Relationship between death anxiety and coping with death competence among Chinese oncology nurses: A chain mediation model

Abstract

BACKGROUND

Death anxiety (DA) is a prevalent psychological challenge among oncology nurses that affects their emotional well-being and professional competence in coping with death-related situations. Death-related attitudes and resilience are critical factors that may mediate the relationship between DA and coping with death competence (CDC). However, few studies have examined the chain-mediating effect of these factors among Chinese oncology nurses. This study aimed to investigate the association between DA and CDC among Chinese oncology nurses, with a focus on the mediating roles of death attitude and resilience.

AIM

To investigate the association between DA and CDC among Chinese oncology nurses.

METHODS

A national cross-sectional survey was conducted among Chinese oncology nurses using an electronic questionnaire distributed in Wenjuanxing, China. In total, 615 valid responses were obtained. The participants completed the Templer death anxiety scale, death attitude profile-revised, Connor-Davidson resilience scale, and coping with death scale. A chain mediation analysis was performed using the PROCESS macro in SPSS to examine the relationships between these variables.

RESULTS

The findings indicated that DA had a significant direct effect on CDC [effect = 0.201, 95% confidence interval (CI): 0.112-0.322]. In addition to this direct effect, three significant indirect pathways were observed: (1) Death attitude (effect = 0.118, 95%CI: 0.056-0.163); (2) Resilience (effect = 0.108, 95%CI: 0.032-0.176); and (3) A sequential mediation pathway involving both death attitude and resilience (effect = 0.071, 95%CI: 0.042-0.123). The total indirect effects of the three mediation paths accounted for 29.7% of the relationship between DA and CDC.

CONCLUSION

Using a chain mediation model, this study explored the mechanisms linking DA, death attitude, resilience, and CDC among Chinese oncology nurses. These findings highlighted the crucial role of death attitude and resilience in mediating the relationship between DA and CDC. Interventions aimed at fostering adaptive attitudes toward death and enhancing resilience may improve nurses’ ability to cope with death-related stressors, ultimately benefiting their psychological well-being and professional competence.

Key Words: Death anxiety; Death attitude; Resilience; Coping with death competence; Oncology nurses; Chain mediation model

Core Tip: Death anxiety (DA) is a significant psychological challenge for oncology nurses, affecting their ability to cope with death-related stress in clinical practice. This study explored the mediating roles of death attitude and resilience in the relationship between DA and coping with death competence among Chinese oncology nurses. Based on data from a national cross-sectional survey, the findings highlight that resilience and adaptive death attitudes play crucial roles in reducing the negative impact of DA. These results provide valuable insights for developing targeted interventions to enhance nurses’ coping skills, ultimately improving their psychological well-being and quality of end-of-life care.

INTRODUCTION

Oncology nurses, particularly those in China, play a crucial role in providing end-of-life care, psychological support, and symptom management to patients with cancer[1]. Due to the high burden of cancer in China, oncology nurses frequently encounter terminally ill patients, making them highly susceptible to death anxiety (DA) and emotional distress. The psychological impact of continuously witnessing a patient’s suffering and mortality can affect their coping abilities, resilience, and overall well-being[2]. Understanding how Chinese oncology nurses’ attitudes toward death and their resilience influence their ability to cope with death-related stress is essential for improving their psychological preparedness, enhancing patient care, and mitigating the risk of burnout[3]. DA characterized by the fear and distress associated with the inevitability of death has been widely recognized as a significant psychological concern among healthcare providers, especially in fields such as oncology[4]. One of the most significant emotional challenges faced by oncology nurses is DA, which is a pervasive fear and distress related to the inevitability of death[5]. Given the increasing burden of cancer-related mortality, Chinese oncology nurses face substantial psychological challenges when coping with death-related stress, which may affect their ability to provide palliative and end-of-life care[6]. A study in Iran showed that DA could affect the mental health of healthcare providers, leading to burnout and depression[7]. The anxiety that nurses experience in relation to death can also affect their interactions with patients, potentially compromising the quality of care and emotional support provided.

