Exploring the relationship between death anxiety and empathy among nursing students at an early stage of their clinical internships

Abstract

BACKGROUND

Death anxiety is a common emotional response to death, and it varies in intensity across cultures and regions. However, there is a paucity of research on death anxiety among nursing students during their clinical internship, especially in relation to their emotional experiences and behavioral responses.

AIM

To explore the relationship between empathy and death anxiety as well as to identify factors influencing students’ empathetic skills during their initial clinical experiences.

METHODS

This cross-sectional study included 473 nursing students enrolled from across vocational colleges in Quanzhou (Fujian Province, China) during June–July 2023. These students were trained at three Grade-A general hospitals. The Empathy Scale and Death Anxiety Scale were applied to assess their empathetic skills and death anxiety levels during the early stages of the clinical internship. Data analyses employed descriptive statistics, correlation analyses, independent sample t-tests, one-way analysis of variance, and multiple linear regression analysis.

RESULTS

The mean death anxiety score was 46.33 ± 6.29, with 95.6% of participants exhibiting high death anxiety. The mean scores across dimensions were as follows: Cognitive-affective, 18.08 ± 3.15; pain and illness, 13.25 ± 2.41; awareness of the passage of time, 5.58 ± 1.40; stimuli related to death, 9.40 ± 1.56. The mean empathy score was 63.78 ± 11.49. Regression analysis revealed that students’ subject major, total death anxiety level, and pain and stress dimensions acted as significant predictors of their empathetic skills during early clinical practice (P < 0.05).

CONCLUSION

Vocational nursing students, especially those in midwifery with higher death anxiety, exhibited lower empathetic skills during the early stages of their clinical internship. Nursing educators should take measures to enhance the empathetic skills of students through appropriate training and support for students with high death anxiety levels.

Key Words: Early-stages; Clinical internships; Nursing students; Empathy; Death anxiety

Core Tip: This study examined death anxiety as an internal psychological response and empathy as an external behavioral expression. The results provided a clearer understanding of the psychological changes occurring in nursing students during the early stages of their clinical training.

INTRODUCTION

Internship is a critical stage in the career development of nursing students, bridging the gap between education and professional practice. This period plays a significant role in shaping students’ career habits and professional identity[1]. Consequently, it has garnered considerable attention from scholars, particularly because professional identity plays a crucial role in determining students’ long-term career trajectories in nursing[2]. Research indicates that professional identity among nursing students can be reflected through their expression of empathy[3,4]. Empathy refers to the ability to consider patients’ perspectives, understand their situations, and share their feelings. High empathy levels are positively correlated with improved nursing quality[5]. Research has indicated that both external environmental factors and internal psychological factors shape the empathy levels among nursing students[6,7]. Nevertheless, there is a paucity of research exploring internal psychological factors, especially during the internship phase.

Moreover, research has shown that nursing students often encounter emotional challenges, such as anxiety and fear, during clinical practice, which can significantly influence their clinical performance[8]. Death anxiety, a negative emotional response triggered by the prospect of death, is a notable example. Despite its potential impact, the influence of death anxiety on the empathy and professional identity of nursing students during the early stages of their internship is not well characterized.

Therefore, this study explored the interrelationships between death anxiety, empathy, and professional identity among nursing students during the early phase of their internship. By examining death anxiety as an internal psychological factor, the study aims to provide a theoretical basis for nursing education administrators to develop early intervention and management strategies. These strategies can foster empathy development and fortify professional identity among nursing students, ultimately enhancing their overall professional growth.

MATERIALS AND METHODS

Study design

This was a cross-sectional study of a convenience sample of 473 nursing students enrolled from higher vocational colleges between June and July 2023. Participants were undergoing clinical practice at three Grade-A general hospitals in Quanzhou, Fujian Province. The inclusion criteria were as follows: (1) Full-time enrollment in a higher vocational medical college, having passed the college entrance examination; (2) Specialization in nursing or midwifery; (3) Clinical practice experience of at least 1 month but no more than 3 months during the investigation period; and (4) Willingness to participate and complete the questionnaire survey. The exclusion criteria consisted of prior formal clinical practice experience, absence due to illness or leave during the survey period that resulted in less than 1 month of clinical practice, and students who had applied for, suspended, or withdrawn from their studies during the survey period.

Sample size calculation

This study considered demographic information and 18 independent variables. Using the Kendall sample estimation method[9], the recommended sample size was 5–10 times the number of independent variables, yielding an estimated sample size of 98-216 cases after factoring a 20% attrition.

