Czech Adaption of the Collett–Lester Fear of Death Scale in a Sample of Nursing Students

Abstract

The use of multidimensional scales for assessing fear of death among nursing students can assist in teaching and evaluating the effectiveness of targeted training in thanatology. Research has demonstrated good psychometric characteristics of the Czech version of the Collett–Lester Fear of Death Scale (CL-FODS). It was applied to nursing students (N = 256), who reported as their biggest fear the process of their own dying. Greater fear of death and dying was found in students who had no experience of the dying and death of a loved one. Good internal consistency was achieved for the four subscales of the Czech CL-FODS.

Keywords

attitudes death death anxiety death education death dying hospitals

Although death is the inevitable end of life, it is not a frequently discussed topic. Neimeyer (1994) defines fear of death as a human experience in everyday life rather than in extreme situations when there is the threat of imminent death. It includes several components: preparation for one’s own death, fear of the dying process, and fear of the death of other people. Anxiety and fear of death are normal and are often instilled in the process of socialization. Therefore, negative social attitudes toward death and dying, and cultural conceptions can affect the feelings of fear and anxiety of death (Mooney, 1999). Naderi and Esmaili (2009) indicate other factors affecting the level of anxiety and fear of death: predominantly mental health and actual experience of death. Nazarzadeh, Sarokhani, and Sayehmiri (2015) found a relationship between fear of death and dying and general health condition. Differences in fear of death in individual items may also be affected by religion, cultural opinions about death, and quality of life. A number of empirical studies have shown cultural differences in reactions to death and dying, reflecting the ascription of distinct cultural values and meanings to life and death (Kubler-Ross, 1975; Stroebe, Bergen, Gergen, & Stroebe, 1992; Yang & Chen, 2009) and religiosity (Ellis, Wahab, & Ratnasingan, 2013; Power & Smith, 2008). Personal attitudes to death are also influenced by the way of life a person lives. Those who live happier and more meaningful lives are usually less afraid of death or have a neutral attitude toward it (Payne, Dean, & Kalus, 1998).

Almost all nurses encounter dying and death in patients, and they should provide them and their family with sensitive care. Each health professional approaches a dying patient according to how they understand the phenomenon of death and dying (Haškovcová, 2000). Some studies have demonstrated a significant relationship between the attitudes toward death of nurses and their personal approach to clinical work with dying patients (McClatchey & King, 2015; Wong, Reker, & Resser, 1994). Payne et al. (1998) report that nurses who have a great anxiety of death and dying deal with the emotional burden of their work by distancing themselves from patients and focusing primarily on biological aspects of care. Neimeyer (1994) also demonstrates that health professionals with a high level of fear of death frequently use “avoidance” coping strategies. For this reason, it is appropriate to include the concept of perception of death in the education of nurses already on undergraduate study programs.

Training future health professionals in the field of death and dying is an important preparation for their profession. The quality and quantity of education in thanatology varies. Vávrová and Polepilová (2010), based on an analysis of syllabi in thanatology and palliative care included in university courses for the caring professions, stated that the vocational training of those students working with dying people is currently inadequate in the Czech Republic. Students who persevered to a graduate degree received only further lessons in death avoidance. Nurses, physicians, and other health workers who are relied upon to provide care services were not helped to understand their own death-related feelings, much less anyone else’s (Kastenbaum, 2012).

Lester (1994), Hegedus, Zana, and Ratnasingan (2008), and McClatchey and King (2015) show, based on research, that education and targeted training in the field of death and dying among university students of health subjects can reduce their fear and anxiety of death. In lessons, fear of death scales can be used which can be evaluated in the context of educational programs focusing on attitudes to death.