Coping with death competence (CDC) is the ability to effectively handle the emotional, psychological, and professional challenges associated with death and dying[8]. For oncology nurses who frequently care for terminally ill patients, this competency is crucial for maintaining emotional well-being and delivering high-quality end-of-life care[9]. A nurse’s ability to cope effectively with death not only impacts their mental health, but also influences their interactions with patients and families, ultimately shaping the overall quality of palliative care[10]. Given the emotional burden associated with end-of-life care, understanding the factors that contribute to CDC is essential to develop targeted interventions to support oncology nurses in managing death-related stress.

Death attitude encompasses an individual's thoughts, emotions, and behaviors related to death, reflecting their overall perception of and response to mortality[11]. It plays a crucial role in shaping how nurses manage death-related stress and influences their ability to cope with patient deaths[12]. A positive death attitude, characterized by acceptance and openness, may help mitigate the negative impact of DA, whereas a negative or avoidant attitude can exacerbate distress and impair coping mechanisms[13]. Resilience, defined as the ability to adapt positively to adversity, is another key factor influencing how nurses cope with death[14]. Nurses with higher resilience are better equipped to manage emotional stress, maintain professional competence, and sustain psychological well-being despite frequent exposure to death and dying[15]. Resilience acts as a protective factor that allows individuals to regulate their emotional responses to DA and develop effective coping strategies[16].

Although research on the psychological difficulties experienced by oncology nurses is increasing, there remains a notable gap in regard to understanding the intricate relationship between DA and CDC, along with the potential mediating effects of death attitude and resilience. While it is well-established that oncology nurses experience heightened psychological distress due to frequent exposure to death and dying. However, the psychological mechanisms underlying these associations have received limited attention. Exploring these mechanisms is crucial for developing psychological interventions tailored to support oncology nurses. Oncology nurses face distinct challenges, such as extended exposure to terminal illness and end-of-life care, which call for a more in-depth investigation into the interaction of relevant psychological mechanisms. To address this need, the present study employed a chain mediation model to provide a thorough understanding of their psychological experiences and guide the development of effective strategies for improving coping abilities.

This study’s conceptual model is grounded in stress-coping theory, which posits that awareness of mortality can trigger psychological distress and influence coping responses. In oncology nursing, frequent exposure to death and patient suffering presents a significant stressor, often leading to DA, which may impair professional functioning. According to stress-coping theory, personal resources such as psychological resilience and adaptive death attitudes play a key role in moderating stress. Resilience helps individuals adapt positively to adversity, buffering the effects of DA, while constructive attitudes toward death can promote healthier emotional and behavioral coping. These mediating factors may enhance nurses’ competence in dealing with death-related challenges and improve care quality. Drawing from prior research, the conceptual framework shown in Figure 1 outlines the following hypotheses: (1) DA, death attitude, resilience, and CDC are significantly interrelated among Chinese oncology nurses; (2) Death attitude and resilience act as independent mediators in the relationship between DA and CDC; and (3) Both variables function together as sequential mediators in regard to the relationship between DA and CDC.

Figure 1 The theoretical model and the chain mediation model of death anxiety and coping with death competence. A: The theoretical framework based on stress coping theory; B: The chain mediation model of death attitude and resilience in the relationship between death anxiety and coping with death competence with standardized beta. ^bP < 0.001.

MATERIALS AND METHODS

Participants and procedure

This study was conducted using an electronic questionnaire survey at the National Oncology Nursing Conference held by the Chinese Nursing Association in Changsha, Hunan Province, from July 28 to July 30, 2023. The inclusion criteria were as follows: (1) Currently working as an oncology nurse in a hospital setting; (2) At least one year of work experience in oncology nursing, and (3) The ability to read and complete the questionnaire independently. The exclusion criteria were as follows: (1) Nurses on long-term leave (e.g., medical or maternity leave) at the time of the survey; and (2) Those with non-oncology nursing roles (e.g., administrative or research positions).

The survey was distributed through Wenjuanxing (https://www.wjx.cn/), a widely used online survey platform in China. Participants were recruited using convenience sampling with a questionnaire link shared through professional oncology nursing networks and conference communication channels. Before completing the survey, the participants were informed of the study’s objectives, voluntary participation, and data confidentiality. Only those who provided informed consent completed the questionnaire. Duplicate submissions and incomplete responses were excluded from the final analysis to ensure data quality.