Measures

Demographic data: Demographic data were collected to identify factors influencing nursing students’ empathy and death anxiety. The demographic characteristics assessed included basic information (e.g., gender, ethnicity, and religion), family-related factors (e.g., parents’ health status), and the extent of understanding regarding death education courses, as informed by relevant literature.

Empathy scale for nursing students: The Chinese version of the Jefferson Empathy Scale for Nursing Students, translated by Qiu ZJ, was used to assess empathy levels among nursing students. This 20-item scale is organized into three key dimensions: Attitude choice, empathic care, and being in patients’ shoes. Each item is rated on a 7-point Likert scale, with higher scores indicating greater empathy. The total score provides an overall measure of empathy. The scale has demonstrated strong reliability (Cronbach’s α = 0.836) and validity, making it suitable for this study[10].

Death anxiety scale: The Chinese version of the Death Anxiety Scale, developed by Templer DI and translated by Yang H, was employed to assess death anxiety. This 15-item scale encompasses four dimensions: Cognitive-affective, pain and illness, awareness of time passing, and stimuli related to death. Responses were measured on a 5-point Likert scale, with higher scores indicating greater death anxiety. According to the high-score standard of the Yes/No version scale, a score of ≥ 35 is categorized as high death anxiety. The scale has demonstrated satisfactory reliability (Cronbach’s α = 0.71) and validity[11].

Data collection and quality control

Following approval from the nursing department and obtaining informed consent from participants, the researcher distributed the questionnaire via an electronic QR code. The questionnaire was designed to take approximately 10 minutes to complete, with an automatic timeout feature. A total of 500 questionnaires were distributed to eligible subjects. Of these, 17 were excluded due to issues such as straight-line responding and multiple submissions. This resulted in 473 valid responses included in the final analysis, yielding an effective response rate of 94.6%.

Statistical analysis

Data were analyzed using SPSS 22.0 software. Descriptive statistics (mean ± SD) were used to summarize empathy and death anxiety levels of vocational nursing students during their early clinical internships. Independent sample t-tests and analysis of variance (ANOVA) were conducted to examine differences in empathy. Multiple linear regression analysis was performed to investigate the influencing factors. Pearson correlation analysis was used to explore the relationship between empathy and death anxiety. A P value of < 0.05 was considered indicative of statistical significance.

RESULTS

Empathetic skills and death anxiety level of vocational nursing students during the early stage of their clinical internships

The total death anxiety score was (46.33 ± 6.29), with a high death anxiety rate of 95.6%. The scores across the dimensions were as follows: Cognitive-affective (18.08 ± 3.15), pain and illness (13.25 ± 2.41), awareness of the passage of time (5.58 ± 1.40), and stimuli related to death (9.40 ± 1.56). In addition, the total empathy score during the early practice phase was 63.78 ± 11.49, with attitude choice scoring 5.54 ± 3.11, being in patients’ shoes at 31.47 ± 6.48, and empathetic care scoring 26.77 ± 5.11.

Demographic factors affecting empathetic skills of vocational nursing students during clinical the early stages of their internships

The results of the one-way ANOVA revealed that midwifery students exhibited significantly lower empathy when compared to nursing students, with the differences reaching statistical significance (P < 0.05). Gender, religion, being an only child, family’s economic status, parent’s health status, access to death education, and whether students had elected a death education course had no significant impact on their empathetic skills (P > 0.05). Table 1 shows the detailed results.

Table 1 The influence of demographic factors on empathy (n = 473), n (%)/mean ± SD.

Variable	n (%)	Empathy scores	t/F value	P value
Gender
Male	16 (3.4)	66.94 ± 13.95	1.119	0.264
Female	457 (96.6)	63.67 ± 11.40
Major
Nursing	335 (70.8)	64.73 ± 11.59	2.817	0.005
Midwifery	138 (29.2)	61.48 ± 10.94
Religion
No	303 (64.1)	63.82 ± 11.43	0.088	0.930
Yes	170 (35.9)	63.72 ± 11.62
Being an only child
Yes	40 (8.5)	65.23 ± 12.35	0.831	0.406
No	433 (91.5)	63.65 ± 11.41
Family economic status
Very good	8 (1.7)	64.63 ± 12.59	0.234	0.919
Good	10 (2.1)	65.30 ± 12.48
Moderate	348 (73.6)	63.97 ± 11.57
Bad	81 (17.1)	63.15 ± 11.12
Very bad	26 (5.5)	62.38 ± 11.51
Parents' health status
Very bad	9 (1.9)	60.00 ± 10.94	0.554	0.696
Bad	21 (4.4)	63.24 ± 10.71
Moderate	186 (39.3)	63.20 ± 11.04
Good	197 (41.6)	64.30 ± 11.82
Very good	60 (12.7)	64.62 ± 12.23
Knowledge of death education
Have no idea	155 (32.8)	64.11 ± 12.10	0.972	0.379
Know a bit	304 (64.3)	63.80 ± 11.07
Know well	14 (3.0)	59.64 ± 13.57
Have a death education course before
Yes	74 (15.6)	62.64 ± 11.05	-0.933	0.351
No	399 (84.4)	63.99 ± 11.57

