Self-Transcendence as a Mediator of the Relationship Between Reminiscence Functions and Death Anxiety: Implications for Psychiatric Nurses

Abstract

Background:

Jordan’s population of older adults is growing due to improved health care and lifestyle, but the country has limited mental health care resources, causing challenges for the health care system. Reminiscence is a point of nursing intervention and a way for psychiatric nurses to help people improve their mental health by expanding their personal boundaries (self-transcendence).

Aims:

The study aimed to examine the mediating effects of self-transcendence on the relationship between reminiscence functions and death anxiety in a sample of Jordanian older adults. Psychiatric nurses can refine reminiscence therapy by targeting aspects of self-transcendence to reduce death anxiety.

Methods:

An online cross-sectional survey was employed to collect the data. A total of 319 older adults participated in the study. The sample was recruited using convenience and snowball sampling strategies through social media and personal contacts.

Results:

The reminiscence function of “Bitterness Revival,” gender, the presence of a life-threatening disease, a history of psychiatric disorder, and the work sector were statistically significant predictors of death anxiety. This model accounts for 24% of the death anxiety score (F = 7.789, p < .001). Reminiscence functions 1, 2, and 5 predicted self-transcendence. This model explained 25% of the variance in the self-transcendence score (F = 6.548, p < .001). Self-transcendence exerts a positive, partial mediating effect between “Bitterness Revival” and death anxiety, controlling for other covariates in the death anxiety model (p = .016).

Conclusions:

The study is informative for understanding the role of self-transcendence in buffering death anxiety, notwithstanding “Bitterness Revival” reminiscences. This knowledge reveals practical implications for psychiatric nurses about the importance of developing reminiscence interventions to promote self-transcendence and ease death anxiety.

Keywords

death anxiety mental health reminiscence functions self-transcendence

In line with the World Health Organization (WHO) Mental Health Gap Action Program (mhGAP), which seeks to enhance mental health care, older adults’ mental health is crucial at older ages equally to other life stages, as older people are vulnerable to developing mental illnesses (World Health Organization [WHO], 2017). Like other older people worldwide, Jordanian older adults, the target population of the present research, are at risk of developing mental health conditions. Jordan is a low-to-middle-income country with limited mental health care resources and has faced a rapid increase in the number of older adults over the past decade, from 3.67% in 2021 to 4.8% in 2022 (World Population Review, 2022). The main reasons for Jordan’s older population’s dramatic growth can be attributed to advancements in medicine and technology, lifestyle improvement, falling mortality, low fertility rates, and the availability of better health care (Worldometers, 2022). This demographic transition and its related behavioral and biopsychosocial changes impose challenges for Jordan’s mental health care system (Kofahi et al., 2021). It also requires psychiatric nurses to be well-versed in clinical practice to manage actual or suspected mental health conditions and provide quality mental health care to older adults.

According to Erikson’s (1963) theory of psychosocial development, people in the late stage of their lives foster a feeling of completeness as a result of integrating the experiences and wisdom they have accumulated throughout their lives. Older adults reflect on their lives, find meaning in life, and strive for this so-called ego integrity. At this stage, older adults intentionally or spontaneously ponder their memories and stories from the past to find life’s meanings, accept the negative past, or improve social bonds; this process of recollecting past experiences and memories is termed as reminiscence (Webster, 1993). Through recalling positive aspects of memories, older adults can cope with and adjust to difficult life situations (such as anxiety surrounding death), resulting in enhanced mental health in the late stages of life (Erikson, 1963). Reminiscence is a point of nursing intervention and a way for psychiatric nurses to help people improve their mental health by expanding their personal boundaries (self-transcendence) (Stinson & Kirk, 2006; Woods et al., 2018).

The key distinction between reminiscence therapy and reminiscence is that reminiscence therapy is a structured mental process guided by a health care professional, whereas reminiscence, as we use it in the current study, is a cognitive process that naturally occurs as an introspective process with free-flowing thoughts about the past (Butler, 1963). These memories can be informally shared with others in social contexts in the form of storytelling (Webster, 1993). A growing body of literature indicates that this reminiscence process, when left unguided, may be conducive to triggering negative thoughts and causing anxiety. For example, Webster (1997) showed that reminiscence for death preparation contributed to higher levels of death anxiety and had a negative influence on psychological functioning (Cappeliez et al., 2005). In contrast, a healthy expansion of self-boundaries (i.e., self-transcendence) through positive reminiscence contributed to improving mental health (Stinson & Kirk, 2006). Without the guidance of a mental health specialist, memories of the past become less controlled and may devolve into rumination (Hofer et al., 2017). These unbounded negative memories lead to emotional and psychological distress, allowing individuals to begin exaggerating their conceptions and consequent fears about death (Jo & An, 2018).

Reminiscence as a planned intervention is a common psychotherapy used in hospitals, geropsychiatric units, nursing homes, dementia care facilities, and other health care settings (Jo & An, 2018). It is primarily employed as an enjoyable activity through which the reminiscence facilitator prompts individuals to recall experiences and memories for a particular purpose (Woods et al., 2018). The group members can learn from one another, become more socially active, and identify areas of commonality through reminiscence sessions. It can also be a helpful way to reduce death anxiety and promote self-transcendence (Jo & An, 2018). However, unstructured reminiscence may be seen to affect death anxiety and self-transcendence differently based on personal and contextual factors. Thus, this study aims to investigate the role of cross-cultural differences in unstructured reminiscence. Specifically, we examine the mediating role of self-transcendence in the relationship between reminiscence functions and death anxiety in a sample of Jordanian older adults practicing unstructured reminiscence.