The sample size for this study was determined using the formula for descriptive cross-sectional studies. Based on a preliminary investigation, the mean CDC score of oncology nurses was estimated to be 133.57 ± 26.78. Using these values, the estimated sample size was calculated to be 500. To account for potential non-response or invalid questionnaires, the final sample size was adjusted to 550 participants, considering an estimated invalid response rate of 10%. Ultimately, 615 valid questionnaires were retained from the 640 distributed, achieving an effective response rate of 96.0%.

Measures

Sociodemographic characteristics: Sociodemographic characteristics included sex, age, educational level, hospital level, years of work experience in oncology care, religion, and experience of bereavement.

The Templer death anxiety scale: The Templer death anxiety scale (T-DAS), originally developed by Templer[17] and later revised by Hong et al[18], is one of the most widely used tools for measuring the degree of DA in patients with cancer. The scale consists of 15 items divided into four dimensions: Cognition (six items), emotion (four items), time awareness (two items), and stress and pain (three items). Each item is scored as either “yes” (1 point) or “no” (0 points), with six items reverse-scored. A higher total score reflects greater DA, and a score of ≥ 7 indicates the presence of DA. In this study, the T-DAS demonstrated good reliability with a Cronbach’s alpha coefficient of 0.826.

The death attitude profile revised scale: The death attitude profile revised (DAP-R) scale, developed by Jansen et al[19], is a widely used tool for assessing attitudes toward death. In 2014, Han et al[20] translated and culturally adapted the DAP-R into Chinese using Brislin’s cross-cultural translation model, which includes forward translation, expert panel review, back-translation, and pretesting with a pilot sample. The scale comprises 32 items across five dimensions: Fear of death (seven items), death avoidance (five items), neutral acceptance (five items), approach acceptance (10 items), and escape acceptance (five items). Each item is rated on a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree), with higher scores indicating stronger agreement with the corresponding attitude. This scale provides a comprehensive evaluation of individuals’ perspectives on death. In this study, the DAP-R exhibited strong internal consistency with a Cronbach’s alpha coefficient of 0.89.

The Connor-Davidson resilience scale: The Connor-Davidson resilience scale was developed by Connor and Davidson[21]. The Chinese version, revised by Wang et al[22], evaluates resilience across three dimensions: Resilience, strength, and optimism. This version consists of 25 items measured using a 5-point Likert scale with responses ranging from 1 (“strongly disagree”) to 5 (“strongly agree”). The total score ranges from 25 to 125, with higher scores indicating greater mental toughness. Higher scores indicate stronger resilience. The scale demonstrated good reliability and validity, with a Cronbach’s alpha of 0.85. This approach has been extensively validated and applied in research.

Coping with death scale: The coping with death scale (CDS), developed by Bugen[23], was also translated and adapted into Chinese using rigorous cross-cultural translation procedures. The adaptation process included bilingual translation, expert validation, and cognitive interviews with Chinese nurses to ensure clarity, cultural relevance, and sensitivity. The scale consists of 30 items that examine various coping competencies, including emotional regulation, problem solving, and acceptance. Each item is rated on a 7-point Likert scale, where 1 represents “strongly disagree” and 7 represents “strongly agree”, with higher scores indicating a stronger ability to cope with death. The total score provides an overall assessment of coping ability, and there are no reverse-scored items. In this study, the CDS demonstrated strong reliability with a Cronbach’s alpha of 0.91.

Statistical analysis

Data analysis was conducted using IBM SPSS software (version 26.0; IBM Corp.). Descriptive statistics were used to summarize the dataset according to distribution patterns. For the continuous variables with a normal distribution, results were reported as mean ± SD, whereas categorical variables were described using frequencies and percentages. The relationships among DA, death attitude, resilience, and CDC were examined using Pearson’s correlation analysis. Statistical significance was set at P < 0.05. To explore the mediating roles of death attitudes and resilience in the relationship between DA and CDC, a chain mediation analysis was performed using the PROCESS macro for SPSS (model 6). A bootstrap method with 5000 resamples was used to test the significance of the mediating effect. A bias-corrected non-parametric test was applied, and a bootstrap 95% confidence interval (CI) that did not contain 0 indicated a statistically significant mediation effect.