Correlational analysis between empathetic skills and death anxiety of vocational nursing students at an early stage of their clinical internships

Pearson’s correlational analysis revealed the following associations: Higher scores on the pain and illness dimension of death anxiety among vocational nursing students in the early stage of practice were associated with a lower empathetic skill and its three-dimensional scores, indicating a negative correlation (P < 0.05). Additionally, the “being in patients’ shoes” dimension of empathy was found to be positively correlated with the time awareness dimension of death anxiety (P < 0.05). Furthermore, the total death anxiety score was negatively correlated with the empathic care dimension of empathy, suggesting that lower total death anxiety scores were associated with higher empathic care dimension scores (P < 0.05). Table 2 shows the detailed results.

Table 2 Correlation analysis between empathy and death anxiety.

	The total of empathy scores	Attitude choice	Empathic care	Being in patients’ shoes
The total of death anxiety scores	-0.060	-0.008	-0.091a	-0.056
Cognitive-affective	-0.026	0.028	-0.083	-0.017
Pain and illness	-0.159b	-0.112a	-0.138b	-0.128b
Awareness of time passing	0.049	0.098a	0.001	-0.025
Stimuli related to death	0.012	-0.002	0.011	0.030

^aP < 0.05.

^bP < 0.01.

Multiple linear regression analysis of the empathetic skills of vocational nursing students during the early stages of their clinical internships

In the multiple linear regression analysis, the empathetic skills of vocational nursing students during the early stage of practice were treated as a dependent variable, while the basic demographic data and the total death anxiety score and its dimensions served as the independent variables. The inclusion criterion for variables was set at α = 0.05 and the exclusion criterion at β = 0.10. The results of the analysis revealed that the empathy of vocational nursing students in the early stage of practice was significantly influenced by their academic major subject, the total death anxiety score, and the pain and illness dimension of death anxiety (P < 0.05). Table 3 shows the detailed results.

Table 3 Multiple linear regression analysis on empathy of vocational nursing students.

Factors	β	SE	β'	t value	P value	R2
Constant	71.209	4.021		17.711	< 0.001	0.053
Pain and illness	-1.424	0.347	-0.299	-4.106	< 0.001
Major	-3.265	1.138	-0.129	-2.869	0.004
The total of death anxiety scores	0.338	0.133	0.185	2.536	0.012

Cross-major differences in empathy and death anxiety scores among students

We conducted a comparative analysis of students from different fields of subject majors, focusing on their empathetic skills and death anxiety levels. The results revealed significant differences in the overall empathy scores among the midwifery students. Notably, the differences in the empathetic skills were confined to the attitude choice dimension. Nursing students exhibited significantly higher scores in the attitude choice dimension when compared to midwifery students (P < 0.05). Furthermore, the comparison of death anxiety levels between the two groups indicated that the discrepancies were limited to the cognitive-affective aspect. Midwifery students demonstrated substantially higher scores in this aspect when compared to nursing students (P < 0.05). Table 4 shows the detailed results.

Table 4 Cross-major differences in empathy and death anxiety among students, mean ± SD.