Instruments for measuring fear of death are classified as one-dimensional or multidimensional scales. One-dimensional scales are used to express one’s own evaluation of fear of death. Multidimensional scales distinguish attitudes toward death and dying of oneself and others (Naderi & Esmaili, 2009). The evolution of measures of attitudes toward death has been in the direction of greater differentiation and specificity, moving from global assessments to more multidimensional scales (Neimeyer, Moser, & Wittkovski, 2003; Tomás-Sábado, Limonero, & Abdel-Khalek, 2007). The following measuring scales can be used for research and clinical practice: The Collett–Lester Fear of Death Scale (CL-FODS), the Multidimensional Fear of Death Scale, and The Multidimensional Measure of Attitudes toward Death. However, they are hardly ever used in the Czech Republic. CL-FODS is a frequently used scale in the area of research, and it is also the one we used in our research. The CL-FODS was created by Collett and Lester in 1969 to eliminate the content heterogeneity problem of the items in the scales used to measure fear of death. The authors suggested that fear of death is a multidimensional concept with different possible causes, which can make a person react differently to the idea of death as a state or as a process (Collett & Lester, 1969; Venegas, Alvarado, & Barriga, 2011). The CL-FODS instrument has been validated in several cultural contexts, evidencing acceptable psychometric characteristics (Abdal-Khalek, 2004; Kolawole & Olusegun, 2008; Neimeyer, Moser, & Wittkowski, 2003; Tomás-Sábado et al., 2007; Venegas et al., 2011).

The first version of the CL-FODS (Collet & Lester, 1969) contained 36 items, with a different number of items for each of the subscales. Later, Lester (1990, 1994) presented a revised version, in which all the subscales had the same number of items (eight) and the scoring system was also simplified. Later, Lester and Abdel-Khalek (2003) published a CL-FODS instrument consisting of 28 items, with seven items on each subscale.

The aim of this study was to develop a Czech version of the CL-FODS (28 items) in nursing students and to explore its psychometric properties (internal consistency and factorial structure). An additional aim was to compare fear of death in nursing students according to year of study, age, and experience of death of a loved one.

Method

Participants

The study was conducted at the University of Ostrava and involved 256 female nursing students in their first to fifth year of (full time and part time) study. The students were between 19 and 52 years of age, their mean age was 24.5 (SD = 6.9). The part-time students worked concurrently as nursing assistants in a hospital. Their mean age was significantly higher (34.6).

The scale was administered to students in group testing sessions during classes. All students voluntarily responded to the questionnaire, having been assured of its anonymity and confidentiality.

Instrument—The revised CL-FODS

To assess fear of death, the Czech version of the 28-item revised CL-FODS (Lester & Abdel-Khalek, 2003) was used. The CL-FODS is a classic multidimensional instrument used in assessing attitudes toward death and is unique in that it distinguishes between death, and the process of dying, for both oneself and others (Tomás-Sábado et al., 2007). It is used mainly for evaluating anxiety and fear of death in nurses, psychologists, doctors, and students of these professions (Mooney, 1999). The items are organized into four separate subscales: (1) fear of one's own death, (2) fear of the process of dying, (3) fear of the death of others, and (4) fear of the process of the dying of others. Each of the four subscales contains seven items. The answers are given on a 1 (nothing) to 5 (much) Likert-type scale (Lester, 1994). Figures are obtained for the total score, and for each subscale, based on calculation of the average of the respective answers. Total scores range from 28 to 140; the score in each subscale can range from 7 to 35, with higher scores denoting higher anxiety of death or dying. Three additional items regarding age, field of study, and experience of the death of a loved one in the past 2 years were part of the questionnaire.

The CL-FODS was translated into Czech from English by two bilingual experts. A reverse translation was then completed. In addition, the Czech scale was submitted to expert review to guarantee the comprehensibility of the items, followed by a pilot test of the instrument in which 25 participants showed good understanding of the scale.

Data Analysis

The data were processed using the SPSS Version 21 statistics software. All statistical tests were evaluated at a level of statistical significance of 5%. The psychometric properties of the CL-FODS were tested with selected methods recommended for measuring psychometric properties of questionnaires used in health care, namely, construct validity, internal consistency, and interpretability (Terwee et al., 2007).

Reliability was assessed through internal consistency, using Cronbach’s α coefficient, with an acceptable value being α > .70 (Terwee et al., 2007). Item-total correlation was indicated by a value of at least 0.40 (Ware & Gandek, 1998). The scales were correlated with each other (Spearman’s rank correlation coefficient).