RESULTS

Sociodemographic characteristics

The sociodemographic characteristics of the oncology nurses are summarized as follows: Eight (1.3%) were male and 607 (98.7%) were female. For work experience in oncology care, 62 (10.1%) had ≤ 1 year, 220 (35.8%) had 2-5 years, 240 (39.1%) had 5-10 years, and 93 (15.0%) had more than 10 years of experience. In terms of religious beliefs, 39 (6.3%) participants were identified as religious, while 576 (93.7%) reported no religious affiliation. Regarding bereavement experiences, 271 (44.1%) participants had previously experienced the death of a loved one, while 344 (55.9%) had not. The detailed characteristics are presented in Table 1.

Table 1 Participants’ demographic and clinical characteristics (n = 615).

Characteristics	Variable	Frequency	Percent (%)
Gender	Male	8	1.3
	Female	607	98.7
Age	20-30	171	27.8
	31-40	381	61.9
	≥ 41	63	10.3
Educational level	Junior college and below	87	14.2
	Bachelor’s degree	503	81.8
	Master’s degree and above	25	4.0
Hospital level	Tertiary hospitals	486	79.1
	Secondary hospitals	84	13.6
	Primary hospitals	45	7.3
Years of working experience in oncology care	≤ 1 year	62	10.1
	2-5 years	220	35.8
	5-10 years	240	39.1
	≥ 10 years	93	15.0
Religion	No	576	93.7
	Yes	39	6.3
Bereavement experience	No	344	55.9
	Yes	271	44.1

Correlation analysis

DA showed a significant negative correlation with CDC, while death attitude and resilience were negatively correlated with DA. Moreover, both death attitudes and resilience were positively correlated with CDC. Detailed scores and correlations among the study variables are presented in Table 2.

Table 2 Correlations among death anxiety, death attitude, resilience and coping with death competence.

Outcome variables	Mean	SD	1	2	3	4
Death anxiety	7.1	1.9	1.00
Death attitude	89.5	10.6	-0.710a	1.00
Resilience	78.8	15.7	-0.651a	0.671a	1.00
Coping with death competence	134.3	26.2	-0.721a	0.532a	0.611a	1.00

^aP < 0.01.

Mediating effect analysis

Model 6 of the PROCESS macro was employed to investigate the mediating roles of death attitudes and resilience in the association between DA and CDC. The regression results are presented in Table 3. Firstly, DA exhibited a significant negative association with death attitude (β = -0.743, P < 0.001), and death attitude was found to be positively linked to resilience (β = 0.490, P < 0.001). Furthermore, DA had a direct negative effect on CDC (β = -0.296, P < 0.001), providing support for hypothesis 1. Consistent with hypothesis 2, resilience was positively related to CDC (β = 0.398, P < 0.001), thus indicating that a more positive death attitude contributes to higher resilience, which subsequently enhances coping competence. Additionally, DA was negatively associated with resilience (β = -0.467, P < 0.001), confirming a potential indirect pathway through death attitude and resilience. These findings therefore support hypothesis 3, demonstrating a significant chain-mediating effect, in which DA influences CDC through a sequential pathway involving both death attitude and resilience. Figure 1 illustrates the structure of this mediation chain, highlighting the direct and indirect mechanisms underlying the relationship between DA and CDC.

Table 3 Regression results in the chain mediation analysis.

Criterion	Predictors	R	R2	F	coefficients	β	t	95%CI
Death attitude	Death anxiety	0.828	0.685	68.608	-0.265	-0.243	-6.254	-0.285 to 0.332
Resilience	Death anxiety	0.783	0.613	78.568	-0.154	-0.467	-8.863	-0.243 to 0.144
	Death attitude				0.423	0.490	8.247	0.322 to 0.723
Coping with death competence	Death anxiety	0.892	0.796	135.439	-0.041	-0.296	-7.353	-0.055 to 0.054
	Death attitude				0.178	0.357	8.374	-0.076 to 0.297
	Resilience				0.154	0.398	9.264	-0.143 to 0.255

CI: Confidence interval.

