Introduction

Contemporary thanatology and palliative care emphasize the need for comprehensive preparation of healthcare professionals to provide care for patients at the end of life. Traditional thanatological education focuses on preparing specialists, such as nurses, physicians, and clergy, to care for dying individuals. One of the primary goals of palliative care is to ensure dignified and as pain-free as possible conditions of dying, while moving away from interventions aimed solely at prolonging life at all costs. Therefore, the education of healthcare professionals should include not only the ability to recognize the dying process but also the development of competencies related to holistic patient care. Such care should address the biological, psychological, social, and spiritual needs of the patient. Particular importance is also attributed to appropriate verbal and non-verbal communication with patients and their families, as well as providing emotional support to the patient’s relatives [1].

In previous decades, the education model for nurses in Poland provided limited development of competencies related to coping with difficult, stressful, and problematic situations, both theoretically and practically. Meanwhile, according to the Code of Professional Ethics for Nurses and Midwives of the Republic of Poland, nurses and midwives are obliged to provide patients with humane terminal care and dignified conditions of dying while respecting their values and beliefs [2]. This requires healthcare professionals to possess not only high professional competencies but also appropriate psychological and emotional preparation. Due to the nature of their profession, nurses are constantly exposed to suffering, death, and the emotions of patients’ families, making them particularly vulnerable to strong psychological stressors. Therefore, it is essential to develop skills in stress management techniques, relaxation methods, and cognitive-behavioral strategies supporting effective functioning in critical situations.

Modern medicine, socially perceived as having almost unlimited therapeutic possibilities, often results in intensive medical interventions being undertaken even in cases of irreversible disease and impending death. Consequently, patients at the end of life are frequently hospitalized in anesthesiology and intensive care units despite the lack of realistic prospects for improvement. This not only limits the availability of beds for patients with a chance of survival but also generates numerous ethical and emotional dilemmas among healthcare professionals [3].

The patient’s right to dignified dying is regulated by Article 20(2) of the Act of 6 November 2008 on Patient Rights and the Patient Ombudsman, according to which a terminally ill patient has the right to healthcare services aimed at alleviating pain and other suffering, as well as the right to die peacefully and with dignity [4]. In practice, this means ensuring appropriate care conditions, respecting the patient’s privacy, and enabling the presence of close relatives, which is often best achieved in a home environment.

Currently, nursing education standards increasingly incorporate issues related to palliative care, communication with terminally ill patients, and psychological aspects of coping with stress and emotional burden. However, there remains a significant need to develop practical competencies concerning coping strategies in critical situations, futile therapy, and ethical conflicts related to caring for dying patients. Professional and holistic end-of-life care requires nurses to possess not only knowledge and professional experience but also emotional maturity, empathy, high personal standards, and appropriately directed education. This is particularly evident in intensive care units (ICUs), where patient care is characterized by the unique coexistence of two fundamental goals: implementing life-sustaining interventions while simultaneously providing end-of-life care when further treatment is no longer beneficial. Consequently, ICU nurses are frequently required to balance efforts to preserve life with the ethical obligation to ensure patients’ comfort and dignity at the end of life. This duality of professional roles may represent a significant source of moral conflict and should be considered a key contextual factor when interpreting nurses’ attitudes toward death and end-of-life care [5, 6].

In contrast to palliative or geriatric care, where death is often anticipated as the natural consequence of progressive chronic illness, the ICU population is highly heterogeneous. It includes not only older adults with multiple comorbidities but also younger patients admitted following severe trauma, major surgery, acute organ failure, or other potentially reversible critical conditions. As a result, death in the ICU is not always perceived as an expected or natural stage of life, which may further complicate healthcare professionals’ experiences and ethical decision-making regarding the withholding or withdrawal of life-sustaining treatment [7-9].

Therefore, the organizational and clinical context of intensive care practice should be regarded as an important determinant of nurses’ perceptions of death, dying, and end-of-life care.

The aim of the study was to assess attitudes towards patient death and analyze stress coping strategies among nursing staff working in medical intensive care units.

Material and methods

The study was conducted among 157 professionally active nurses working in anesthesiology and intensive care units. Prior to commencing the study, approval was obtained from the Bioethics Committee of the Pomeranian Medical University in Szczecin (KB.006.67.2024). A diagnostic survey method was used, employing an original questionnaire and a standardized research tool, namely the Coping Inventory for Stressful Situations (CISS).