Construct validity was tested by exploratory factor analysis, the principal component method, with a Varimax rotation. Before the factor analysis was performed, its adequacy was verified by the Kaiser–Meyer–Olkin (KMO) measure and Bartlett’s test of sphericity. The validity of the fear of death construct was further analyzed by element statistics, interelement, and element-total score correlation.

Interpretability is defined as the degree to which one can assign qualitative meaning to quantitative scores (Terwee et al., 2007). We compared means and SD of scores of relevant subgroups of students expected to differ in score (groups with different ages, class, type of study, and experience of the death of a loved one). The Shapiro–Wilk test was used to check the normality of the data set. Student’s t test was used to compare the means of two independent samples. Multiple linear regression was used to determine the relative independent contribution of independent variables to dependent variables.

Results

The sample included 256 female nursing students. Table 1 reports the descriptive statistics of the demographic characteristics of the sample.

Table 1.

The Demographic Characteristics of the Sample.

Characteristics	Nursing bachelor degree n = 193	Pediatric nursing master degree n = 11	Geriatric nursing master degree n = 52	Total n = 256
	N (%)	N (%)	N (%)	N (%)
Age (mean – SD)	24.5 (6.9)	24.2 (0.8)	28.9 (8.0)	25.4 (7.2)
19–24 Years	144 (74.6)	8 (72.7)	29 (55.8)	181 (70.7)
≥25 Years	49 (25.4)	3 (27.3)	23 (44.2)	75 (29.3)
Academic year
1	76 (39.4)	0	0	76 (29.7)
2	23 (11.9)	0	0	23 (9.0)
3	94 (48.7)	0	0	94 (26.7)
4	0	11 (100)	44 (84.6)	55 (21.5)
5	0	0	8 (15.4)	8 (3.1)
Type of study
Full time	140 (72.5)	11 (100)	33 (63.5)	184 (71.9)
Part time	53 (27.5)	0	19 (36.5)	72 (28.1)
Experience of the loss of a loved one
Yes	100 (51.8)	8 (72.7)	23 (44.2)	131 (51.2)
No	93 (48.2)	3 (27.3)	29 (55.8)	125 (48.8)

Note. n = 256. SD = standard deviation.

The mean fear of death score among the nursing students was moderately high. The highest score (31.9) per subscale corresponded to the fear of the process of one's own dying. Conversely, the lowest score (24.0) found in the subscale corresponded to the fear of one's own death. The results of subscale descriptive variables are shown in Table 2.

Table 2.

Mean, Standard Deviation, α Coefficient, and Intercorrelations of the Collett-Lester Fear of Death Scale Subscales.

Subscales of CL-FODS	Subscale descriptive variables N = 256				Dying of self	Death of others	Dying of others
	Mean (SD)	α	Min − max	Death of self	Intercorrelations of subscales
Death of self	21.2 (6.6)	.836	7–35	1.000
Dying of self	28.0 (4.8)	.822	9–35	0.513	1.000
Death of others	25.9 (4.5)	.748	14–35	0.451	0.525	1.000
Dying of others	23.4 (4.8)	.786	8–35	0.491	0.490	0.586	1.000
Total score	112.2 (18.6)	.907	51–140	0.819	0.784	0.777	0.791

Note. SD = standard deviation.

Reliability of the CL-FODS

The total internal reliability of the CL-FODS was established at 0.914, which indicates that 91% of the variability in the obtained scores represents actual differences among people, while 9% reflects random oscillations. The Cronbach’s α coefficients of all subscales were greater than .75. It is safe to conclude that the subscales of the Czech version of the Revised CL-FODS have good internal consistency (Table 2).

As can be seen from Table 2, all the intercorrelations of the subscales are significant, positive, and ranged from .451 to .586.

Factor Analysis

Before factor analysis was performed, its adequacy was verified by the KMO measure and Bartlett’s test of sphericity. The KMO value was .89, which is very high compared to the recommended minimal value of .60. Bartlett’s test of sphericity was used to test the null hypothesis that the correlation matrix of the variables involved is an identity matrix, suggesting zero correlation coefficients between the variables. The null hypothesis was rejected, meaning that a factor analysis could be performed (χ²= 3,249.9, df = 496, p < .001).