The outcomes of the sequential mediation analysis are presented in Table 4. The direct effect of DA on CDC remained significant (effect size = 0.201; 95%CI: 0.112-0.322). The indirect effect via death attitude alone (DA-death attitude-CDC) was statistically significant, though smaller in magnitude (effect size = 0.118; 95%CI: 0.056-0.163). Likewise, the indirect pathway through resilience alone (DA-resilience-CDC) also reached significance (effect size = 0.108; 95%CI: 0.032-0.176). The combined chain mediation path (DA-death attitude-resilience-CDC) showed a moderate yet significant effect (effect size = 0.071; 95%CI: 0.042-0.123). Altogether, the total effect of DA on CDC, encompassing both the direct and indirect paths, was found to be statistically significant (effect size = 0.498; 95%CI: 0.395-0.614). These results confirm that death attitude and resilience serve not only as individual mediators, but also as sequential mediators in the relationship between DA and CDC.

Table 4 Test results of bootstrap mediation effect.

Effect relationship	Effect size	Effect ratio	Boot LLCI	Boot ULCI
Total effect	0.498		0.395	0.614
Direct effect	0.201	41.56	0.112	0.322
Total indirect effect	0.297	58.44	0.165	0.392
Death anxiety to death attitude to coping with death competence	0.118	23.81	0.056	0.163
Death anxiety to resilience to coping with death competence	0.108	21.25	0.032	0.176
Death anxiety to death attitude to resilience to coping with death competence	0.071	13.38	0.042	0.123

Boot LLCI: Bootstrap lower confidence interval; Boot ULCI: Bootstrap upper confidence interval.

DISCUSSION

This study explored the mediating effects of death attitude and resilience on the relationship between DA and CDC among Chinese oncology nurses. Our results showed that both death attitude and resilience significantly mediated this relationship, highlighting the complex psychological processes that influence nurses’ ability to manage the challenges associated with death and end-of-life care.

This study showed that oncology nurses had a total CDC score of 134.3 ± 26.2, indicating that Chinese oncology nurses’ competency in coping with death was at an intermediate level. A survey conducted by Povedano-Jimenez et al[9] on Spanish nurses found that most respondents demonstrated strong competency in coping with death. These findings suggest that Chinese oncology nurses have lower CDC scores than their counterparts in Spain and other Western countries, highlighting the possible differences in education, training, and cultural perspectives on death. By contrast, nursing curricula in several Asian countries, including China, Japan, and South Korea, have historically placed greater emphasis on technical skills and protocol adherence, with limited focus on the psychosocial or emotional dimensions of care[24]. This discrepancy may be attributed not only to differences in nursing education but also to cultural factors. In Chinese society, traditional Confucian values and beliefs render death a taboo subject often linked with bad luck, limiting open discussions around death. Concepts like filial piety and family-centered decision-making can further complicate end-of-life communication, as families may avoid disclosing terminal prognoses to patients. These cultural norms may prevent nurses from developing positive death attitudes and reduce opportunities for experiential learning in palliative care settings. By contrast, Western nursing education often incorporates death education and psychological training, fostering a holistic approach to patient care that enhances nurses’ coping competency in dealing with death-related situations[25].

Consistent with our hypothesis, death attitude was found to mediate the relationship between DA and CDC. Nurses’ attitudes toward death, whether accepting or fearful, played a crucial role in shaping how they experienced DA and their ability to cope with the emotional strain of working with terminally ill patients[26]. Nurses who had a more positive death attitude were less affected by DA, which allowed them to approach end-of-life care with greater emotional balance and composure[27]. In contrast, nurses with a negative death attitude tended to experience heightened DA, which hindered their coping abilities. This finding aligns with previous studies that have shown how attitudes toward death can influence emotional responses and coping mechanisms in healthcare settings[28]. Therefore, the death attitude serves as an essential mediator that either amplifies or mitigates the psychological effects of DA on nursing practice.