Jordan as a Representative of Arab/Western Cross-Cultural Differences

As a Middle Eastern country, Jordan is primarily a Muslim country (92% Muslim vs 8% Christian) of Arabic origin (98% Arabic vs 2% identified as non-Arabic) (Worldometers, 2022). However, Muslim individuals do not necessarily speak Arabic and vice versa. More than 11 million individuals live in Jordan (48.6% of them female) (World Population Review, 2022), of whom 4.8% of individuals are older adults (defined as 65+ by the WHO in 2022). The expected duration of life is 80.1 years of age.

Jordanians have a strong cultural identity rooted in sustained traditions and customs originating in the nomadic desert tribes in the Arabian Peninsula (Purnell & Fenkl, 2019). Jordanians feel a strong sense of cultural security and exhibit tolerance of expression (Shoup, 2007). It is this tolerance that fosters the diversity seen in art, as well as in the various religious sects and ethnicities residing in a relatively small country. Whether Muslim or Christian, however, Arabs share many cardinal customs and beliefs due to their inherently connected past (Purnell & Fenkl, 2019).

Oral storytelling is prevalent among older Jordanian adults, as many use it to solidify political, cultural, and social identities (Shoup, 2007). Such identities could include forced migration due to war, resistance against the feudal system, or even more positive events relating to their family, or the camaraderie felt during the shared military experience. Reminiscing about historical events is another way that Jordanians connect, particularly over the Middle East’s political and religious issues. When connecting socially, Jordanians will typically recount happy memories about their ancestors and try to bond with others through stories about their childhood, commonality over food preparation, and marital practices (Purnell & Fenkl, 2019). A notable aspect of Jordanian culture is that they are very nostalgic in hopes of glorifying the memories and history of those that have passed away or have become difficult to contact. This greatly affects why individuals reminisce in the Jordanian culture differently from Western cultures that typically focus more on the present (Abu Khait et al., 2022). Jordan, in comparison with all Arab countries, has an average-sized population but a higher proportion of older adults. The vast majority are literate, having completed primary education. Jordanians’ receptiveness to Western culture, technology, and social media also helps to boost interest in this type of study and increase participation. Finally, many of the study’s researchers are Jordanians, acutely aware of the population of interest and attuned to the cultural nuances.

Reminiscence Functions

Reminiscence has eight functions, positively or negatively affecting mental health (Webster, 1993, 1997). As a cognitive process, reminiscence may occur as introspective thoughts or at a public level by reflecting on and sharing personal memories with a therapist or group of people (Coleman, 2005). These eight reminiscence functions include (1) “Identity” (firming key aspects of the sense of self), (2) “Problem-Solving” (depending on coping strategies used in the past and the strengthening points to address the present problems), (3) “Death Preparation” (accepting one’s own mortality with a feeling of wholeness and sense of closure), (4) “Bitterness Revival” (reviving memories associated with unpleasant feelings and negative thoughts), (5) “Intimacy Maintenance” (maintaining memories of significant people who do not physically exist), (6) “Boredom Reduction” (reflecting on the good old days of dwelling in the past to avoid boring situations or due to lack of participation in goal-directed activities), (7) “Teach/Inform” (imparting life lessons, values, traditions, and legacy from one generation to another), and (8) “Conversation” (informal sharing of personal memories to connect with others and enhance social connection).

The various functions of reminiscence can be categorized into three dimensions: “self-positive functions,” “self-negative functions,” and “pro-social functions” (Cappeliez et al., 2005; Fernández-Pérez et al., 2020; Zimmermann & Forstmeier, 2018). Self-positive functions (“Identity,” “Problem-Solving,” and “Death Preparation”) indirectly improve mental health, but only when mediated by other factors such as coping ability (King et al., 2017). Provoking self-positive functions of reminiscence may be linked to fostering better physical and psychological well-being. In contrast, self-negative functions (“Boredom Reduction,” “Bitterness Revival,” “Intimacy Maintenance”) are directly correlated with worsening mental health (Hofer et al., 2017). Pro-social functions of reminiscence (“Conversation” & “Teach/Inform”) foster connectedness with others and are linked to health indices because they encourage socializing (O’Rourke et al., 2017).

Bitterness Revival, of particular interest in this study, includes rehashing painful experiences and dwelling on the past. It also refers to obsessive reminiscence, focusing on the rumination of negative memories and prior unresolved conflicts, which causes guilt and related despair. Bitterness Revival is linked to inducing loneliness and causing psychological distress through emotional vulnerability. Naturally, it is positively associated with increasing depression through persistent rumination on these negative emotions, having a detrimental effect on mental health (Zimmermann & Forstmeier, 2018).

Self-Transcendence

Self-transcendence is the cultivation of insight into one’s existence through the healthy expansion of one’s personal boundaries (Reed, 1991). This expansion of self-boundaries is multidimensional: inward through internal thought processes; outward through connection with others; temporal through integrating one’s past and future to foster the present; and transpersonal through connections with a higher dimension, such as spirituality (Reed, 1991). Activities that increase self-awareness and broaden one’s perspectives, such as seeking meaning(s) in one’s life and prior experiences, contribute to increased self-transcendence (Abu Khait et al., 2020). When people have achieved self-transcendence, they can see themselves as important parts of the universe as a whole (McCarthy et al., 2017; Reed, 1991). This makes it easier for them to deal with problems in their lives.

According to the theory of self-transcendence (Kim et al., 2014), the process of recalling one’s remote past can contribute to broadening healthy personal boundaries (i.e., self-transcendence) and finding life meanings in memories (McCarthy et al., 2017). Butler (1963) emphasized the importance of vulnerability as a critical influence of aging, and reminiscence serves as a universal response to this emotion. Vulnerability can prompt older adults’ inner resources to transcend limitations and disabilities. Recalling memories can heighten one’s capacity to broaden intrapersonal, interpersonal, transpersonal, and temporal self-boundaries and give meaning to these memories (Stinson & Kirk, 2006). Enhanced introspection brought on by external events might spark the recollection process and fortify peoples’ inner strengths (McCarthy et al., 2017). Inspiring a person to look for a deeper purpose in life and encouraging self-transcendence via remembering the past might positively affect one’s mental health (Stinson & Kirk, 2006). For example, intrapersonal techniques help people expand their inner boundaries by making sense of their own experiences, such as coming to terms with the loss.