Factors	Nursing	Midwifery	t value	P value
The total of empathy scores	64.73 ± 11.59	61.48 ± 10.94	2.817	0.005
Attitude choice	31.99 ± 6.61	30.20 ± 5.99	2.877	0.004
Empathic care	27.04 ± 5.09	26.12 ± 5.12	1.784	0.075
Being in patients’ shoes	5.70 ± 3.19	5.17 ± 2.88	1.770	0.078
The total of death anxiety scores	46.02 ± 6.42	47.06 ± 5.94	-1.627	0.104
Cognitive-affective	17.86 ± 3.11	18.62 ± 3.19	-2.397	0.017
Pain and illness	13.19 ± 2.46	13.42 ± 2.30	-0.963	0.336
Awareness of time passing	5.62 ± 1.40	5.49 ± 1.42	0.903	0.367
Stimuli related to death	9.36 ± 1.54	9.52 ± 1.60	-1.055	0.292

DISCUSSION

This study investigated the psychological changes experienced by nursing students during the early stages of their clinical internship. Research suggests that nursing students undergo significant psychological adjustments as they transition into the role of nurses, with anxiety being a common negative emotional response[12]. This anxiety often manifests as nervousness, insomnia, irritability, and difficulty communicating effectively with patients[13]. Previous studies have also highlighted that anxiety among nursing students can impair their ability to empathize[14]. Notably, students who encounter patient death for the first time are particularly prone to heightened anxiety[15], which can compromise both the quality of their internship experience and patient safety. This study examines death anxiety as an internal psychological response and empathy as an external behavioral expression, aiming to gain a deeper understanding of the psychological transformations nursing students experience during the early stages of their clinical training.

Our findings indicate that death anxiety is a widespread phenomenon among nursing students during the early stages of their clinical internship. Notably, the death anxiety rate of 95.6% observed in this study surpasses the high rate of 89.9% reported among Chinese college students during the coronavirus disease 2019 (COVID-19) pandemic[16]. Moreover, the average death anxiety scores in this study exceeded those reported by Xu et al[17] for nursing students who had completed their internship. Research by Mestre et al[18] suggests that the fear of death among senior students tends to decrease with increased internship experience. However, our study highlights the critical importance of addressing death anxiety among students during the early stages of their internship, when anxiety levels are highest. Our findings also corroborate previous research indicating that females tend to experience higher levels of death anxiety and avoid contact with dying patients[19]. This conclusion is further supported by the demographic composition of our study, in which 95.8% of the participants were female. Therefore, nursing programs, which predominantly consist of female students, should prioritize addressing death anxiety. Interventions targeting the early stages of internship are crucial to mitigate the negative impact of this intrinsic factor on students’ mental health.

In the present study, the mean total empathy score of vocational nursing students during the early stage of clinical internship was 63.78 ± 11.49. This finding diverges from the results reported by Dong et al[20], who investigated nursing students during their internship without specifying the stage of practice. The key difference lies in the focus of this study on the early stage of internship, whereas Dong et al[20] did not delineate the internship stage. This suggests a relatively low level of empathy exhibited by vocational nursing students in the early stage of internship.

This study highlights the importance of focusing on the early internship stage, providing valuable insights into the empathy levels of vocational nursing students. Furthermore, compared to nursing students in the middle and later stages of internship, those in the early stage exhibited lower empathy. As the nursing students in this study were new to clinical practice and lacked prior internship experience, the findings indirectly suggest a correlation between empathy and internship duration. This highlights the need for early interventions to enhance empathy among nursing students during their initial clinical training. The findings are consistent with those of Korkmaz Korkmaz Doğdu et al[21], who reported low empathy levels among both vocational and undergraduate nursing students. These congruent results emphasize the need to strengthen empathy training for nursing students. Additionally, a comparison with the study by Lee et al[22] revealed that nursing students’ empathy tends to decline who were less satisfied with clinical practice. This suggests that nursing education administrators should closely monitor changes in students’ empathy and prioritize empathy development early in their training to prevent decline and promote empathetic patient care.

In this study, when compared to nursing students in the field of nursing major, midwifery students exhibited significantly lower empathy levels during the early stage of their internship. This finding is consistent with the results of Lv et al[23], who also reported lower empathy levels among midwifery students. Although the internship duration was similar for both specialties, the clinical department distribution differed slightly, with midwifery students spending more time in the Department of Obstetrics and Gynecology. Past research suggests that midwives exhibit lower empathy levels due to their prolonged exposure to high-intensity work involving pregnant women[24]. This observation may provide insight into the relatively lower empathy levels observed among midwifery students during their professional practice. To further elucidate the specific dimensions of empathetic skills and death anxiety levels across different subject majors, this study compared the results relevant to the nursing and midwifery students by subjecting them to regression analysis. The results indicated that the primary factor contributing to the lower empathetic skills among midwifery students was their attitudes. In other words, midwifery students exhibited weaker capabilities in adopting others’ psychological perspectives when compared to their nursing counterparts. These findings underscore the importance of prioritizing empathy development in midwifery students during their early clinical training by the respective nursing educators and managers. Furthermore, the current findings revealed that midwifery students exhibited more pronounced anxiety in the cognitive-affective dimensions of death anxiety. Specifically, the prolonged exposure of midwifery students to the fields of obstetrics and gynecology during their early internship, which involves more experiences related to the joy of life and fewer encounters with death, may have contributed to their inadequate tolerance in the cognitive-affective dimension. Moreover, the lack of adequate mentorship and peer support often leaves midwifery students to navigate these challenging situations independently[25], which potentially increases their susceptibility to job burnout and ultimately affects their empathetic skills.