The four components explained 50.5% of the total variance. The first component, which explained 29.8% of the variance, had significant loadings on nine items (all items on the Dying of Self subscale, Item 15 [losing someone close to you] on the Death of Others subscale and Item 24 [watching the person suffer pain] on the Dying of Others subscale). The second component explained 8.2% of the variance, with significant loadings on eight items: all the items on the Death of Self subscale and one item (Item 28—Being reminded that you are going to go through the same experience1 day) on the Dying of Others subscale. The third component, which explained 7.3% of the variance, had loadings on seven items in the subscale Fear of Dying of Others, and one item (Item 20: Feeling guilty that you are relieved that the person is dead), on the Death of Others subscale. The fourth component explained 5.2% of variance, with significant loadings on six items on the Death of Others subscale with the exception of Item 20 (Table 3).

Table 3.

Rotated (Varimax) Factor Structure of the Czech Form to the Collett-Lester Fear of Death Scale (32 Items), and Total-Element Statistics.

Items of CL-FODS	Factors				C. item-total correlation	α if item deleted
	1	2	3	4	C. item-total correlation	α if item deleted
Death of self
Item 1	0.077	0.715	0.124	0.189	0.638	0.806
Item 2	0.238	0.597	0.150	0.081	0.583	0.816
Item 3	0.160	0.620	0.121	0.227	0.582	0.815
Item 4	0.379	0.441	0.139	0.079	0.441	0.834
Item 5	0.150	0.746	0.088	0.052	0.643	0.805
Item 6	0.164	0.746	0.192	0.090	0.687	0.797
Item 7	0.066	0.694	0.078	0.096	0.540	0.822
Dying of self
Item 8	0.746	0.252	0.079	0.110	0.672	0.784
Item 9	0.658	0.305	0.085	0.028	0.581	0.798
Item 10	0.564	0.061	0.136	0.036	0.407	0.825
Item 11	0.689	0.060	0.031	0.235	0.607	0.794
Item 12	0.646	0.229	0.112	0.154	0.639	0.787
Item 13	0.497	0.353	0.233	0.115	0.553	0.804
Item 14	0.565	0.159	0.205	0.215	0.533	0.805
Death of others
Item 15	0.553	0.068	0.068	0.455	0.425	0.732
Item 16	0.180	0.182	0.345	0.604	0.423	0.736
Item 17	0.273	0.174	0.065	0.752	0.632	0.682
Item 18	0.141	0.184	0.184	0.599	0.518	0.706
Item 19	0.225	0.125	0.199	0.717	0.631	0.681
Item 20	0.100	0.179	0.444	0.377	0.232	0.783
Item 21	0.304	0.080	0.187	0.625	0.577	0.694
Dying of others
Item 22	0.013	0.221	0.613	0.183	0.506	0.761
Item 23	0.059	0.165	0.727	0.061	0.569	0.748
Item 24	0.532	0.050	0.423	0.208	0.425	0.781
Item 25	0.170	0.099	0.714	0.216	0.624	0.738
Item 26	0.307	0.024	0.592	0.217	0.563	0.750
Item 27	0.208	0.080	0.623	0.234	0.546	0.753
Item 28	0.088	0.494	0.461	0.033	0.424	0.781
Eigenvalues	8.4	2.3	2.1	1.4
Percentage variance	29.8	8.2	7.3	5.2

Note. Bold-type values denote a factor loading ≥ 0.40; α = Cronbach’s α coefficient; C. item-total correlation = corrected item-total correlation.

For the four subscales in Table 3, each of the seven items is positively correlated inside the respective subscale. Item 20 (feeling guilty that you are relieved that the person is dead) is the element with the lowest correlation (r < .3) within the respective subscales. It can be observed that the reliability coefficient decreases when this element is extracted, which increase if the element is eliminated. These results indicate that the items are homogeneous and that the four subscales consistently measure the characteristics they were elaborated for.

Correlation Between Fear of Death and the Observed Parameters

Using Spearman's correlation coefficient, we found no relationship between fear of death in individual domains of the CL-FODS, students’ age (Pearson’s r ranged from .009 to .096), and academic year (Pearson’s r ranged from .006 to .089). No statistically significant difference was established in the domains of CL-FODS in full-time and part-time students (p values ranged from .084 to .570).

