Exploring Death Anxiety and Burnout
Among Staff Members Who Work
In Outpatient Hemodialysis Units
Valerie L. Lee
Anita H. King
he outpatient hemodialysis
T
(HD) unit is a fast-paced, tech-
nological environment that
requires healthcare workers to
receive special training for the devel-
opment of a unique set of skills.
Patients who receive HD treatments
have been diagnosed with end stage
renal disease (ESRD), are in a pro-
gressively declining state of health,
and have an average life expectancy
of 6.2 years (United States Renal Data
System [USRDS], 2013). Registered
nurses, patient care technicians, social
workers, dietitians, and other staff
members who work in HD units and
provide life-supporting treatments
three to four times per week over a
period of months or years often
develop close relationships with their
patients. The intensity of work
required to prolong life in this patient
population can cause frustration,
moral distress, compassion fatigue,
depression, and burnout in caregivers
Valerie L. Lee, DNP, MSN, FNP-C, is a
Doctor of Nursing Practice, St. Luke’s Clinic,
Nephrology, Boise, ID, and has served as
President-Elect and President of ANNA’s
Sawtooth Chapter. She may be contacted directly
via email at jLeeElec@aol.com
Anita H. King, DNP, MA, FNP-BC, CDE,
FAADE, is a Clinical Associate Professor, College
of Nursing University of South Alabama,
Fairhope, AL.
Acknowledgements: Thank you to Dr. Micheal
Adcox for his clinical guidance through this proj-
ect; to Dana Camacho, MBA, BSN, Group
Facility Administrator, for her assistance with
data collection; and to Richard Remington, MS,
for his assistance with statistical analysis.
Statement of Disclosure: The authors reported
no actual or potential conflict of interest in rela-
tion to this continuing nursing education activity.
Note: Additional statements of disclosure and
instructions for CNE evaluation can be found on
page 486.
Nephrology Nursing Journal September-October 2014
Continuing Nursing
Education
Copyright 2014 American Nephrology Nurses’ Association
Lee, V.L., & King, A.H. (2014). Exploring death anxiety and burnout among staff mem-
bers who work in outpatient hemodialysis units. Nephrology Nursing Journal, 41(5), 479-
485, 518.
Outpatient hemodialysis unit staff members are at risk for psychological stress, including
death anxiety, unresolved grieving, and burnout, due to frequent interactions with chron-
ically ill patients who have a high mortality rate. Experiencing death anxiety and
burnout may impair the ability to build interpersonal relationships, decrease job satis-
faction, and impact quality of patient care. A quantitative study to evaluate the effect of
educational classes on the level of death anxiety and burnout among hemodialysis care-
givers revealed a decrease in participants’ level of death anxiety and a decrease in emo-
tional exhaustion in one area that was directly related to the work environment.
Information from the study can be used to decrease psychological stress through educa-
tion and support for staff members who work in the hemodialysis unit environment.
Key Words: Death anxiety, burnout, unresolved grieving, hemodialysis, end-of-
life care.
Goal
To provide an overview of the impact unresolved psychological stress, primarily death
anxiety and burnout, has on nephrology nurses and other staff members working in out-
patient hemodialysis units.
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.
2. Discuss the benefits to nurses and other dialysis staff of receiving education
about the life expectancy and complicated health issues of patients with ESRD.
working in outpatient hemodialysis whom they have had frequent interac-
tion in meaningful relationships. Job
units (Ashker, Penprase, & Salman,
2012; Dermody & Bennett, 2008; stress, emotional exhaustion, and cyn-
Hayes & Bonner, 2010). The high icism can lead to job dissatisfaction,
patient death rate can lead to unre- absenteeism, and a high rate of turn-
solved grieving (Gerow et al., 2010) over among caregivers working in
and death anxiety in caregivers who hemodialysis units (Flynn, Thomas-
experience the loss of people with Hawkins, & Clarke, 2009; Hayes &
This offering for 1.4 contact hours is provided by the American Nephrology Nurses’
Association (ANNA).
