valerie L. Lee, DNP, MSN, FNP-C, is a 2. Discuss the benefits to nurses and other dialysis staff of receiving education
Doctor of Nursing Practice, St. Luke’s Clinic, about the life expectancy and complicated health issues of patients with ESRD.
Nephrology, Boise, ID, and has served as
President-Elect and President of ANNA’s
Sawtooth Chapter. She may be contacted directly working in outpatient hemodialysis whom they have had frequent interac-
via email at jLeeElec@aol.com tion in meaningful relationships. Job
units (Ashker, Penprase, & Salman,
Anita H. King, DNP, MA, FNP-BC, CDE, 2012; Dermody & Bennett, 2008; stress, emotional exhaustion, and cyn-
FAADE, is a Clinical Associate Professor, College Hayes & Bonner, 2010). The high icism can lead to job dissatisfaction,
of Nursing University of South Alabama, patient death rate can lead to unre- absenteeism, and a high rate of turn-
Fairhope, AL. solved grieving (Gerow et al., 2010) over among caregivers working in
Acknowledgements: Thank you to Dr. Micheal and death anxiety in caregivers who hemodialysis units (Flynn, Thomas-
Adcox for his clinical guidance through this proj- experience the loss of people with Hawkins, & Clarke, 2009; Hayes &
ect; to Dana Camacho, MBA, BSN, Group
Facility Administrator, for her assistance with
data collection; and to Richard Remington, MS, This offering for 1.4 contact hours is provided by the American Nephrology Nurses’
for his assistance with statistical analysis.
Association (ANNA).
Statement of Disclosure: The authors reported American Nephrology Nurses’ Association is accredited as a provider of continuing nursing
no actual or potential conflict of interest in rela- education by the American Nurses Credentialing Center Commission on Accreditation.
tion to this continuing nursing education activity.
ANNA is a provider approved by the California Board of Registered Nursing, provider number
Note: Additional statements of disclosure and CEP 00910.
instructions for CNE evaluation can be found on This CNE article meets the Nephrology Nursing Certification Commission’s (NNCC’s) continu-
page 486.
ing nursing education requirements for certification and recertification.

Nephrology Nursing Journal September-October 2014 Vol. 41, No. 5 479

Exploring Death Anxiety and Burnout among Staff Members Who Work in Outpatient Hemodialysis Units