We found significant differences (p < .05) regarding the constructs fear of one's own death, the death of others, and the dying of others, reflecting different personal experience of grief. Those without experience of losing relatives demonstrated greater fear of their own death and fear of the death and dying of others. Moreover, this study found that experience of the death of a loved one served as an effective predictor of fear regarding the dying process, respectively, one's own death, the death of others, and the dying of others (Table 4).

Table 4.

Comparison of Fear of Death According to Students’ Experience of Grief (Independent t Test and Regression Analysis).

	Experience of the death of a loved one
	No	Yes		Regression
	Mean (SD)	Mean (SD)	p	β (p)
Death of self	22.2 (6.5)	20.3 (6.6)	0.025	−0.140 (0.025)
Dying of self	28.0 (4.9)	28.0 (4.8)	0.970	−0.002 (0.967)
Death of others	26.6 (4.5)	25.3 (4.4)	0.019	−0.146 (0.019)
Dying of others	24.1 (4.5)	22.8 (4.9)	0.029	−0.136 (0.029)
Total score	100.8 (16.0)	96.3 (16.6)	0.029	−0.134 (0.029)

Note. Bold-type values denote a statistically significant p value. SD = standard deviation.

Discussion

In recent decades, research on attitudes to death, including fear of death, death anxiety, and death competency, has flourished (Bath, 2010). At present, it is postulated that death anxiety is caused by consciousness of one’s own mortality (Kaklauskaité & Vonzodiene, 2015; Sherman, Norman, & McsSherry, 2010). However, the uncertainty of what awaits one after death is regarded as more frightening than death itself (Kaklauskaité & Vonzodiene, 2015; Ozanne, Graneheim, & Strang, 2013). Measuring the fear of death in health settings is relevant because the meaning of death entails a certain denial and evasion in our society, even among health professionals, including nurses. The availability of valid instruments addressing fear of death permits research that helps to visualize one construct and factor at a time, which is considered a determinant of end of life quality of care and quality of life (Lange, Thom, & Kline, 2008; Mohamed Ali, & Said, 2010; Venegas et al., 2011).

The main finding of this study was to demonstrate the adequate psychometric characteristics of the Czech version of the revised CL-FODS (28 items) in the population of nursing students. Its sound internal consistency was demonstrated through a high Cronbach’s α coefficient for the global scale, as well as for each subscale, and was similar to the results obtained in studies that used the same scale in a student population in Chile (Venegas et al., 2011), Kuwait (Abdel-Khalek & Lester, 2004), Nigeria (Kolawole & Olusegun, 2008), and Spain (Tomás-Sábado et al., 2007). However, the Cronbach’s α coefficient in the present study was lower than the results obtained by Lester and Abdel-Khalek (2003).

However, the extracted components provided considerable support for the factorial validity of the CL-FODS. The loadings onto the four components in the present study were congruent with the hypothetical factors in the original theoretical constructions of the scale. Correlational analysis has shown that subscale scores on the four subscales of the CL-FODS are significantly associated.

When evaluating nursing students’ fear of death, we found their greatest fear to be that of the process of dying and the least significant fear to be that of their own death. This was consistent with results reported in research by Mooney (1999) and Kaklauskaité and Antineiené (2016), involving medical students. On the other hand, Hegedus et al. (2008) and Zana, Szabó, and Hegedus (2009) found that nurses were more afraid of the death of their loved ones, and the impact of their own death on their loved ones and only after this were they afraid of their own dying. Similarly, Bath (2010) found the fear of dying, and death of others scores to be higher than the fear of dying, and one's own death scores in psychology students.

Previous studies regarding the association between fear of death and demographic characteristics, such as age and gender, have been inconclusive. Cicirelli (1998) assessed fears related to death expressed by two age-groups within a sample of college students. No differences with regard to age were found. Neimeyer (1985) and Thorson and Powell (1994) found a negative correlation between age and death anxiety. Thorson and Powell (1994) reported a curvilinear trend in which death anxiety was relatively high in adolescents, peaked in middle adulthood, and was lowest in old age. Zana et al. (2009) give evidence that people at the age of 15 to 25 years are more anxious and afraid of death than those over 55 years. Haškovcová (2000) discusses the so-called sequestration of death, which is typical in young people at the age of 18 to 25 years. The understandable fear of one’s own future extinction is suppressed, often accompanied by a desire to deal with this eventuality. However, in our study, no relationship between nursing students’ age and fear of death was found, consistent with a study by Lester (2015).