American Nephrology Nurses’ Association is accredited as a provider of continuing nursing
education by the American Nurses Credentialing Center Commission on Accreditation.
ANNA is a provider approved by the California Board of Registered Nursing, provider number
CEP 00910.
This CNE article meets the Nephrology Nursing Certification Commission’s (NNCC’s) continu-
ing nursing education requirements for certification and recertification.
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,
2011). Staff turnover due to unre-
solved psychological stress can affect
the efficiency and morale of the HD
care team, and can lead to low quality
care, poor patient outcomes,
and decreased patient satisfaction
(Argentero, Dell’Olivo, & Ferretti,
2008; Hayes & Bonner, 2010). This
quantitative study was designed to
explore the effect of an educational
intervention on the level of death
anxiety and burnout in caregivers
who work in the outpatient HD envi-
ronment.
Defining the Concepts of Death
Anxiety and Burnout
Caregivers who experience death
anxiety have anxious thoughts or feel-
ings when thinking about or talking
about death and/or the dying process,
or when interacting with someone
who is dying (Lehto & Stein, 2009;
Mallet, Jurs, Price, & Slenker, 1991;
Tomer, 1994). These uncomfortable
thoughts or feelings may be due to the
avoidance of discussions about death
and dying in the American culture
(Nyatanga & deVocht, 2006). With
the focus of medical care in the
United States primarily on prolong-
ing life and avoiding death, many
nurses and physicians feel inade-
quately trained to provide high quali-
ty end-of-life (EOL) care or to com-
municate effectively with a patient
who is dying (Billings, Engelberg,
Curtis, Block, & Sullivan, 2010;
Peterson et al., 2010a; Schell, Green,
Tulksy, & Arnold, 2013; White &
Coyne, 2011).
According to Maslach, Schaufeli,
and Leiter (2001), caregivers who are
experiencing burnout feel emotional-
ly exhausted, are indifferent or cyni-
cal toward the needs of other people,
and have decreased satisfaction with
personal accomplishments. They are
often inefficient in performing occu-
pational tasks. They may also have a
high rate of absenteeism and fre-
quently express intent to leave their
jobs.
The presence of burnout and/or
the fear of a patient’s death or dying
480
process, also known as death anxiety,
can prevent a therapeutic interaction
between patients and caregivers and
can hinder the delivery of quality HD
and EOL care (Deffner & Bell, 2005,
Lehto & Stein, 2009). Nurses, patient
care technicians, and other dialysis
staff members who have not received
formal education about death, dying,
or the grieving process may not feel
qualified or confident enough to initi-
ate or participate in discussions about
EOL preferences with patients who
are in a declining state of health
(Hopkins et al., 2011). Providing edu-
cation and support can help these
important caregivers cope with death,
dying, personal loss, and the grieving
process while providing care to a pro-
gressively ill patient population.
Literature Review
In preparation for the study, a
comprehensive search for evidence
was performed. Studies of healthcare
workers were reviewed that explored
1) the presence of death anxiety while
providing care to patients who are
nearing the EOL, 2) the presence of
burnout while providing care to
patients who are receiving HD treat-
ments, 3) the relationship between the
presence of death anxiety and the
presence of burnout, and 4) the influ-
ence of education on levels of anxi-
ety, exhaustion, helplessness, job sat-
isfaction, and patient care quality
indicators. Several databases were
searched, including Clinical Evi-
dence, Cochrane Library, the
Cumulated Index of Nursing and
Allied Health Literature (CINAHL),
DynaMed, Google Scholar, Medline
at Ovid, Nursing Reference Center,
PubMed, and SCOPUS.