The original questionnaire consisted of 27 closed-ended questions concerning sociodemographic data, types of emotions experienced, factors influencing attitudes towards patient death, contacts with patients at the end of life and their families, difficulties in caring for dying patients, and methods of coping with stress. Attitudes toward death were operationalized based on responses to the author-developed questionnaire. A rational attitude was indicated by the response: “Death is a natural phenomenon; if nothing more can be done for the patient, their suffering should not be prolonged, and they should be allowed to die peacefully”. A denial attitude was identified by the response: “I do not accept peaceful dying; life should be fought for until the very end, regardless of the means or costs involved”. The response “I avoid contact with dying patients and their family members” was interpreted as an indicator of an avoidant attitude, whereas responses referring to feelings of fear, helplessness, and difficulty communicating with dying patients were considered indicators of an anxiety-related attitude.

The CISS questionnaire is a tool used to assess stress coping styles, developed by Norman S. Endler and James D.A. Parker. The Polish adaptation of the questionnaire was prepared by Piotr Szczepaniak, Jan Strelau, and Kazimierz Wiśniewski. The scale consists of 48 statements describing various behaviors undertaken in stressful situations. Respondents assessed, on a five-point scale, the frequency with which they used particular behaviors in difficult and stressful situations. The results were presented using three scales: task-oriented coping (SSZ), emotion-oriented coping (SSE), and avoidance-oriented coping (SSU). The avoidance-oriented style included two forms: engaging in substitute activities (ACZ) and seeking social contacts (PKT). The score range for SSZ, SSE, and SSU was 16-80 points, for ACZ 8-40 points, and for PKT 5-25 points [10].

Statistical analysis

Descriptive statistics and statistical inference methods were used to analyze the results. Quantitative variables were described using the arithmetic mean, standard deviation, median, minimum and maximum values, and quartiles. The Pearson chi-square test was used to assess the association between coping styles and methods of coping with stress related to the death of a patient. In all analyses, the statistical significance level was set at p < 0.05. Statistical analyses were performed using the appropriate modules of the GNU PSPP statistical software package.

Results

The study involved 157 nursing staff members. The vast majority of respondents were women (94.3%). The participants were aged between 20 and 70 years, with the average age falling within 51-60 years. The largest group of respondents comprised individuals aged 51-60 years (39.5%), while the smallest group consisted of people aged 61 years and older (7%). Respondents in relationships accounted for 76.0% of respondents, while 24% reported being single. The majority of participants (64%) lived in urban areas, whereas 36% of respondents lived in rural areas. A two-level response scale was used to describe the level of education: secondary education and higher education. The majority of respondents had secondary education (62%), while 38% had higher education. Among the respondents, the largest group (30%) had worked in the nursing profession for 21-30 years, whereas the smallest group (12%) had worked for less than 5 years (Table 1).

In the study group, more than half of the respondents (59.2%) reported frequent contact with dying patients. Occasional contact with dying patients was reported by 23.6% of nurses, whereas 17.2% of the staff reported frequent exposure to dying patients (Table 2).

Analysis of the participating nurses’ attitudes toward death showed that the most frequently selected response reflected a rational attitude toward death, accepting the dying process as a natural part of life. This response was selected by 71.1% of the respondents. A denial attitude, manifested by a complete lack of acceptance of death, was observed in 3.2% of the participants. A clear tendency to avoid contact with dying patients was noted in 18.5% of respondents, while an intensified fear in contact with a dying person, expressed through a lack of engagement in care, was identified in 15.9% of the surveyed nurses (Table 3).

In the next part of the study, the frequency of specific emotional reactions related to the death of a patient was analyzed. The majority of respondents (71.3%) reported frequent feelings of anger in response to a patient’s death, while 41.4% reported accepting a patient’s death with calmness. Prayer as a coping response was reported by 7.6% of nurses, whereas 48.4% stated that they never engaged in such behavior. Additionally, 52.2% of respondents stated that a patient’s death never caused them to feel aversion toward their profession. At the same time, 61.1% of participants frequently experienced feelings of sadness and depression in connection with a patient’s death (Table 4).