There are many practices that can enhance self-transcendence (McCarthy et al., 2017): (1) connectivity within a group setting (connecting with others dealing with similar issues through focused discussion and reminiscing), (2) intrapersonal practices (mediation, prayer, self-reflection, and visualization), (3) imaginative/artistic experiences, and (4) self-directed learning transfer from the group setting. These techniques help individuals assume ownership of their own healing and recognize what helps them through this process.

The majority of Jordanians are Muslim. For the participants that follow Islam, their religious persuasion helps them transcend their limitations and disabilities and is a way to overcome life’s challenges and accept death (Atkinson, 2015). For Muslims, Islam is not just a religion but a way of life; it plays a significant part in helping them cope with adversity by serving as a moral and spiritual compass during trying times (Shoup, 2007). Overall, older adults consider religion to be an integral part of their identity. Religion is positively associated with improved mental health, serving to reduce death anxiety (Abbas et al., 2021). Religious activity boosts feelings of well-being, increases adaptation, and promotes a sense of meaning and purpose in life (Jong, 2020). This can serve as a coping mechanism in dealing with illness, disability, and their own mortality.

Jordanian older adults can extend their feelings of connectedness in this lifetime through transpersonal self-transcendence. By establishing a relationship with God, they can healthily expand their personal spiritual boundaries, and this feeling of spiritual connectedness contributes greatly to a feeling of overall connectedness for the individual. By building this sense of connectedness, individuals can consequently broaden healthy self-boundaries and ultimately promote mental health.

Death Anxiety

Most older adults realize that the aging process and death are inevitable. Their recognition of this fact motivates them to use memories and past experiences as a mechanism for death preparation and as a means of pastime, which helps them prepare for death by alleviating death anxiety (Sheykhi et al., 2020). Death anxiety is a subjective feeling for most individuals of anxiety surrounding death or the dying process. Consequently, individuals respond to death anxiety differently (Abdollahi et al., 2019). Such variations in response to death anxiety may reveal cultural diversity (Sebea et al., 2021); culture affords its affiliates support in combating fear of death (Brown et al., 2014).

According to the Terror Management Theory (Kashima, 2010), “death anxiety” is a predominantly negative emotion because it occurs when a person dwells too much on the certainty of their mortality and frequently worries about their inevitable death. It is typically diagnosed under three conditions: an individual cannot ever think about dying without fear; fear of death persists for more than 6 months; or it interferes with daily life and relationships.

The severity of anxiety relating to death differs by culture (Sebea et al., 2021). Overall, Westerners (those from the United States, Canada, and Australia) had a greater fear of dying than Indians did, regardless of age (Pandya & Kathuria, 2021). Abdel-Khalek (2004) examined the death anxiety levels of various non-Western cultures and found minimal differences between the Egyptian sample and those from other cultures. Reacting to death is culture-specific and is not an innate emotion but something that can be taught (Mercês et al., 2019). The fear of dying is ingrained in young children from a very young age. An infant or toddler’s early social interactions with the world give them the knowledge they need to avoid potential threats and deal with them if they are encountered (Mercês et al., 2019). Negative emotions like sadness, fear, and preoccupation can be expressed through physical manifestations. As in the present case, a person’s religious or spiritual views often provide the best explanation for such emotions. Previous research (Bektaş et al., 2017; Mehri Nejad et al., 2017) has found that older people afraid of death have negative reminiscence functions.

Death anxiety has been studied in many mental disorders, such as somatic symptom disorders, anxiety disorders, obsessive-compulsive disorders, and post-traumatic stress disorder (PTSD; Abbas et al., 2021; Iverach et al., 2014; Khodarahimi et al., 2021; Mavrogiorgou et al., 2020). These studies have shown a positive relationship between mental health history and death anxiety. For example, people with somatic symptom disorders often have death anxiety because they are afraid of physiological failure, pain, being alone, and losing control and power (Laçiner et al., 2022). Obsessional symptoms are employed to dispose of death anxiety (Bektaş et al., 2017; Bozo et al., 2018). Fear of death and anxiety about being apart from loved ones were linked, which suggests that death anxiety may make the fear of being apart from loved ones worse. PTSD symptoms also worsen death anxiety by affecting the anxiety-buffering mechanisms (Iverach et al., 2014). After death salience induction, people with PTSD have been shown not to have an intact anxiety buffering mechanism (Iverach et al., 2014).

As older adults approach death, most endeavor to put their lives into perspective. Through spiritual reminiscence, recalling past memories and experiences using religious faith and practice, older adults share life stories with a focus on meaning and connection. Understanding and emphasizing the meaning of past life experiences allows an individual to freely talk about fears associated with dying (MacKinlay & Trevitt, 2010) and can help develop strategies to accept changes in health.

Statement of the Problem and Significance

Transcultural research has indicated that reminiscence functions are positively or negatively linked to mental health (Cappeliez et al., 2005; Ros et al., 2016). Consequently, several researchers have proposed conducting further studies to test the fundamental relationship between reminiscence functions and mental health across cultures (Abu Khait et al., 2022; Cappeliez et al., 2005). To date, no empirical studies have provided support for a relationship between reminiscence functions and mental health–related outcomes among older adults in the context of Arab culture (Abu Khait et al., 2022), particularly those relevant to clinical constructs (e.g., self-transcendence and death anxiety). As a result, the purpose of this study is to close this gap by investigating the mediating effect of self-transcendence on the relationship between reminiscence function subscales and death anxiety in a sample of Jordanian community-dwelling older adults. With self-transcendence as a significant mediator in the relationship between “Bitterness Revival” and death anxiety, we may target aspects of self-transcendence by developing reminiscence interventions to reduce death anxiety among older adults.