Death Anxiety in Healthcare
Workers
Providing care to patients who
are in a declining state of health in-
creases feelings of anxiety in health-
care workers. Mallet et al. (1991) stud-
ied hospice and critical care nurses
and discovered a positive relationship
between emotional stress, death anxi-
ety, and burnout. Robbins, Lloyd,
Nephrology Nursing Journal
Carpenter, and Bender (1992) found
high levels of both work-related anxi-
ety and death anxiety among care
assistants who provided EOL care to
residents in extended care facilities. A
study by Deffner and Bell (2005)
revealed that nurses who experienced
a high level of death anxiety felt less
comfortable communicating with
patients and their families about
death. A literature review of the con-
cept of death anxiety by Lehto and
Stein (2009) emphasized that nurses
are in a critical position to influence
the level of death anxiety in individu-
als who are nearing the EOL. These
influential caregivers may be reluc-
tant or unable to interact with patients
in a therapeutic manner if they are
personally experiencing a high level
of death anxiety. A study by Peterson
et al. (2010b) revealed that many
nurses and nursing students had a
personal fear of death and experi-
enced an increased level of stress
when providing care to dying patients
and their families. A study of nurses
who worked in the nephrology field
by Ho, Barbero, Hidalgo, and Camps
(2010) revealed that a majority of
these caregivers found EOL care to
be an emotionally demanding part of
their job. The nurses felt that special
training was needed to communicate
effectively, provide psychological
support, and comfortably discuss
EOL issues with patients and family
members. The study also revealed
that nurses who had an opportunity
to verbalize their feelings with sup-
portive peers had a more positive atti-
tude toward providing care to dying
patients.
Burnout in Healthcare
Workers
Many factors in the outpatient
HD unit environment contribute to
the level of psychological stress and
burnout in healthcare workers. Hayes
and Bonner (2010) reviewed nine
international studies exploring the
relationship between stress, burnout,
and job satisfaction in nurses working
in the HD environment. They found
several environmental factors that
contributed to caregiver stress and
September-October 2014 Vol. 41, No. 5
burnout, including 1) difficult inter-
personal relationships with physi-
cians; 2) care environment chal-
lenges, such as risk of exposure to
bloodborne pathogens and becoming
emotionally attached to patients who
have a progressive decline in health
and who eventually die; 3) exposure
to violence and abuse from patients;
and 4) organizational stressors, such
as workload, inadequate staffing, lim-
ited access to educational opportuni-
ties, lack of time for meals, and lack of
time for adequately meeting patient
needs. A study of nurses working in
outpatient HD units by Gardner and
Walton (2011) revealed that nurses
felt 1) isolated due to working in a dis-
jointed and ineffective healthcare sys-
tem, 2) overwhelmed by a stressful
work environment, 3) disrespected as
nursing professionals by administra-
tion and medical providers, and 4)
disconnected from their own personal
expectations of what they felt they
should be as a nurse.
Personal characteristics of health-
care workers also contribute to psy-
chological stress and burnout.
Bohmert, Kuhnert, and Nienhaus
(2011) evaluated 19 international
studies and one literature review.
They found higher levels of burnout
were present if a dialysis unit health-
care worker was 1) an unmarried
male, 2) had limited opportunity to
perform administrative or education-
al tasks, 3) worked more than 40
hours per week, 4) had a work history
of more than 10 years in dialysis units,
5) worked in a unit with more than 50
patients, or 6) worked with more than
11 staff members. A study of clinical
and non-clinical HD unit staff mem-
bers by Ross, Jones, Callaghan, Eales,
and Ashman (2009) revealed that
16% of the participants described
symptoms of psychological distress,
such as depression, inability to cope,
anxiety-based insomnia, and low self-
esteem.
Nurses who work in HD units
have been found to have a high level
of burnout. A study of nurses working
in the nephrology field by Harwood,
Ridley, Wilson, and Laschinger (2010)
Nephrology Nursing Journal September-October 2014
revealed these caregivers had high
levels of emotional exhaustion and
cynicism. The authors suggested that a
negative work environment that
lacked support, resources, opportuni-
ties, and empowerment for nurses
may have contributed to the high lev-
els of emotional exhaustion found in
the study. A significant association was
found between these burnout in-
dicators and adverse physical and/or
mental health symptoms, and with the
nurses’ intent to resign from their jobs.