Previous studies regarding the association between fear of death and academic year of study have also been inconclusive. Chen, Del Ben, Fortson, and Lewis (2006), in a sample of American nursing students, reported that students in the final year of study exhibited a greater fear of death than newer students. Aradilla-Herrero, Tomás-Sábado, and Gómez-Benito (2012–2013) report that as students progress through their studies, they show less fear of the death of others. In our study, no relationship between length of study (academic year) and fear of death was found.

Identifying and differentiating the different aspects of the fear of death and dying are salient when nursing students had experience of the death of a loved one. In the study findings, lack of experience of grief greatly increased fear of death and dying. Experience of the death of a loved one was the only predictor of fear of death and death anxiety.

This study has some limitations that should be taken into account. One of the main limitations is the cross-sectional nature of the study. We did not examine whether nursing students’ attitudes toward death change over the course of study. The effect of nursing education on the respondents’ attitudes was not monitored.

In conclusion, the Czech version of the CL-FODS had good psychometric characteristics when applied to nursing students and can be recommended for use in research and clinical assessment in the Czech Republic. The use of instruments with weak psychometric properties can seriously compromise the credibility of research findings (Garre-Olmo et al., 2010). The Czech version of the CL-FODS can promote cross-cultural research on attitudes to death. Owing to the use of an internationally recognized instrument, the study results can be compared with other similar studies. Research into responses to the CL-FODS of participants from different specialties is urgently required. The CL-FODS could become a suitable instrument for determining the effectiveness of teaching and courses in thanatology. It is necessary to conduct further research to determine whether education in thanatology can reduce nurses’ and other health professionals’ anxiety and fear of death and dying, which forms are most effective.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Author Biographies

Radka Bužgová was born in Czech Republic. She earned a bachelor's degree in Health Social and Geriatric Care (ZSF OU Ostrava), a master's degree in Social Political and Social Work (PdF UHK, Hradec Králové), a PhD in Specialization in Health Service, Prevention, Rehabilitation and Therapeutic Care for Children, Adults and Seniors (ZSF JCU, České Budějovice). She is an assistant professor at the University of Ostrava, Faculty of Medicine, Department of Nursing and Midwifery, Ostrava, Czech Republic and advisor for survivors in Home hospice Ondrášek in Ostrava. She participated in research projects and grants: ADEL—Advocacies for frail and incompetent elderly in Europe: Comparative analysis of national systems and innovative approaches, Institut für Sozialforschung und Gessellschafspolitik (ISG); IGA MZ ČR NT 13417-4/2012—Identification of patient and family needs in palliative care related to quality of life (principal Investigator); TAČR TB02MPSV015—The level of need of health and social services for mastering the basic necessities of life determined by the level of dependence of people aged 50 and over and its time and financial demands (co-coordinator); and AZV MZ ČR—Neuropalliative rehabilitation approach to preserve the quality of life in patients with an advanced stage of selected neurological diseases (principal investigator). She has given lectures (first author) in 23 international conference in Czech Republic and 11 foreign international conference. Her publications include 18 articles in journals with impact factor (15 first author), 48 articles in journals in Scopus, 2 books (1 first author), 12 articles in peer-review journals; and citations include 26 WOS (web of science) and 46 Scopus.

Eva Janíková was born in Czech Republic. She earned a master's degree in teaching of social and health science courses for secondary and higher professional schools (PdF UP, Olomouc). Now she studies PhD in Nursing (LF OU, Ostrava). The doctoral thesis is focused on Supervision and Burnout syndrome in Health Care. She is an assistant professor at the University of Ostrava, Faculty of Medicine, Department of Nursing and Midwifery, Ostrava, Czech Republic and nurse in Surgery Department in Faculty hospital, Ostrava, Czech Republic. She participated in the following research projects and grants: Efficiency of supervision for professionals in Health care (SGS) and Psychosocial support and teaching of social-interactional skills for students of Medical Faculty, University of Ostrava (IRP). Her lectures as first author include four international conferences in Czech Republic and two foreign international conferences. Her publications include one article in journals with impact factor (1 first author), three articles in journals in SCOPUS, two books (1 first author), and one article in peer-review journals.