Reminiscence can evoke the process of exploring meaning in life, enhance emotional stability, expand healthy personal boundaries (self-transcendence), and increase a positive outlook on life, which may, in turn, promote psychosocial health (Fiske, 2019; McCarthy et al., 2017; Vitale et al., 2014). For example, higher levels of self-transcendence are linked to improved mental health (McCarthy et al., 2017). Therefore, investigating how self-transcendence affects reminiscence functions and death anxiety in older adults may help psychiatric nurses illuminate ways to develop successful reminiscence interventions that reduce death anxiety and promote healthy self-boundaries.

Materials and Methods

Study Design

A cross-sectional study was conducted using an online survey. The Institutional Review Board of The Hashemite University University reviewed and approved the present study (No. 11/14/2020/2021). This study followed the ethical guidelines of the 1964 Helsinki Declaration and its amendments. Participants formally consented to their participation in the study prior to data collection, as they were given an information sheet, asked to confirm their eligibility, and provided consent by clicking through an online form.

Participants

The inclusion criteria for the participants were as follows: (1) participants ages 65 and above; (2) participants who could communicate, read, and write either on their own or with the assistance of their caregivers; and (3) participants who could use online platforms. The required sample size was estimated using G-Power (Cohen et al., 2003) for the multiple linear regression to achieve a statistical power of 99%, a medium effect size (f²) of .15, and an alpha level of .01 for up to five predictors to be 231. With a sample size of 319, this indicates an adequate sample size.

Study Procedure

The survey was conducted using the Google Forms web survey platform. Convenience and snowball sampling strategies were used to recruit eligible community-dwelling older adults through social media and personal contacts of the study authors. Participants were also encouraged to share the study link with their eligible acquaintances to increase the number of study participants, which allowed us to conduct a nationwide survey during a pandemic and quarantine restrictions. Participants were provided with extensive online information about the survey’s objectives before deciding whether or not to participate. The information gathered was treated with the strictest confidentiality and anonymity. The information was stored in an electronic format that required a password to access.

Measures

Sociodemographic Data

Age, gender, marital status, residency, education level, work sector, a life-threatening disease, and a psychiatric disease history were all collected.

The Adjusted Arabic Reminiscence Functions Scale (AARFS)

It is a 32-item self-report that addresses why people reminisce through six subscales (Abu Khait et al., 2022). This new scale was culturally adapted and tested for validity based on the original Reminiscence Functions Scale (RFS) (Webster, 1993, 1997). The RFS is widely used to measure reasons for reminiscence functions (Webster, 1993, 1997). Older adults respond to the scale’s items on a 6-point Likert-type scale, ranging from 1 = never to 6 = very frequently, how often they reminisce with the given purpose in mind (Webster, 1997). A total score is the sum of all the items, where a lower score signifies lower reminiscence functions (Webster, 1993). Cronbach’s alpha values range from .81 to .91 for the subscales (Abu Khait et al., 2022). The range of Cronbach’s alpha in this study is .77 (Teach/Inform & Conversation) to .85 (Identity/Problem-Solving), indicating internally reliable metrics for our sample.

The Arabic Scale of Death Anxiety

The Arabic Scale of Death Anxiety (ASDA) is a self-reported questionnaire consisting of 20 items that assess fear of death (Abdel-Khalek, 2004). Participants are asked to indicate on a 5-point Likert-type scale ranging from 1 = no to 5 = very much. The sum of the scores from the 20 items is used to compute the total score (ranges from 20 to 100), with a lower score signifying lower levels of death anxiety (Templer, 1991). The internal consistency of ASDA, measured by Cronbach’s alpha, is between .88 and .93. The Cronbach’s alpha of the ASDA in the current study is .94.

The Self-Transcendence Scale

The Self-Transcendence Scale (STS) is a self-reported instrument that assesses one’s capacity for self-transcendence (Reed, 1991). The STS comprises 15 items with responses based on a 4-point scale ranging from 1 = not at all to 4 = very much. Generally, a score between 15 and 30 suggests a low level of self-transcendence, a score between 31 and 45 is considered moderate, and a score between 46 and 60 reveals high levels of self-transcendence. Based on Cronbach’s alpha ranges (.80–.88), the internal consistency of this scale was found to be acceptable (Reed, 1991; Reed & Runquist, 2007). Cronbach’s alpha in the current study is .87.

Analytic Strategy

Data analysis was run in R version 3.6.2 (Tingley et al., 2014) to obtain descriptive and inferential statistics with a significance level (α) of .05 in all final analyses. A univariate and multivariate model selection approach was used to determine the appropriate predictors to use in modeling death anxiety and self-transcendence (separately). For the univariate analysis, one of three options was used for examining whether a candidate predictor should be included in the multivariate model (α = .20): two-sample t-test, one-way analysis of variance (ANOVA), or simple linear regression. Contextual input was also used at the univariate level to include any covariates directly related to the research hypothesis. Once the appropriate covariates were selected, we could then run the multivariate model and assess multicollinearity (generalized variance inflation factor [GVIF]) and model assumptions. The finalized multivariate models have allowed us to examine the effects of specific demographics and the RFS factors on each response variable, respectively. Using the multivariate model for death anxiety, we can investigate the mediation effect of self-transcendence on the relationship between death anxiety and any RFS factors that are significant predictors of both death anxiety and self-transcendence. Significance in both models may indicate that the observed effect of the given RFS factor on death anxiety could be, in fact, just the effect of that RFS factor on self-transcendence. Such a masking of effects motivates the question of mediation. In our case, we examine the mediation effect of self-transcendence on the relationship between death anxiety and any RFS factor that is significant in both models, controlling for all other demographics and RFS factor scores present in the death anxiety mode.