In addition to the death attitude, resilience was another significant mediator in the relationship between DA and CDC. Our findings suggest that resilience helps nurses cope with the psychological burden of DA by enabling them to adapt to and recover from the emotional stress of caring for dying patients. Nurses with higher levels of resilience demonstrated better emotional regulation and coping strategies, allowing them to navigate the challenges of oncology nursing more effectively[29]. These results indicate that resilience is a protective factor against emotional distress and burnout, particularly in high-stress environments such as oncology[30]. By fostering resilience, nurses can develop healthier coping strategies and maintain their professional competence when faced with death-related stressors.

Furthermore, this study identified a sequential mediating effect of death attitude and resilience, highlighting the interconnectedness of these factors in oncology nursing. Our findings suggest that a positive death attitude reduces DA, which, in turn, enhances resilience and strengthens nurses’ abilities to cope with death-related challenges. This sequential pathway underscores the dynamic interaction between attitude and resilience, indicating that these factors do not operate in isolation, but rather influence each other in shaping nursing competence in end-of-life care.

These findings have important implications for oncology nurses’ education and support. Death education targeting attitudes towards death could play a crucial role in reducing DA and improving CDC. Death-training programs that promote open discussions about death, encourage reflective practices, and foster a positive death attitude may help nurses develop a more accepting view of death and reduce emotional distress. Successful models have emerged within Chinese universities and hospitals. For example, Sun Yat-sen University has piloted a death education course that includes lectures, role-playing, and group reflection, which was found to improve students’ death acceptance and emotional resilience. Additionally, the Peking Union Medical College has integrated palliative care simulation training and reflective writing into its curriculum, showing promising results in enhancing empathy and reducing emotional avoidance related to death[31]. Additionally, enhancing resilience through psychological interventions such as mindfulness, stress management, and coping skills training could further help nurses manage DA and improve their emotional well-being[32]. By focusing on these psychological dimensions, health care institutions can ensure that nurses are better equipped to handle the emotional challenges of oncology nursing.

However, this study had several limitations. First, the cross-sectional design limited our ability to draw causal conclusions regarding the relationships among DA, death attitude, resilience, and CDC. Future longitudinal studies could offer more insight into how these factors evolve over time and influence nurses’ long-term coping abilities. Furthermore, the sample had a significant gender imbalance, with 98.7% of participants being female, which limits the generalizability of the findings to male oncology nurses. Gender-related differences in emotional expression and coping strategies may influence responses to death-related stress, and future studies should aim for more gender-balanced samples. Additionally, reliance on self-reported data may introduce bias as nurses may underreport or overreport their emotional responses. Future research should consider using multiple data sources or observational methods to strengthen the validity of these findings.

In conclusion, our study highlighted the significant role played by death attitude and resilience in mediating the relationship between DA and CDC among Chinese oncology nurses. These findings underscore the importance of addressing both intrinsic and extrinsic factors in supporting nurses caring for terminally ill patients. By fostering positive death attitudes and enhancing resilience, healthcare organizations can help nurses manage the emotional challenges of oncology practice, thereby improving their ability to provide compassionate and competent end-of-life care.

CONCLUSION

This study explored the mediating effects of death attitude and resilience on the relationship between DA and CDC among Chinese oncology nurses using a national cross-sectional design. These findings suggest that both death attitude and resilience play significant roles in mediating the relationship between DA and the ability to cope with death. Specifically, a positive death attitude and higher resilience levels were associated with improved coping with death-related challenges, providing valuable insights into the psychological processes that influence CDC among healthcare professionals. The results underscore the importance of enhancing oncology nurses’ death attitude and resilience to better equip them to manage the emotional and professional demands of death-related situations. These findings suggest that death education aimed at improving death attitude and boosting resilience can support nurses in coping with DA, ultimately enhancing their death competence and promoting better patient care. Future death education training and support programs should focus on strengthening these psychological resources to improve the emotional well-being and professional effectiveness of oncology nurses in the face of challenging end-of-life care.