Among the variables identified by nursing staff as influencing their attitudes toward patient death, the dominant factor was the patient’s age, indicated by 87.9% of respondents, followed by the cause of death (67.5%). The surveyed nurses also identified other factors that they perceived as affecting their attitudes, such as the type of death (40.1%), close relationships with the patient (38.2%), and relationships with the patient’s family (22.9%). At the same time, 50.3% of nurses believed that it is not possible to become accustomed to patient death, as each case is accompanied by different circumstances and emotions. In contrast, 7.6% of respondents indicated that developing a routine in this area may be a sign of professional burnout. Meanwhile, 37.6% of participants stated that with increasing years of work experience, it is possible to develop a certain level of habituation, which leads to perceiving death as a commonplace phenomenon that does not evoke strong emotional reactions (Table 5).

The most frequently used coping strategies for stress and difficulties related to caring for dying patients in the studied group of nursing staff were engagement in professional work (78%) and spending time on hobbies and personal interests or receiving support from close persons (71%). Support from colleagues also played an important role, as indicated by 52% of respondents, as well as prayer and faith in God, reported by 45% of participants. At the same time, 22% of respondents admitted that they had not developed any effective coping strategies for stress, while 40% experienced difficulties in alleviating feelings of tension and anxiety. In contrast, 12% of the participants reported using psychological support (Fig. 1).

The analysis of coping with stress and tension among the surveyed nurses using the CISS questionnaire showed that the dominant coping styles in difficult situations were the task-oriented style (5.6 ±1.5) and the avoidance-oriented style through seeking social contact as a form of substitute activity (5.6 ±1.6) (Table 6).

The analysis of relationships between coping styles and ways of dealing with stress in situations involving patient death revealed statistically significant differences in the task-oriented coping style (SSZ), avoidance-oriented coping style (SSU), and seeking social contact (PKT) in relation to selected coping methods (p < 0.05).

The results indicate that individuals characterized by a high level of task-oriented coping most often chose engagement in work and job-related duties as a way of dealing with stress associated with patient death (2.1%). Staff who display the emotion-oriented style are more likely to cope with stress through focusing on work (1.8%) or their faith in God (1.3%). Furthermore, nurses with a high level of avoidance-oriented coping most often managed stress by seeking support from close persons (1.9%). Regarding the seeking social contact style, it was found that individuals with high scores in this dimension most frequently used support from colleagues as a way of coping with emotional difficulties (2.4%) (Table 7).

Discussion

Nursing staff, particularly those employed in intensive care units, belong to professional groups that are especially vulnerable to frequent exposure to patient death. Situations related to dying and death constitute a significant source of psychological and emotional burden. Numerous studies indicate that nurses experience negative emotional states in response to patient death, including anxiety, uncertainty, a sense of loss, psychological distress, and a reduced sense of professional efficacy. Experiencing such emotions may affect professional functioning, limiting the ability to provide care in accordance with the highest quality standards. Moreover, negative emotional reactions associated with caring for terminally ill patients may hinder the establishment and maintenance of effective communication with both the patient and their family members. Long-term exposure to suffering and death may also lead to gradual emotional desensitization and reduced sensitivity to patients’ needs. At the same time, becoming fully emotionally involved in the situation of every dying patient is impossible and could contribute to excessive psychological burden among healthcare professionals. Therefore, individual psychological resources and effective stress-coping strategies are of great importance, as they enable the reduction of emotional tension and maintenance of the ability to perform professional duties effectively [11, 12]. The results of the present study indicate that caring for dying patients is a frequent experience among nursing staff. More than three-quarters of respondents reported frequent or constant contact with patients at the end of life, confirming the specific nature of work in anesthesiology and intensive care units. It should be emphasized, however, that end-of-life care in the ICU differs substantially from care provided in palliative or hospice settings. Intensive care units admit not only older patients with advanced chronic diseases but also younger patients for whom the primary therapeutic goal is recovery and survival. Consequently, ICU nurses, while performing their professional duties, provide both intensive life-sustaining treatment and end-of-life care when further therapy becomes futile. This duality may generate ethical dilemmas and moral distress, which are less pronounced in settings where the primary goal of care is comfort rather than curative treatment [10, 11].