Results

Characteristics of Older Adults

A total of 319 participants completed the survey. Of all the participants, 56.11% are females, 73.67% live in urban areas, 75.86% are married, and 35.74% have completed their secondary education. Other demographic characteristics are presented in Table 1.

Table 1.

Sample Characteristics and Death Anxiety, Self-Transcendence by Characteristics (N = 319).

Demographic	Category	Frequency (n = 319)	Percent of respondents	Death anxiety (M ± SD)	Self-transcendence (M ± SD)
Gender	Female	179	56.11	58.69 ± 19.68	48.90 ± 7.56
Gender	Male	140	43.89	48.02 ± 17.92	49.30 ± 7.57
Residency	Rural	84	26.33	53.63 ± 20.76	48.70 ± 8.40
Residency	Urban	235	73.67	54.14 ± 19.25	49.21 ± 7.24
Marital status	Divorced	10	3.13	59.80 ± 18.97	50.20 ± 8.48
	Married	242	75.86	51.46 ± 19.18	49.57 ± 7.14
	Single	19	5.96	66.11 ± 16.71	48.89 ± 8.33
	Widow	48	15.05	60.85 ± 19.94	46.44 ± 8.68
Education level	Bachelor	47	14.73	50.11 ± 21.54	50.94 ± 8.22
	College	74	23.20	55.04 ± 19.07	50.57 ± 6.66
	Primary	73	22.88	56.16 ± 21.04	48.30 ± 8.28
	Secondary	114	35.74	53.35 ± 18.34	47.88 ± 7.29
	Vocational	11	3.45	56.27 ± 18.61	48.64 ± 5.70
Work sector	No work	135	42.32	60.47 ± 20.03	48.04 ± 7.79
	Own business	15	4.70	59.53 ± 18.78	50.40 ± 6.27
	Private sector	51	15.99	49.45 ± 14.53	50.06 ± 5.25
	Retired	118	36.99	47.88 ± 18.87	49.67 ± 8.17
Life-threatening disease	No	262	82.13	52.72 ± 19.05	49.66 ± 7.18
Life-threatening disease	Yes	57	17.87	59.93 ± 21.28	46.40 ± 8.66
History of psychiatric disease	No	298	93.42	53.16 ± 19.64	49.36 ± 7.44
History of psychiatric disease	Yes	21	6.58	66.10 ± 15.31	45.05 ± 8.12

Differences in the Mean of Death Anxiety and Self-Transcendence

As shown in Table 1, females had higher mean scores in death anxiety (58.69 ± 19.68), whereas males obtained higher mean scores in self-transcendence (49.30 ± 7.57). Those who live in urban areas reported a higher mean score in death anxiety (54.14 ± 19.25) and a higher mean in self-transcendence (49.21 ± 7.24). While single participants obtained the highest mean score in death anxiety (66.11 ± 16.71) compared with other marriage statutes, those divorced reported the highest mean scores in self-transcendence (50.20 ± 8.48). Those who have completed vocational education had the highest mean death anxiety score (56.27 ± 18.61), while those who have completed a bachelor’s degree reported the highest mean scores in self-transcendence (50.94 ± 8.22). Participants with no work obtained the highest mean scores in death anxiety (60.47 ± 20.03), while those who have their own business scored the highest mean scores in self-transcendence (50.40 ± 6.27). Those with a life-threatening disease scored higher mean death anxiety scores (59.93 ± 21.28), whereas those who did not report a life-threatening condition obtained higher mean scores in self-transcendence (49.66 ± 7.18). Finally, participants who acknowledged a history of psychiatric disorders scored higher in mean death anxiety scores (66.10 ± 15.31) compared with their counterparts who reported higher mean scores in self-transcendence (49.36 ± 7.44).

Predicting Death Anxiety

All significant univariate predictors (α = .20), in conjunction with those deemed contextually relevant, were used for death anxiety and self-transcendence, respectively, to create each final multivariate regression model (see Tables 2 and 3). These multivariate models allowed us to make inferences about the impact of demographic variables on a particular score (death anxiety or self-transcendence), controlling for the effect of all covariates in the given model (see Table 3).

Table 2.

Univariate Results.

Demographic	Methodology*	Included in multivariate analysis at alpha cutoff of 0.20 (p-value, test statistic)
Demographic	Methodology*	Death anxiety	Self-transcendence
RFS Factor 1 (Identity/Problem-solving)	Simple linear regression	Included ( F = 16.18, p < .001)	Included ( F = 23.95, p < .001)
RFS Factor 2 (Boredom reduction)	Simple linear regression	Included ( F = 15.49, p < .001)	Included ( F = 4.18, p < .001)
RFS Factor 3 (Death preparation)	Simple linear regression	Included ( F = 14.49, p < .001)	Included ( F = 1.75, p = .187)
RFS Factor 4 (Conversation/Teach-inform)	Simple linear regression	Included ( F = 2.54, p = .112)	Included ( F = 8.21, p = .004)
RFS Factor 5 (Bitterness revival)	Simple linear regression	Included ( F = 46.60, p < .001)	Included ( F = 15.84, p < .001)
RFS Factor 6 (Intimacy maintenance)	Simple linear regression	Included ( F = 4.34, p = .038)	Contextually relevant ( F = 0.19, p = .663)
Age	Simple linear regression	Not included (F = 0.34, p = .559)	Included ( F = 1.81, p = .180)
Gender	Two-sample t-test	Included ( t = −5.06, p < .001)	Not included (t = 0.47, p = .639)
Residency	Two-sample t-test	Not included (t = −0.20, p = .843)	Not included (t = −0.49, p = .624)
Life-threatening disease	Two-sample t-test	Included ( t = 2.36, p = .021)	Included ( t = −2.65, p = .010)
History of psychiatric disease	Two-sample t-test	Included ( t = 3.67, p = .001)	Included ( t = −2.36, p = .027)
Marital status	One-way ANOVA	Included ( F = 6.30, p < .001)	Included ( F = 2.40, p = .068)
Education level	One-way ANOVA	Not included (F = 0.80, p = .524)	Included ( F = 2.39, p = .050)
Work sector	One-way ANOVA	Included ( F = 10.97, p < .001)	Included ( F = 1.54, p = .203)

*Note. RFS = Reminiscence Functions Scale; ANOVA = analysis of variance.