Bonner, 2010; O’Brien, 2011; Wolfe, process, also known as death anxiety, Carpenter, and Bender (1992) found
2011). Staff turnover due to unre- can prevent a therapeutic interaction high levels of both work-related anxi-
solved psychological stress can affect between patients and caregivers and ety and death anxiety among care
the efficiency and morale of the HD can hinder the delivery of quality HD assistants who provided EOL care to
care team, and can lead to low quality and EOL care (Deffner & Bell, 2005, residents in extended care facilities. A
care, poor patient outcomes, Lehto & Stein, 2009). Nurses, patient study by Deffner and Bell (2005)
and decreased patient satisfaction care technicians, and other dialysis revealed that nurses who experienced
(Argentero, Dell’Olivo, & Ferretti, staff members who have not received a high level of death anxiety felt less
2008; Hayes & Bonner, 2010). This formal education about death, dying, comfortable communicating with
quantitative study was designed to or the grieving process may not feel patients and their families about
explore the effect of an educational qualified or confident enough to initi- death. A literature review of the con-
intervention on the level of death ate or participate in discussions about cept of death anxiety by Lehto and
anxiety and burnout in caregivers EOL preferences with patients who Stein (2009) emphasized that nurses
who work in the outpatient HD envi- are in a declining state of health are in a critical position to influence
ronment. (Hopkins et al., 2011). Providing edu- the level of death anxiety in individu-
cation and support can help these als who are nearing the EOL. These
important caregivers cope with death, influential caregivers may be reluc-
Defining the Concepts of Death
dying, personal loss, and the grieving tant or unable to interact with patients
Anxiety and Burnout
process while providing care to a pro- in a therapeutic manner if they are
Caregivers who experience death gressively ill patient population. personally experiencing a high level
anxiety have anxious thoughts or feel- of death anxiety. A study by Peterson
ings when thinking about or talking et al. (2010b) revealed that many
Literature Review
about death and/or the dying process, nurses and nursing students had a
or when interacting with someone In preparation for the study, a personal fear of death and experi-
who is dying (Lehto & Stein, 2009; comprehensive search for evidence enced an increased level of stress
Mallet, Jurs, Price, & Slenker, 1991; was performed. Studies of healthcare when providing care to dying patients
Tomer, 1994). These uncomfortable workers were reviewed that explored and their families. A study of nurses
thoughts or feelings may be due to the 1) the presence of death anxiety while who worked in the nephrology field
avoidance of discussions about death providing care to patients who are by Ho, Barbero, Hidalgo, and Camps
and dying in the American culture nearing the EOL, 2) the presence of (2010) revealed that a majority of
(Nyatanga & deVocht, 2006). With burnout while providing care to these caregivers found EOL care to
the focus of medical care in the patients who are receiving HD treat- be an emotionally demanding part of
United States primarily on prolong- ments, 3) the relationship between the their job. The nurses felt that special
ing life and avoiding death, many presence of death anxiety and the training was needed to communicate
nurses and physicians feel inade- presence of burnout, and 4) the influ- effectively, provide psychological
quately trained to provide high quali- ence of education on levels of anxi- support, and comfortably discuss
ty end-of-life (EOL) care or to com- ety, exhaustion, helplessness, job sat- EOL issues with patients and family
municate effectively with a patient isfaction, and patient care quality members. The study also revealed
who is dying (Billings, Engelberg, indicators. Several databases were that nurses who had an opportunity
Curtis, Block, & Sullivan, 2010; searched, including Clinical Evi- to verbalize their feelings with sup-
Peterson et al., 2010a; Schell, Green, dence, Cochrane Library, the portive peers had a more positive atti-
Tulksy, & Arnold, 2013; White & Cumulated Index of Nursing and tude toward providing care to dying
Coyne, 2011). Allied Health Literature (CINAHL), patients.
According to Maslach, Schaufeli, DynaMed, Google Scholar, Medline
and Leiter (2001), caregivers who are at Ovid, Nursing Reference Center, Burnout in Healthcare
experiencing burnout feel emotional- PubMed, and SCOPUS. Workers
ly exhausted, are indifferent or cyni- Many factors in the outpatient
cal toward the needs of other people, Death Anxiety in Healthcare HD unit environment contribute to
and have decreased satisfaction with Workers the level of psychological stress and
personal accomplishments. They are Providing care to patients who burnout in healthcare workers. Hayes
often inefficient in performing occu- are in a declining state of health in- and Bonner (2010) reviewed nine
pational tasks. They may also have a creases feelings of anxiety in health- international studies exploring the
high rate of absenteeism and fre- care workers. Mallet et al. (1991) stud- relationship between stress, burnout,
quently express intent to leave their ied hospice and critical care nurses and job satisfaction in nurses working
jobs. and discovered a positive relationship in the HD environment. They found
The presence of burnout and/or between emotional stress, death anxi- several environmental factors that
the fear of a patient’s death or dying ety, and burnout. Robbins, Lloyd, contributed to caregiver stress and