In the studied group, a rational attitude towards patient death predominated (77.1%). The majority of healthcare professionals perceived death as a natural stage of life and accepted the legitimacy of withdrawing life-sustaining interventions in situations where there were no realistic chances of improving the patient’s condition and when further treatment would only prolong suffering. At the same time, some nursing staff reported negative emotions associated with caring for dying patients, such as fear, helplessness, or discomfort in interactions with patients and their families. Only 17.8% of nurses reported feeling fully prepared to accompany patients during the final stage of life. Different results were obtained by Guzowski et al., who reported that acceptance of death as a natural phenomenon was the least frequently represented attitude (35.3%). Furthermore, nearly half of respondents (48.6%) did not accept a passive approach towards the dying process, emphasizing the necessity of undertaking life-saving interventions regardless of prognosis. The authors also reported frequent occurrence of attitudes characterized by fear and withdrawal in relationships with dying patients and their relatives [13]. These findings should, however, be interpreted with caution, as the study by Guzowski et al. was conducted in a sample drawn from the general population rather than among nurses. Consequently, the respondents differed substantially from ICU nurses in terms of professional experience, clinical exposure to death, and involvement in end-of-life decision-making.

Similarly, Sleziona et al. reported that nearly half of the nurses (48.3%) reported being willing to accompany and support patients during the terminal phase of life, whereas more than one-third experienced feelings of helplessness or discomfort when caring for dying patients [14].

Mickiewicz et al. found that a considerable proportion of healthcare professionals did not experience fear when caring for dying patients (42.4%) and did not avoid relationships or conversations with patients and their families (59.5%). At the same time, the vast majority of respondents (85.5%) considered death a natural and inevitable phenomenon, although 32.9% believed that all possible actions should be taken to save the patient’s life [15]. These observations are broadly consistent with the findings of the present study. However, the cited studies included nurses from a variety of hospital wards and were not limited to intensive care units, which may partly explain the observed differences. In contrast, the findings reported by Zawiślak et al. should be interpreted with caution, as the study was conducted among hospice nurses, 90% of whom reported no major difficulties in providing care for dying patients [16]. These results are not unexpected, given that hospice care is inherently focused on supporting patients at the end of life, and healthcare professionals working in these settings may have more training and experience in caring for terminally ill patients. By contrast, ICU nurses work in an environment where death frequently occurs despite intensive life-sustaining interventions, making acceptance of dying and communication with patients’ families considerably more challenging. Research by Niedojad et al. showed that 69% of nurses perceived death as a natural life process, comparable to birth. For 28% of respondents, death represented the end of suffering and pain, whereas 45% declared full acceptance of death and dying as an inseparable element of human existence [17]. Nevertheless, the study included nurses employed in both surgical and non-surgical wards without specifying the proportion of participants working in intensive care units. Therefore, direct comparison of these findings is limited, as the frequency of exposure to patient death and the clinical context vary considerably across hospital settings. Copp emphasized that the lack of acceptance of death as a natural part of life may contribute to increased anxiety among healthcare professionals caring for patients at the end of life. Such attitudes have been suggested to contribute to reduced contact with dying patients, emotional distancing, and routinization of care activities, which may negatively affect the quality of care provided [18]. Therefore, the findings should be interpreted within the specific clinical context of intensive care, as frequent exposure to sudden patient deterioration, therapeutic uncertainty, and ethically complex decisions regarding the withholding or withdrawal of life-sustaining treatment may distinguish ICU nurses from healthcare professionals working in palliative care units, hospices, or general hospital settings.

Particular importance in the analysis of attitudes towards patient death is attributed to the emotional reactions reported by the surveyed nurses. The results of the present study indicate that the most frequently reported reaction was calm acceptance of the patient’s death (34.3%). A considerable proportion of respondents also reported feelings of sadness and depression (22.2%), while some participants indicated spiritual reactions, such as prayer or turning to God. A small percentage of nurses experienced anger related to a sense of injustice regarding the situation. At the same time, patient death rarely resulted in a negative evaluation of the nursing profession, whereas more than half of respondents indicated that experiencing patient death did not affect their attitudes towards their profession. The coexistence of emotions such as calmness, sadness, or a sense of injustice may reflect the complex way in which nursing staff experience patient death. On the one hand, nurses demonstrate the ability to accept the inevitability of death; on the other hand, they remain sensitive to the suffering of patients and their relatives. These findings suggest that despite significant emotional burden, the majority of healthcare professionals maintain a sense of meaning in their work and demonstrate professional commitment to patient care. The findings of the present study are partially consistent with the findings of Reczyńska, in which 38% of respondents declared calm acceptance of patient death, whereas 37% experienced anger and a sense of injustice associated with the patient’s death. Sadness accompanied 42% of participants, and 14% indicated prayer as one of their reactions to patient death. Moreover, more than half of respondents emphasized that the experience of patient death did not influence their evaluation of their professional choice [19].