Table 3.

Multivariate Linear Regression Results.

Death anxiety (F = 7.789, p < .001**, R² = .278, R²_adj = .24)
Variable	Category	Coefficient (SE)	Test statistic (t)	Generalized variance inflation factor (GVIF)	p-value
	(Intercept)	38.942 (7.866)	4.950		<.001**
RFS Factor 1		0.245 (0.167)	1.460	2.503 (1 d.f.)	.145
RFS Factor 2		0.449 (0.248)	1.812	1.851 (1 d.f.)	.071
RFS Factor 3		0.349 (0.296)	1.179	2.059 (1 d.f.)	.239
RFS Factor 4		−0.492 (0.309)	−1.591	2.349 (1 d.f.)	.113
RFS Factor 5		1.162 (0.293)	3.967	1.359 (1 d.f.)	<.001**
RFS Factor 6		−0.287 (0.313)	−0.917	1.413 (1 d.f.)	.360
Gender	Female	(Reference)	(Reference)	1.681 (1 d.f.)	(Reference)
Gender	Male	−6.663 (2.499)	−2.667	1.681 (1 d.f.)	.008**
Life-threatening disease	No	(Reference)	(Reference)	1.099 (1 d.f.)	(Reference)
Life-threatening disease	Yes	5.115 (2.617)	1.955	1.099 (1 d.f.)	.05**
History of psychiatric disease	No	(Reference)	(Reference)	1.065 (1 d.f.)	(Reference)
History of psychiatric disease	Yes	9.153 (3.980)	2.300	1.065 (1 d.f.)	.022**
Marital status	Divorced	(Reference)	(Reference)	1.365 (3 d.f.)	(Reference)
	Married	−5.224 (5.591)	−0.934		.351
	Single	3.468 (6.717)	0.516		.606
	Widow	−4.921 (6.068)	−0.811		.418
Work sector	No work	(Reference)	(Reference)	1.979 (3 d.f.)	(Reference)
	Own business	6.563 (5.127)	1.280		.201
	Private sector	−4.147 (3.307)	−1.254		.211
	Retired	−6.037 (2.731)	−2.211		.028**
Self-transcendence (F = 6.548, p < .001**, R² = .294, R²_adj = .25)
Variable	Category	Coefficient (SE)	Test statistic (t)	Generalized variance inflation factor (GVIF)	p-value
	(Intercept)	48.402 (5.569)	8.691		<.001**
RFS Factor 1		0.411 (0.065)	6.370	2.531 (1 d.f.)	<.001**
RFS Factor 2		−0.473 (0.095)	−4.994	1.848 (1 d.f.)	<.001**
RFS Factor 3		0.071 (0.114)	0.617	2.090 (1 d.f.)	.537
RFS Factor 4		−0.032 (0.120)	−0.266	2.403 (1 d.f.)	.790
RFS Factor 5		−0.539 (0.112)	−4.793	1.362 (1 d.f.)	<.001**
RFS Factor 6		0.179 (0.120)	1.489	1.420 (1 d.f.)	.137
Age		−0.075 (0.068)	−1.100	1.101 (1 d.f.)	.272
Life-threatening disease	No	(Reference)	(Reference)	1.112 (1 d.f.)	(Reference)
Life-threatening disease	Yes	−1.808 (1.009)	−1.791	1.112 (1 d.f.)	.074
History of psychiatric disease	No	(Reference)	(Reference)	1.074 (1 d.f.)	(Reference)
History of psychiatric disease	Yes	−2.343 (1.531)	−1.530	1.074 (1 d.f.)	.127
Marital status	Divorced	(Reference)	(Reference)	1.543 (3 d.f.)	(Reference)
	Married	−0.993 (2.167)	−0.458		.647
	Single	−1.109 (2.586)	−0.429		.669
	Widow	−1.945 (2.382)	−0.816		.415
Education level	Bachelor	(Reference)	(Reference)	1.494 (4 d.f.)	(Reference)
	College	0.924 (1.269)	0.729		.467
	Primary education	0.679 (1.362)	0.498		.619
	Secondary education	−1.728 (1.189)	−1.453		.147
	Vocational education	−1.089	−0.477		.634
Work sector	No work	(Reference)	(Reference)	1.550 (3 d.f.)	(Reference)
	Own business	0.754 (1.890)	0.399		.690
	Private sector	1.513 (1.159)	1.306		.193
	Retired	1.235 (0.933)	1.324		.187

Note. GVIF = generalized variance inflation factor; RFS = Reminiscence Functions Scale.

Note that “statistically significant” is any p-value <.05.

For predicting death anxiety, RFS factors 1 to 6, participants’ sex, presence of a life-threatening disease, a history of psychiatric diseases, marital status, and work sector were all significant at the univariate level and hence selected for the final death anxiety multivariate model (Table 2). In the multivariate model predicting death anxiety, reminiscence factor 5 “Bitterness Revival,” gender, the presence of a life-threatening disease, a history of psychiatric disorder, and work sector were statistically significant predictors. This model accounts for 24% of the variability in death anxiety (F = 7.789, p < .001). With all GVIF less than 3, there is no notable issue of multicollinearity in this model. Residual diagnostics confirmed the normality and homoscedasticity assumptions for this model.