480 Nephrology Nursing Journal September-October 2014 Vol. 41, No. 5

burnout, including 1) difficult inter- revealed these caregivers had high Patient Satisfaction and Care
personal relationships with physi- levels of emotional exhaustion and Outcomes
cians; 2) care environment chal- cynicism. The authors suggested that a Healthcare workers who are sat-
lenges, such as risk of exposure to negative work environment that isfied with their job responsibilities
bloodborne pathogens and becoming lacked support, resources, opportuni- and work environment are less likely
emotionally attached to patients who ties, and empowerment for nurses to experience burnout and are better
have a progressive decline in health may have contributed to the high lev- equipped to provide high quality
and who eventually die; 3) exposure els of emotional exhaustion found in patient care. In addition, patients are
to violence and abuse from patients; the study. A significant association was more satisfied with the care they
and 4) organizational stressors, such found between these burnout in- receive from healthcare workers who
as workload, inadequate staffing, lim- dicators and adverse physical and/or have a positive attitude toward their
ited access to educational opportuni- mental health symptoms, and with the jobs. Gardner, Thomas-Hawkins,
ties, lack of time for meals, and lack of nurses’ intent to resign from their jobs. Fogg, and Latham (2007) found an
time for adequately meeting patient O’Brien (2011) surveyed nurses work- increase in the number of hospitaliza-
needs. A study of nurses working in ing in outpatient HD units and found tions in patients receiving HD treat-
outpatient HD units by Gardner and 33% of participants reported a high ments in facilities where staff nurse
Walton (2011) revealed that nurses level of burnout, and 27.5% of partici- turnover was high and where nurses
felt 1) isolated due to working in a dis- pants reported a moderate level of gave a negative rating of the dialysis
jointed and ineffective healthcare sys- burnout. A study of registered nurses work environment. A study by
tem, 2) overwhelmed by a stressful working in HD facilities by Flynn et Argentero et al. (2008) revealed that
work environment, 3) disrespected as al. (2009) revealed that 31% of the patient satisfaction scores on the qual-
nursing professionals by administra- nurses had scores indicative of emo- ity of dialysis care received increased
tion and medical providers, and 4) tional exhaustion, and 19.3% of the when nurses and physicians who
disconnected from their own personal nurses were planning to leave their worked in the dialysis units had low
expectations of what they felt they current position within the next 12 emotional exhaustion levels and high
should be as a nurse. months. personal accomplishment levels.
Personal characteristics of health- McHugh, Kutney-Lee, Cimiotti,
care workers also contribute to psy- Providing End-of-Life Sloane, and Aiken (2011) found low
chological stress and burnout. Education to Healthcare patient satisfaction scores in hospital
Bohmert, Kuhnert, and Nienhaus Workers units where nurses were dissatisfied
(2011) evaluated 19 international Providing education can improve with their job environment and
studies and one literature review. the comfort and skill levels of health reported a high level of emotional
They found higher levels of burnout caregivers and can improve the qual- exhaustion.
were present if a dialysis unit health- ity of care provided to patients who
care worker was 1) an unmarried are in a declining state of health.
male, 2) had limited opportunity to Mallory (2003) found that providing a Study Methodology
perform administrative or education- six-week interactive palliative educa-
al tasks, 3) worked more than 40 tion course to undergraduate nursing Design and Description
hours per week, 4) had a work history students decreased feelings of death Of Sample
of more than 10 years in dialysis units, anxiety, helplessness, and emotional A quantitative study was design-
5) worked in a unit with more than 50 exhaustion. The course was also ed using convenience sampling. Two
patients, or 6) worked with more than found to improve the participants’ self-report instruments were used for
11 staff members. A study of clinical attitude toward caring for people who collection of pre and post-interven-
and non-clinical HD unit staff mem- are dying when post-education scores tion data. Institutional Review Board
bers by Ross, Jones, Callaghan, Eales, were compared with a control group approval for the study was obtained
and Ashman (2009) revealed that who did not receive the education. A from a southeastern university. Ap-
16% of the participants described study of healthcare professionals and proval was also obtained from the
symptoms of psychological distress, undergraduate medical students by dialysis corporation clinical research
such as depression, inability to cope, Hegedus, Zana, and Szabo (2008) team prior to initiation. A project plan
anxiety-based insomnia, and low self- revealed a decrease in death anxiety proposal was submitted to the region-
esteem. and fear of death scores after partici- al director, facility administrators, and
Nurses who work in HD units pants received a 40-hour course on the medical director for review prior
have been found to have a high level effective communication, stress man- to initiation of the study. Face-to-face
of burnout. A study of nurses working agement techniques, palliative care discussions and letters describing the
in the nephrology field by Harwood, treatments, and clinical management study and inviting participation were
Ridley, Wilson, and Laschinger (2010) of EOL situations. distributed to HD unit staff members
during the recruitment process. Parti-