References

Abdel-Khalek

A. A.

(2004) Convergent validity of the Templer, Collett-Lester, and Arabic Death Anxiety Scales: Rejoinder. Psychological Report 94: 1171–1172.

Abdel-Khalek

Lester

(2004) The factorial structure of the Arabic version of the revised Collett-Lester fear of death scale. Death Studies 28: 787–793.

Aradilla-Herrero

Tomás-Sábado

Gómez-Benito

(2012–2013) Death attitudes and emotional intelligence in nursing students. OMEGA 66: 39–55.

Bath

D. M.

(2010) Separation from loved ones in the fear death. Death Studies 34: 404–425.

Chen

Y. C.

Del Ben

Forson

B. L.

Lewis

(2006) Differential dimensions of death anxiety in nursing students with and without nursing experience. Death Studies 30: 919–929.

Collet

Lester

(1969) The fear of death and the fear of dying. Journal of Psychology 72: 179–181.

Cicirelli

V. C.

(1998) Personal meanings of death in relation to fear of death. Death Studies 22: 713–733.

Ellis

Wahab

E. A.

Ratnasingan

(2013) Religiosity and fear of death: A three-nation comparison. Mental Health, Religion, & Culture 16: 179–199.

Garre-Olmo

Planas-Pujol

López-Pousa

Weiner

M. F.

Turon-Estraada

Juvinia

Vilalta-Franch

(2010) Cross-cultural adaptation and psychometric validation of a Spanish version of the quality of life in late-Stage Dementia Scale. Quality of Life Research 19: 445–453.

10.

Haškovcová

(2000) Thanatologie, Praha, Czech Republic: Galén.

11.

Hegedus

Zana

Szalo

(2008) Effect of end of life education on medical students’ and health care workers’ death attitude. Palliative Medicine 22: 264–269.

12.

Kaklauskaité

Ž.

Antiniené

(2016) Death anxiety and empathy among male and female medical students. Baltic Journal of Sport & Health Sciences 4: 11–18.

13.

Kaklauskaité

Ž.

Vonzodiene

(2015) Relationships between death anxiety and empathy among medical students (pilot study). International Journal of Psychology, Biopsychosocial Approach 17: 117–136.

14.

Kastenbaum

(2012) Death, society, and human experience, New York, NY: Pearson.

15.

Kolawole

Olusegun

(2008) The reliability and validity of revised Collett-Lester Fear of Death Scale (version 3) in Nigeria population. OMEGA 57: 195–205.

16.

Kubler-Ross

(1975) Death: The final stage of growth, Englewood Cliffs, NJ: Prentice Hall.

17.

Lange

Thom

Kline

N. E.

(2008) Assessing nurses ‘attitudes toward death and caring for dying patients in a comprehensive cancer center. Oncolocical Nursing Forum 35: 955–999.

18.

Lester

(1990) The Collett-Lester fear of death scale: The original version and revision. Death Studies 14: 451–468.

19.

Lester

(1994) The Collett-Lester Fear of Death Scale. In: Neimeyer

R. A.

(ed.) Death anxiety handbook: Research, instrumentation, and application, London, England: Taylor & Francis, pp. 45–55.

20.

Lester

(2015) Self-construal and the fear of death. Psychological Reports: Disability & Trauma 117: 376–379.

21.

Lester

Abdel-Khalek

A. M.

(2003) The Collett-Lester Fear of Death scale: A correction. Death studies 27: 81–85.

22.

McClatchey

I. S.

King

(2015) The impact of death education on fear of death and death anxiety among human services students. OMEGA—Journal of Death and Dying 7: 343–361.

23.

Mohamed Ali

Said

(2010) Nurses’ attitudes toward caring for dying patient in mansoura university hospitals. Journal of Medicine and Biomedical Sciences 3: 16–23.