Similar results were obtained by Hryniewiecka and Klimaszewska, who reported that the most common reaction among nursing staff was acceptance of the situation and calm acceptance of the fact of patient death (49%). Other frequently reported reactions included helplessness and anger (18%), whereas sadness, low mood, and crying were reported by 9% of respondents. At the same time, a small proportion of participants admitted that patient death caused doubts or reluctance towards continuing their profession [20]. The literature also emphasizes the importance of religiosity and spirituality as methods of coping with the experience of patient death [16, 17, 21, 22]. In the study by Mickiewicz et al., prayer and crying at the moment of patient death were reported by 2.2% of respondents [15]. Interesting data are also provided by qualitative research conducted by Yang and McIlfatrick [23] among intensive care nurses in Taiwan. The authors demonstrated that nursing staff frequently experience feelings of guilt resulting from the belief that they have not provided patients with sufficient conditions for dignified dying and from the inability to save some patients [23]. The literature also highlights that the necessity to simultaneously perform tasks related to life-saving interventions and provide end-of-life care may create a conflict of professional roles. Long-term functioning under such conditions may increase the risk of professional burnout, emotional exhaustion, and difficulties in maintaining consistency with one’s moral and ethical beliefs [24].

The results of the present study indicate that the most important factor influencing nurses’ attitudes towards patient death is the patient’s age (87.9%), followed by the cause of death (67.5%). Less importance was attributed to the type of death (38.2%), the relationship with the patient (38.2%), and the relationship with the patient’s family (22.9%). These findings suggest that the perception of death among nursing staff is determined not only by the fact of death itself but also by the clinical, emotional, and social context accompanying the dying process. Situations involving the death of young individuals appear to be particularly difficult, as they are often perceived as premature and inconsistent with the natural order of life. The results of the present study are supported by findings reported by other authors. Gniewek et al. reported that patient age was the most important factor influencing attitudes towards death for 34.6% of respondents. A significant role was also attributed to relationships with the patient and their family (25.1%) as well as the cause of death (23.5%). Furthermore, 12.7% of participants indicated that the type of death was an important factor, emphasizing that acceptance of death becomes easier when the patient’s condition is severe and irreversible [25]. Similar observations were reported by Dębska et al. [26], Gregorasz [27], and Kluczek et al. [28], who consistently emphasized that young age of the patient represents one of the most challenging aspects of the dying process, while the death of a child is an especially emotionally burdensome experience for nursing staff.

An important issue addressed both in the present study and in the literature is the possibility of becoming accustomed to patient death. More than half of respondents (50.3%) believed that this was not possible because every death occurs under different circumstances and is associated with individual emotional experiences. This finding indicates that the experience of death retains its unique and unrepeatable character for many nurses, regardless of professional experience or the number of similar events encountered during their careers. At the same time, 37.6% of participants expressed the opinion that with time and professional experience, partial adaptation to the phenomenon of death becomes possible. It may be assumed that this process represents an adaptive mechanism that allows nurses to maintain psychological balance and perform professional duties effectively. However, it should be emphasized that the boundary between professional emotional distance and emotional desensitization is very subtle. This is reflected in the fact that 7.6% of respondents considered becoming accustomed to patient death as a manifestation of professional burnout. Similar findings were obtained by Niedojad et al., who reported that 44% of respondents perceived emotional reactions to patient death as a complex issue that is difficult to assess unequivocally. At the same time, 23% of participants agreed with the statement that death had become a routine element of their work and no longer evoked strong emotions, whereas 12% disagreed with this opinion and 21% were unable to express a definite position [17]. Comparable results were obtained by Sleziona et al., according to whom 63.3% of nurses believed that it was possible to partially become accustomed to patient death and develop a certain level of emotional resilience, although such experiences were still accompanied by emotions and personal reflections. In contrast, 19.2% of respondents considered death to remain an individual and unique event to which one cannot become immune. Furthermore, 14.2% associated becoming accustomed to death with symptoms of professional burnout, while only 3.3% reported that with increasing professional experience, death becomes an ordinary phenomenon that no longer evokes emotions [14]. The present findings indicate that nursing staff function between the necessity of maintaining professional distance and the need to preserve an empathetic approach towards patients. The ability to balance these attitudes appears crucial for maintaining high-quality care and protecting the mental health of nurses working in intensive care settings.