This study’s findings revealed that death anxiety significantly influences the empathy of vocational nursing students during the early stage of their internship. The current result conforms to those of Chen et al’s research, which explored the relationship between media involvement and death anxiety during the COVID-19 outbreak, emphasizing the mediating roles of empathy and sympathy[26]. In addition, as this study focused on the early internship stage, the results consistently suggested that nursing students begin to experience death anxiety early in their internship, which possibly impacts their empathetic skills.

Correlation analysis revealed a significant negative correlation between the emotional care dimension of empathy and the total score of death anxiety. Emotional care refers to the ability of nurses to help patients regulate their emotional states and provide comfort[27]. Research has shown that nursing students are more prone to death anxiety during the internship stage[28], which helps explain the regulatory role of death anxiety in shaping the empathy of nursing students during the early internship stage. These findings underscore the importance of addressing death anxiety in nursing students during the early stages of clinical practice. Specifically, students exhibiting high levels of death anxiety should receive targeted interventions aimed at enhancing their empathetic responses.

This study further explored death anxiety, identifying stress and pain as key dimensions that influence empathy. Correlation analysis revealed that stress and pain, resulting from nursing students’ encounters with patient death, negatively impact nursing interns’ abilities in opinion selection, emotional care, and perspective-taking[29]. This suggests that nursing students lack effective coping mechanisms for managing death anxiety, which in turn impairs their ability to form opinions, switch perspectives, and provide emotional care to patients.

Research suggests that death education courses can help alleviate death anxiety among nursing students[30]. However, this study’s investigation into the cognition and study status of death education did not yield the expected results. This could be attributed to two factors: First, the limited cognition of death education among participants, and second, the low attendance rate of death education courses among nursing students (only 12%). This limited exposure to death education may be insufficient to influence their ability to manage death anxiety. Moreover, the content of existing death education courses lacks systematic progression and fails to provide effective measures for managing death anxiety. These findings highlight the need to design death education courses that are more aligned with clinical practice, ensuring they can effectively address and alleviate death anxiety among nursing students.

Limitations and future research imperatives

The study has several limitations. First, the nursing students who participated in their first clinical practice were recruited through convenience sampling, which may have limited the representativeness of the sample. Second, no analysis was conducted on the institutions or a comparison of empathy ability levels among nursing students participating in their second clinical practice during the same period. In addition, the study focused solely on the early stage of clinical practice and did not include follow-up observations of nursing students in the middle or later stages of their practice. Consequently, the findings cannot comprehensively describe the empathetic skill profile of vocational college nursing students, as they only represent the situation at the research site. This limitation may influence the generalizability of the overall results. Furthermore, the study only described death anxiety levels without analyzing its manifestation at specific stages, which restricts nursing managers’ ability to accurately determine the types of anxiety. To address the limitations of this study, in the future, researchers should undertake more in-depth investigations. For instance, future studies could expand the sample to include nursing students at different internship stages, track temporal changes in empathy levels, and explore how empathy varies across different educational settings. Examining these factors would provide a deeper understanding of the determinants of empathy in nursing students. The results obtained can inform evidence-based strategies to enhance empathetic skills during training. In addition, incorporating tools such as the State-Trait Anxiety Inventory could assist nursing managers in identifying nursing students’ anxiety states, thereby enabling more targeted and effective interventions.

CONCLUSION

During the early internship period, the vocational nursing students demonstrated lower empathetic skills and heightened death anxiety levels. Notably, midwifery students experiencing high death anxiety were more likely to exhibit inadequate empathetic skills. This study further clarified that the empathetic skills of midwifery students primarily manifest in attitude choice, whereas death anxiety primarily emerges in the cognitive-affective domain, distinguishing them from nursing students. To address this concern, nursing administrators in colleges and hospitals should consider tailoring internship arrangements to students’ specific majors and implementing early identification and intervention strategies for those experiencing high death anxiety. Such measures would promote the development and expression of empathy during the internship period.