Controlling for the other covariates in the death anxiety multivariate model, we observed that for every one-unit increase in RFS Factor 5 score, there is, on average, a 1.162-point increase in death anxiety score (p < .001). Males have, on average, a 6.663-point lower death anxiety score than females (p = .008). Those with a disease threatening their life have, on average, a 5.115-point higher death anxiety score than those who do not (p = .05). Participants with a history of a psychiatric disease have, on average, a 9.153-point higher death anxiety score than those that don’t (p = .022). Those who are retired have, on average, a 6.037-point lower death anxiety score than those with no work (p = .028).

Predicting Self-Transcendence

In predicting self-transcendence, RFS factors 1 to 6, participants’ age, a life-threatening disease, a history of psychiatric diseases, marital status, education level, and work sector were all significant at the univariate level and selected for the final multivariate model (see Table 2).

The significant predictors for self-transcendence at the multivariate level were RFS Factors 1, 2, and 5. The final multivariate self-transcendence model explains 25% of the variability in the self-transcendence score (F = 6.548, p < .001). All GVIF values are below 3, again indicating that there is no multicollinearity issue with the model, and residual diagnostics confirmed that the regression assumptions hold for this model as well. Controlling for the other covariates in this model, we found that for every one-unit increase in the RFS Factor 1 “Identity/Problem-Solving” score, there is, on average, a 0.411-point increase in the self-transcendence score (p < .001). Similarly, for every one-unit increase in the RFS Factor 2 “Boredom Reduction” score, there is, on average, a 0.473-point decrease in the self-transcendence score (p < .001). For every one-unit increase in the RFS Factor 5 “Bitterness Revival” score, there is, on average, a 0.539-point decrease in the self-transcendence score (p < .001).

Mediation Analysis

Since RFS Factor 5 “Bitterness Revival” was a significant predictor of both death anxiety and self-transcendence, we aimed to examine whether the impact of RFS Factor 5 on death anxiety was the true effect, or mediated through its relationship with self-transcendence (controlling for the other covariates in the death anxiety multivariate model). Hence, in the mediation analysis, the treatment variable is RFS Factor 5, the mediating variable is self-transcendence, and the response variable is death anxiety (Figure 1). We conducted this analysis by controlling for all other covariates in the death anxiety multivariate model (Table 3). In our case, the total effect, direct effect, and indirect effect are all positive.

The average causal mediation effect (ACME), that is, the indirect effect, is 0.181 (95% CI: [0.039, 0.380]). This indirect effect was statistically significant at the alpha cutoff level of 0.05 (p = .016). Hence, we have a significant mediation effect of self-transcendence on the relationship between “Bitterness Revival” and death anxiety (controlling for the other covariates in the death anxiety multivariate model). The corresponding proportion of the total effect that is mediated is 15.63%. The average direct effects (ADE), that is, the direct effect, is 0.977 (95% CI: [0.359, 1.580]) and the total effect is 0.158 (95% CI: [0.539, 1.750]). Both the direct and total effects were statistically significant at the alpha significance level of 0.05 (p < .001 for both). Because the direct effect is still significant after incorporating the mediating covariate, we can conclude that self-transcendence partially mediates the relationship between RFS Factor 5 “Bitterness Revival” and death anxiety (controlling for all other covariates in the death anxiety multivariate model).

Discussion

Differences in the Mean of Death Anxiety and Self-Transcendence

Our results showed that female participants scored higher mean scores in death anxiety than male participants, implying that Jordanian females are more prone to death anxiety. In contrast, Jordanian males obtained higher mean scores in self-transcendence. These results are consistent with previous literature that has revealed that females scored higher on death anxiety measures when compared with males (Adelirad et al., 2021; Pei et al., 2022), while males reported higher mean scores on self-transcendence (Costa et al., 2016; Norberg et al., 2015). Possible explanations for this result might be attributed to sex-role differences such as bravery (Adelirad et al., 2021; Templer, 1991); Jordanian males may hide their anxiety as this would offend their masculinity. This spurs males to adopt self-transcendence strategies to cope with their fears.

The current study findings indicate that participants from urban areas had a higher mean score in death anxiety and self-transcendence. This is an expected finding given that people living in cities have access to physical and mental health services, which results in early diagnosis of their conditions. This may also allow them to know the risks of death and what exacerbates death-related fears (Zhang et al., 2019). In addition, this access to resources would help expand their self-boundaries and transcede limitations, promoting mental health (Liu, Wang, et al., 2021).

In line with previous literature (Guner et al., 2023), single participants reported the highest mean scores in death anxiety, and divorced people had the highest mean scores in self-transcendence. This finding, however, differs from other prior research (Rababa et al., 2021), which has shown that widowed older adults reported significantly higher death anxiety levels. This result may be explained by the fact that single participants might not find a partner to share their fears about death, leading to increased death anxiety. Those divorced might also use past coping strategies based on their experiences to manage their problems and promote healthy personal boundaries and mental health.

In the current study, participants who completed vocational education and a bachelor’s degree had the highest mean scores in death anxiety and self-transcendence, respectively. This finding is in agreement with Guner and colleagues’ (2023) findings. It seems possible that these results are because higher education levels may shield people from negative emotions and allow them to see beyond their own constructed notions of who they are. It is clear from these findings that culture significantly affects the development of death anxiety and self-transcendence in older adults.

As expected, those who do not have a job reported the highest mean scores in death anxiety. This finding is in line with previous literature (Shakil et al., 2022); death anxiety is more prevalent among those who do not work compared with those who do. The current study shows that those with their own business had the highest mean scores in self-transcendence. This result may be explained by the fact that Jordanian older adults tend to have close friends connected to their job and attempt to maintain persistent bonds, thus creating a communication network related to their business that facilitates finding meaning and purpose in their lives. Some older adults may come to terms with their anxieties and recognize the importance of establishing appropriate limits for themselves (Kim et al., 2014).