The results of the present study demonstrated that the predominant coping styles in difficult situations among the surveyed nurses were the task-oriented coping style and the avoidance-oriented style involving seeking social contacts. This was confirmed by the coping strategies selected by respondents, including engagement in work (78%), support from close relatives and friends, development of personal interests (71%), and seeking support from colleagues (52%). Faith and prayer also played an important role (45%). Such a diverse range of coping methods indicates that nursing staff seek both active, task-oriented ways of managing tension and strategies based on interpersonal relationships and personal resources. Similar findings were reported by Reczyńska [19]. Although the dominant stress-coping style among the respondents in that study was the emotion-focused style, participants most frequently managed difficulties through faith in God (59.8%), involvement in work (44.5%), and support from close people (41.3%) [19].

The task-oriented coping style is considered one of the most adaptive stress-management strategies among nursing staff because it promotes focusing on problem-solving, work organization, and maintaining professional effectiveness despite high emotional burden. At the same time, the literature indicates that focusing solely on tasks should not constitute the only strategy for coping with psychological stress. Long-term suppression of emotions or excessive involvement exclusively in professional duties may hinder the processing of emotional experiences and increase the risk of mental health problems and professional burnout [29-33].

The associations observed in the present study should be interpreted as relationships rather than evidence that a particular coping style determines the choice of a specific coping strategy. As the analyses were based on cross-tabulations of categorical variables, no conclusions can be drawn regarding causal relationships or individual behavioral patterns. These findings demonstrate that support provided to nurses should be differentiated and should include both training in constructive coping strategies and real access to professional conversations, supervision, and psychological support in the workplace.

In light of the present findings, the implementation of ongoing support systems may be warranted in units with a high risk of emotional burden, including psychological consultations, team meetings following difficult patient deaths, communication training with patients’ families, and education in thanatology.

When interpreting the results, the limitations of the study should be taken into account. The analysis included nursing staff working in the specific environment of anesthesiology and intensive care units; therefore, the findings should not be automatically generalized to all groups of nurses. The study had a cross-sectional design and was based on respondents’ self-reports, which may involve the risk of subjective assessment of their own emotions and behaviors. Despite these limitations, the results constitute an important contribution to the discussion on the need for systemic support of nursing staff involved in end-of-life care.

Conclusions

Nursing staff working with patients at the end of life most commonly report acceptance of death as a natural stage of life; however, the experience of a patient’s death continues to constitute a significant emotional burden.

The most common emotional responses of nurses to a patient’s death are sadness, dejection, and anger resulting from a sense of injustice, while the majority of respondents report maintaining a sense of purpose and meaning in their profession.

The factors most frequently identified by nurses as influencing their attitudes toward a patient’s death are those related to the patient, particularly the patient’s age and the cause of death, highlighting the importance of individual and relational factors in the context of dying.

The predominant coping strategy identified among the study participants was a task-oriented coping style, complemented by seeking support from family members and colleagues, pursuing personal interests, and engaging in religious practices.

Some nurses reported a lack of effective stress-coping strategies or experienced difficulties in reducing anxiety and tension, indicating the need for systematic psychological support in the workplace.

The study findings suggest the potential value of further developing education in thanatology, providing training in communication with dying patients and their families, and implementing preventive measures aimed at reducing the risk of professional burnout among nursing staff.

Disclosures

This research received no external funding.

The study was approved by the Bioethics Committee of the Pomeranian Medical University in Szczecin (Approval No. KB.006.67.2024).

The authors declare no conflict of interest.

References