O’Brien (2011) surveyed nurses work-
ing in outpatient HD units and found
33% of participants reported a high
level of burnout, and 27.5% of partici-
pants reported a moderate level of
burnout. A study of registered nurses
working in HD facilities by Flynn et
al. (2009) revealed that 31% of the
nurses had scores indicative of emo-
tional exhaustion, and 19.3% of the
nurses were planning to leave their
current position within the next 12
months.
Providing End-of-Life
Education to Healthcare
Workers
Providing education can improve
the comfort and skill levels of health
caregivers and can improve the qual-
ity of care provided to patients who
are in a declining state of health.
Mallory (2003) found that providing a
six-week interactive palliative educa-
tion course to undergraduate nursing
students decreased feelings of death
anxiety, helplessness, and emotional
exhaustion. The course was also
found to improve the participants’
attitude toward caring for people who
are dying when post-education scores
were compared with a control group
who did not receive the education. A
study of healthcare professionals and
undergraduate medical students by
Hegedus, Zana, and Szabo (2008)
revealed a decrease in death anxiety
and fear of death scores after partici-
pants received a 40-hour course on
effective communication, stress man-
agement techniques, palliative care
treatments, and clinical management
of EOL situations.
Vol. 41, No. 5
Patient Satisfaction and Care
Outcomes
Healthcare workers who are sat-
isfied with their job responsibilities
and work environment are less likely
to experience burnout and are better
equipped to provide high quality
patient care. In addition, patients are
more satisfied with the care they
receive from healthcare workers who
have a positive attitude toward their
jobs. Gardner, Thomas-Hawkins,
Fogg, and Latham (2007) found an
increase in the number of hospitaliza-
tions in patients receiving HD treat-
ments in facilities where staff nurse
turnover was high and where nurses
gave a negative rating of the dialysis
work environment. A study by
Argentero et al. (2008) revealed that
patient satisfaction scores on the qual-
ity of dialysis care received increased
when nurses and physicians who
worked in the dialysis units had low
emotional exhaustion levels and high
personal accomplishment levels.
McHugh, Kutney-Lee, Cimiotti,
Sloane, and Aiken (2011) found low
patient satisfaction scores in hospital
units where nurses were dissatisfied
with their job environment and
reported a high level of emotional
exhaustion.
Study Methodology
Design and Description
Of Sample
A quantitative study was design-
ed using convenience sampling. Two
self-report instruments were used for
collection of pre and post-interven-
tion data. Institutional Review Board
approval for the study was obtained
from a southeastern university. Ap-
proval was also obtained from the
dialysis corporation clinical research
team prior to initiation. A project plan
proposal was submitted to the region-
al director, facility administrators, and
the medical director for review prior
to initiation of the study. Face-to-face
discussions and letters describing the
study and inviting participation were
distributed to HD unit staff members
during the recruitment process. Parti-
481
Exploring Death Anxiety and Burnout among Staff Members Who Work in Outpatient Hemodialysis Units
cipants were recruited from five out-
patient HD units within a 60-mile
radius in southwestern Idaho and
eastern Oregon. All dialysis units
were owned by a single dialysis cor-
poration. Two HD units were located
in a suburban area, and three HD
units were located in small rural com-
munities.
Participants
Forty-eight staff members from
five HD units received information
and were eligible to participate in the
study. A total of 15 caregivers from
three of the HD units participated in
some or all of the classes. Four of the
15 participants missed the last class,
did not complete post-intervention
instruments, and were not included in
the study.
Description of Educational
Intervention
The educational intervention
consisted of a series of four interactive
classes that were presented once per
week in each of the three participat-
ing HD units. Classes were presented
for two hours in the late afternoon or
evening in the conference room of
the HD facility. The class atmosphere
was informal, with participants seated
in a round-table format. Dinner was
served during each class. Staff mem-
bers received no compensation for
participating.
The class content was designed to
include 1) a review of renal patholo-
gy, 2) a discussion of the concepts and
symptoms of death anxiety and
burnout, 3) an exploration of the
process of grieving, 4) a discussion of
effective coping and self-care prac-
tices, 5) a review of EOL legislation
and advance directive forms, and 6) a
review of ways to participate in dis-
cussions about EOL preferences with
patients and family members. The
final class allowed time for honoring
and sharing memories of patients
who had made an impact on each
participant’s life. Participants shared
endearing characteristics and the life
lessons they learned while interacting
with these special patients.