Nephrology Nursing Journal September-October 2014 Vol. 41, No. 5 481

Exploring Death Anxiety and Burnout among Staff Members Who Work in Outpatient Hemodialysis Units

cipants were recruited from five out- Data Collection death anxiety, and a score of 8 per
patient HD units within a 60-mile Two pre- and post-intervention participant or 88 for all participants in
radius in southwestern Idaho and instruments were used to promote each category is the lowest possible
eastern Oregon. All dialysis units self-introspection and measure the number or level of death anxiety. A
were owned by a single dialysis cor- effects of the educational intervention paired t-test was used for each ques-
poration. Two HD units were located on the participants’ level of death tion in the four subscales on the
in a suburban area, and three HD anxiety and burnout. The Revised RCFDS and for each of the 16 ques-
units were located in small rural com- Collett-Lester Fear of Death and tions on the MBI to evaluate for a sig-
munities. Dying Scale [RCFDS] (Lester, 1994) nificant difference between the pre-
is a 32-item, five-point Likert scale and post-intervention scores.
Participants instrument that measures feelings
Forty-eight staff members from about the participant’s own death and Results
five HD units received information dying process, and the death and
and were eligible to participate in the dying process of other people. All participants were female. The
study. A total of 15 caregivers from Maslach’s Burnout Inventory [MBI] participants’ age ranged from 23
three of the HD units participated in (Maslach, Jackson, & Leiter, 1996) is a years to over 66 years, with the largest
some or all of the classes. Four of the 16-item, seven-point Likert scale percentage between 36 and 55 years
15 participants missed the last class, instrument that measures emotional (see Table 1). The level of education
did not complete post-intervention exhaustion, cynicism, and satisfaction ranged from a high school diploma to
instruments, and were not included in with personal accomplishments. The a bachelor’s degree. Three partici-
the study. subscales in the MBI provide a three- pants had previously taken a course
dimensional overview of characteris- on death and dying, five participants
Description of Educational tics of burnout. The general survey had been exposed to information
Intervention scale used was designed to measure about death and dying in college
The educational intervention participants’ level of burnout in direct courses, and three participants had
consisted of a series of four interactive relationship with their work. The never received education about death
classes that were presented once per questions address the level of engage- and dying (see Table 1). Participants
week in each of the three participat- ment and energy being directed included six registered nurses, one
ing HD units. Classes were presented toward work performance and the licensed practical nurse, two patient
for two hours in the late afternoon or level of confidence in participants’ care technicians, one dietitian, and
evening in the conference room of effectiveness at work. High scores on one patient care services assistant.
the HD facility. The class atmosphere the exhaustion and cynicism sub- Average scores from all partici-
was informal, with participants seated scales reflect a high degree of pants on the RCFDS indicated a
in a round-table format. Dinner was burnout. A low score on the satisfac- decrease in death anxiety in all four
served during each class. Staff mem- tion with personal accomplishments subcategories (see Figure 1 and Table
bers received no compensation for scale also reflects a high degree of 2). The average score for all partici-
participating. burnout. Question number five on pants in the subscale Anxiety Over
The class content was designed to the Emotional Exhaustion subscale, Your Own Death was 21.3 pre-inter-
include 1) a review of renal patholo- “I feel burned out from my work,” (p. vention and 18.2 post-intervention; in
gy, 2) a discussion of the concepts and 10), was determined by Maslach et al. the subscale Anxiety Over Your Own
symptoms of death anxiety and (1996) to be the strongest indicator of Dying was 29.4 pre-intervention and
burnout, 3) an exploration of the burnout. Identifying numbers rather 26.7 post-intervention; in the subscale
process of grieving, 4) a discussion of than names were used on measure- Anxiety Over The Death Of Others
effective coping and self-care prac- ment instruments to protect anonymi- was 24.2 pre-intervention and 22.6
tices, 5) a review of EOL legislation ty and promote honest disclosure. post-intervention; and in the subscale
and advance directive forms, and 6) a Anxiety Over The Dying Of Others
review of ways to participate in dis- Data Analysis was 24.6 pre-intervention and 20.9
cussions about EOL preferences with Statistical analysis was performed post-intervention. None of the mean
patients and family members. The on the pre- and post-intervention differences in each category was
final class allowed time for honoring instruments. The measurement of found to differ significantly from zero.
and sharing memories of patients death anxiety on the RCFDS is deter- The analysis of the MBI revealed a
who had made an impact on each mined by numerical calculations. The significant decrease in the mean score
participant’s life. Participants shared level of death anxiety in each of the (-0.36) on question number five of the
endearing characteristics and the life four subscales is determined by the emotional exhaustion subscale, “I feel
lessons they learned while interacting total number. A score of 40 per partic- burned out from my work” (Maslach
with these special patients. ipant or 444 for all participants is the et al., 1996, p. 10), after the education-
highest possible number or level of al intervention, with a 95% confi-