24.

Mooney

D. C.

(1999) Construct validity of the revised Collett-Lester Fear of Death and Dying Scale, Queensland, Australia: Griffith University.

25.

Naderi

Eemaili

(2009) Collet-Lester Fear of Death Scale validation and gender-based comparison of death anxiety, suicide ideation and life satisfaction in university students. Journal of Applied Scientific 9: 3308–3316.

26.

Nazarzadeh

Sarokhani

Sayermiri

(2015) The relationship between religious attitudes, fear of death and dying with general health condition: A survey in college students. Journal of religion Health 54: 1672–1680.

27.

Neimeyer

R. A.

(1985) Actualization, integration, and fear of death: A test of the additive hypothesis. Death Studies 9: 235–244.

28.

Neimeyer

R. A.

(1994) Death anxiety handbook: Research, instrumentation, and application, London, England: Taylor & Francis.

29.

Neimeyer

R. A.

Moser

R. P.

Wittkowski

(2003) Assessing attitudes toward dying and death: Psychometric considerations. OMEGA 47: 45–76.

30.

Ozanne

A. O.

Graneheim

U. H.

Strang

(2013) Finding meaning despite anxiety over life and death in amyotrophic lateral sclerosis patients. Journal of Clinical Nursing 22: 2141–2149.

31.

Payne

S. A.

Dean

S. J.

Kalus

(1998) A comparative study of death anxiety in hospice and emergency nurses. Journal of Advanced Nursing 2: 700–706.

32.

Power

T. L.

Smith

S. M.

(2008) Predictors of fear of death and self-mortality: An Atlantic Canadian perspective. Death Studies 32: 253–272.

33.

Sherman

D. W.

Norman

McSherry

C. B.

(2010) A comparison of death anxiety and quality of life of patients with advanced cancer or AIDS and their family caregivers. Journal of the Association of Nurses in AIDS Care 21: 99–112.

34.

Stroebe

Gerben

Gergen

Stroebe

(1992) Broken hearts or broken bonds: Love and death in historical perspective. American Psychologist 47: 1205–1212.

35.

Terwee

C. B.

Bot

S. D.

de Boer

van der Windt

D. A. W. M.

Knol

D. L.

Kedder

de Vet

H. C. W.

(2007) Quality criteria were proposed for measurement properties of health status questionnaires. Journal of Clinical Epidemiology 60: 34–42.

36.

Tomás-Sábado

Limonero

J. T.

Abdel-Khalek

A. M.

(2007) Spanish adaptation of the Collett-Lester Fear of Death Scale. Death Studies 31: 249–260.

37.

Thorson

J. A.

Powell

F. C.

(1994) A revised death anxiety scale. In: Neimeyer

R. A.

(ed.) Death anxiety handbook: Research, instrumentation, and application, Washington, DC: Taylor & Francis, pp. 103–119.

38.

Vávrová

Polepilová

(2010) Výzkumné šetření o vzdělávání studentů pomáhajících profesí v oblasti thanatologie. Sociální práce 10: 71–80.

39.

Venegas

M. E.

Alvarado

O. S.

Barriga

(2011) Validation of Collett-Lester's Fear of Death Scale in a sample of nursing students. Rev. Latino-Am. Enfermagem 19: 1171–1180.

40.

Ware

J. E.

Gandek

(1998) Methods for testing data quality, scaling assumptions, and reliability. Journal of Clinical Epidemiology 51: 945–952.

41.

Wong

P. T. P.

Reker

G. T.

Resser

(1994) Death attitude profile—Revised: A multidimensional measure of attitudes toward death. In: Neimeyer

R. A.

(ed.) Death anxiety handbook: Research, instrumentation and application, Washington, DC: Taylor & Francis, pp. 121–148.

42.

Yang

Ch. Chen

(2009) The study of personal constructs of death and fear of death among Taiwanese adolescents. Death Studies 33: 913–940.

43.

Zana

Á.

Szabó

Hegedus

(2009) Attitudes toward death in Hungary using the Multidimensional Fear of Death Scale. Clinical and Experimental Medical Journal 3: 327–335.