482
Data Collection
Two pre- and post-intervention
instruments were used to promote
self-introspection and measure the
effects of the educational intervention
on the participants’ level of death
anxiety and burnout. The Revised
Collett-Lester Fear of Death and
Dying Scale [RCFDS] (Lester, 1994)
is a 32-item, five-point Likert scale
instrument that measures feelings
about the participant’s own death and
dying process, and the death and
dying process of other people.
Maslach’s Burnout Inventory [MBI]
(Maslach, Jackson, & Leiter, 1996) is a
16-item, seven-point Likert scale
instrument that measures emotional
exhaustion, cynicism, and satisfaction
with personal accomplishments. The
subscales in the MBI provide a three-
dimensional overview of characteris-
tics of burnout. The general survey
scale used was designed to measure
participants’ level of burnout in direct
relationship with their work. The
questions address the level of engage-
ment and energy being directed
toward work performance and the
level of confidence in participants’
effectiveness at work. High scores on
the exhaustion and cynicism sub-
scales reflect a high degree of
burnout. A low score on the satisfac-
tion with personal accomplishments
scale also reflects a high degree of
burnout. Question number five on
the Emotional Exhaustion subscale,
“I feel burned out from my work,” (p.
10), was determined by Maslach et al.
(1996) to be the strongest indicator of
burnout. Identifying numbers rather
than names were used on measure-
ment instruments to protect anonymi-
ty and promote honest disclosure.
Data Analysis
Statistical analysis was performed
on the pre- and post-intervention
instruments. The measurement of
death anxiety on the RCFDS is deter-
mined by numerical calculations. The
level of death anxiety in each of the
four subscales is determined by the
total number. A score of 40 per partic-
ipant or 444 for all participants is the
highest possible number or level of
Nephrology Nursing Journal
death anxiety, and a score of 8 per
participant or 88 for all participants in
each category is the lowest possible
number or level of death anxiety. A
paired t-test was used for each ques-
tion in the four subscales on the
RCFDS and for each of the 16 ques-
tions on the MBI to evaluate for a sig-
nificant difference between the pre-
and post-intervention scores.
Results
All participants were female. The
participants’ age ranged from 23
years to over 66 years, with the largest
percentage between 36 and 55 years
(see Table 1). The level of education
ranged from a high school diploma to
a bachelor’s degree. Three partici-
pants had previously taken a course
on death and dying, five participants
had been exposed to information
about death and dying in college
courses, and three participants had
never received education about death
and dying (see Table 1). Participants
included six registered nurses, one
licensed practical nurse, two patient
care technicians, one dietitian, and
one patient care services assistant.
Average scores from all partici-
pants on the RCFDS indicated a
decrease in death anxiety in all four
subcategories (see Figure 1 and Table
2). The average score for all partici-
pants in the subscale Anxiety Over
Your Own Death was 21.3 pre-inter-
vention and 18.2 post-intervention; in
the subscale Anxiety Over Your Own
Dying was 29.4 pre-intervention and
26.7 post-intervention; in the subscale
Anxiety Over The Death Of Others
was 24.2 pre-intervention and 22.6
post-intervention; and in the subscale
Anxiety Over The Dying Of Others
was 24.6 pre-intervention and 20.9
post-intervention. None of the mean
differences in each category was
found to differ significantly from zero.
The analysis of the MBI revealed a
significant decrease in the mean score
(-0.36) on question number five of the
emotional exhaustion subscale, “I feel
burned out from my work” (Maslach
et al., 1996, p. 10), after the education-
al intervention, with a 95% confi-
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

and support for staff members who
may be grieving the loss of one or
multiple patients. Implementing these
changes in the HD unit environment
may decrease the risk of death anxi-
ety and burnout in caregivers who
provide HD treatments to patients
with ESRD.
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