482 Nephrology Nursing Journal September-October 2014 Vol. 41, No. 5

 Table 1
Participants’ Age and Previous Exposure to Education on Death and Dying (n = 11)

Participant 1 2 3 4 5 6 7 8 9 10 11
Age
18 to 35 X
36 to 45 X X X
46 to 55 X X X X X
56 to 65 X
66 to 75 X
Exposure to Education on Death and Dying
No death/dying education X X X
Some death/dying education in college courses X X X X X
Took a course on death/dying X X X

Figure 1 dence interval of -0.70 to -0.025, and

Pre- and Post-Intervention Results from the Revised Collette-Lester a p-value of 0.04. The mean scores of
Fear of Death and Dying Scale (n = 11) all other questions in the three sub-
scales were not found to be significant
44 (see Table 3).
During the fourth class, time was
allowed for participants to share
38 memories and feelings about patients
Pre who had died. Rituals that had been
Post used to honor patients in the busy
32 hemodialysis unit environment were
29.4 discussed. One HD unit care team
26 honored a patient who had died at
26.7
24.5 home earlier in the day by placing a
24.2 rose in the chair during the time the
22.5
20 21.3 20.9 patient was scheduled to receive treat-
18.2 ment. The ritual could not be contin-
14 ued for other patients due to
decreased unit productivity when
chairs are left empty. One HD unit
8 placed a memory board with names
Own Death Own Dying Others' Death Others’ Dying of patients who had died during the
month near the entrance where it
Note: Potential range for score = 8 to 40. With 40 being the highest level of death could easily be seen by patients and
anxiety. HD unit staff members. Concern was
expressed that this reminder may
Table 2 have caused patients to experience
fear that they could be the next per-
Pre- and Post-Intervention Results from the Revised Collette-Lester
son on the unit to die, or may have
Fear of Death and Dying Scale Paired t-test Evaluation (n = 11) caused increased feelings of sadness
or depression among HD unit care-
95% Confidence Mean of the
Subscale Paired t-Test Interval p-Value Differences givers. Several participants expressed
an interest in attending a memorial
Your Own Death t = -1.97 -6.385 to 0.385 0.08 -3.0 service on a quarterly or semi-annual
Your Own Dying t = -1.20 -7.28 to 2.19 0.26 -2.545 basis to allow time for patients to be
The Death of Others t = -1.09 -4.985 to 1.71 0.30 -1.64
remembered and for staff members to
share feelings.
The Dying of Others t = -0.495 -5.00 to 3.18 0.63 -0.91

Nephrology Nursing Journal September-October 2014 Vol. 41, No. 5 483

Exploring Death Anxiety and Burnout among Staff Members Who Work in Outpatient Hemodialysis Units

Table 3 intervention results. The level of

Pre- and Post-Intervention Results from the Maslach Burnout death anxiety and burnout were
Inventory Paired t-test Evaluation (N = 11) measured from self-report instru-
ments. Some participants may have
95% Confidence Mean of the felt uncomfortable answering ques-
Question t-Test Interval p-Value Differences tions that targeted sensitive issues.
Emotional Exhaustion Subscale
Implications for Nursing
#1 t = 0.0 -1.04 to 1.04 1.0 0.0 Practice
#2 t = -0.80 -0.69 to 0.32 0.44 -0.18 Many dialysis caregivers do not
#3 t = 0.50 -0.93 to 1.48 0.625 0.27 receive education about the life
expectancy and complicated health
#4 t = 1.00 -0.67 to 1.76 0.34 0.545 issues of patients who have been diag-
#5 t = -2.39 -0.70 to 0.02 0.04 -0.36 nosed with ESRD when they are
Cynicism Subscale hired to work in outpatient HD units.
End-of-life education is not a routine
#1 t = -1.0 -1.17 to 0. 45 0.34 -0.36 part of classes provided during the
#2 t = 0.29 -0.61 to 0.79 0.78 0.09 orientation process. This leaves care-
#3 t = 0.39 -0.85 to 1.21 0.70 0.18 givers unprepared for the high num-
ber of patient losses that can occur
#4 t = -0.34 -2.07 to 1.53 0.74 -0.27 annually. The intense, time-coordi-
#5 t = 0.58 -0.77 to 1.31 0.57 0.27 nated, outpatient HD unit environ-
Satisfaction with Personal Accomplishment Subscale ment does not allow time for staff
members to acknowledge and grieve
#1 t = -1.49 -1.36 to 0.27 0.17 -0.545
the loss of one patient before another
#2 t = 0.61 -0.73 to 1.27 0.55 0.27 patient is scheduled to receive treat-
#3 t = -1.49 -0.91 to 0.18 0.17 -0.36 ment in their place. Keeping the treat-
ments on schedule for multiple shifts
#4 t = -0.52 -0.97 to 0.60 0.62 -0.18
allows little time for staff members to
#5 t = -0.20 -0.11 to 0.925 0.85 -0.09 share personal feelings or to receive
#6 t = -0.52 -0.97 to 0.60 0.62 -0.18 emotional support.
The results of this study suggest
that providing an educational inter-
vention that addresses death anxiety,
Discussion of emotional exhaustion and burnout burnout, unresolved grieving, self-
in the primary question “I feel burned care practices, and EOL care can
The post-intervention decrease in out from my work” (Maslach et al., decrease the level of death anxiety in
participants’ level of death anxiety on 1996, p. 10). A decrease in the level of dialysis caregivers and can decrease
all subscales may be due to the oppor- death anxiety did not correlate with a dialysis caregivers’ level of emotional
tunity provided to explore concepts significant improvement in 15 of the exhaustion related to the work envi-
and emotions related to death and the 16 other questions on the MBI. ronment. Providing education and
dying process. The post-intervention support to these important staff mem-
decrease in the level of burnout on Limitations bers may also improve the quality of
question five of the MBI, the most Due to the small sample size and care that is provided to patients in
direct question on the emotional small number of HD units involved in outpatient HD units.
exhaustion subscale, may be related to the study, results may not be general- Providing EOL education during
participants’ improved understanding izable to other units. Scheduling of the new staff orientation process or
of the characteristics of burnout and classes in the late afternoon or evening during an annual education session
the ability to identify these character- after the HD unit was closed may would prepare HD caregivers to
istics during a time of self-introspec- explain the low participation rate. emotionally and physically meet the
tion. Changes were also identified in Offering the classes in a one-day sem- needs of the chronic, progressively ill
other questions in the three subscales inar may lead to improved participa- patient population that they serve.
but were not found to be statistically tion, but this format would not allow Scheduling periodic memorial servic-
significant. In this small study, a reflection on content between ses- es would provide an opportunity for
decrease in the participants’ level of sions. Some participants missed all or caregivers to share feelings and mem-
death anxiety correlated with a signif- a portion of a class, and missed con- ories. These services could also pro-
icant decrease in the participant’s level tent may have had an effect on post- vide an opportunity for team building

484 Nephrology Nursing Journal September-October 2014 Vol. 41, No. 5

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