Finally, older adults living with a life-threatening disease and having a history of psychiatric disorders had higher death anxiety levels and lower self-transcendence levels. These results are in accord with recent studies (Brown et al., 2014; Guner et al., 2023; Khodarahimi et al., 2021), indicating that older people with a disease that threatens their lives tend to worry about dying. In contrast to earlier findings (Ho et al., 2016), people who are free of potentially fatal diseases or psychiatric disorders reported higher scores in self-transcendence. These findings are surprising, as previous literature has indicated that the presence of a life-threatening illness drives patients to self-adjust their lifestyles and cope with difficulties through self-transcendence (Ho et al., 2016; Le Couteur et al., 2020). This is also true if a mental illness is present (Abdel-Khalek, 2004).

Predicting Death Anxiety

Increased reminiscing for “Bitterness Revival” purposes significantly increases death anxiety in the current study, which concurs with previous literature (Cully et al., 2001; Fernández-Pérez et al., 2020). These results are expected as “Bitterness Revival” is associated with poor mental health (Hofer et al., 2017). The continuation of negative thoughts and emotions based on painful memories of past mistakes, losses, and missed opportunities is justified by ruminating on those memories (King et al., 2017). This rumination has plenty of adverse outcomes, including making older adults feel worse about their memories, mood, and future.

The significance of gender as a predictor of death anxiety is congruent with prior literature (Adelirad et al., 2021; Soleimani et al., 2017). These results indicate the need for further research into how gender influences death anxiety and comparisons between non-western and western countries. In our study, participants who live with a life-threatening disease and a history of a psychiatric illness are more worried about dying. This indicates that previous experiences of having a serious illness or a mental illness are significant factors in developing higher death anxiety, consistent with earlier studies (Adelirad et al., 2021). One of the issues that emerge from these findings is that older adults living with these serious illnesses are vulnerable to developing higher death anxiety. Therefore, they need continual screening and early management and diagnosis, especially in these unprecedented times, to prevent lower levels of self-esteem and lessen avoidance behaviors (Pei et al., 2022; Özteke Kozan & Kesici, 2021). Finally, the current study found that retired older adults significantly scored lower in death anxiety. This result corroborates earlier research’s conclusion (Shakil et al., 2022) that work status is a predictor of higher death anxiety levels. The work status of older people serves as an anxiety buffering mechanism, lowering their fears about death (Bozo et al., 2018; Milman et al., 2020).

Predicting Self-Transcendence

In building the final self-transcendence model, RFS Factor 6 “Intimacy Maintenance” (although not significant at the alpha significance level of .20) was included to address the hypothesis of interest. The high values of Cronbach’s alpha tell us that each of the six RFS factors represent different core concepts behind why people reminisce. We need to include all aspects of reminiscence in the final model (all six RFS factors) to fully understand the impact that reminiscence has on self-transcendence.

In the self-transcendence model, increased reminiscing for “Identity/Problem-Solving” purposes significantly improved self-transcendence. Preliminary studies (King et al., 2017; Zimmermann & Forstmeier, 2018) have indicated that using Identity/Problem-Solving purposes helps older adults establish meaning for themselves on the foundations of consolidated identity and find meaning(s) in life, thereby enhancing their self-transcendence. Other older adults might reminisce about resolving problems (Problem-Solving purposes) by rethinking past coping mechanisms. This rethinking could help them deal with past mistakes and avoid repeating them in the present (Shellman, 2016).

In the current study, an increase in the RFS Factor 2 “Boredom Reduction” significantly lowers the self-transcendence. “Boredom Reduction” comprises using pleasurable pastimes to escape current issues (Webster et al., 2010). Although this may become helpful in relieving tensions in a less stimulating environment, it may become maladaptive if used persistently, especially in these unprecedented times (O’Rourke et al., 2015; Webster et al., 2010). In our case, it seems that older adults might use “Boredom Reduction” functions as a maladaptive strategy to expand unhealthy self-boundaries, resulting in poor mental health and heightened fears related to death. “Bitterness Revival,” or “obsessive reminiscence,” includes rumination on unpleasurable memories. Reminiscence for “Bitterness Revival” purposes is consistently associated with adverse mental health outcomes (Hofer et al., 2017; Ros et al., 2016). This could be strong evidence that they were mistreated or discriminated against. The influence of these experiences evolved through the reminiscence process.

Mediation Analysis

We hypothesized that the significant effect of “Bitterness Revival” on death anxiety could be mediated by its significant effect on self-transcendence. This was confirmed through a statistically significant indirect effect (0.181). Controlling for the other covariates, there is a 0.181 reduction in the total effect of “Bitterness Revival” on Death Anxiety due to self-transcendence. As the direct effect (0.977) continues to be significant after including the mediating covariate, this indicates that self-transcendence partially (positively) mediated the association between “Bitterness Revival” and death anxiety. In light of these findings, the conclusion is that reminiscence interventions can help people develop the ability to rise above their own limitations, improving their mental health and reducing their fear of death.

Strengths, Limitations, and Directions for Future Research

This study is currently the first attempt to examine the mediating effects of self-transcendence on the relationship between reminiscence functions and death anxiety within the cultural context of the Middle East. This study extends beyond prior studies that “Bitterness Revival” and self-transcendence contribute to overcoming fears of death. The study also provides primary data about the impact of personal and contextual factors that affect reminiscence functions, helping in designing effective reminiscence interventions. We also discussed how to foster informal reminiscence as a way to increase mental health.

Although the current study presents novel findings, it has a few limitations worth noting. The cross-sectional design of this study necessitates the use of longitudinal studies to conclude the causal effects of the studied variables. More research with a larger, more diverse group of participants is needed to assess relationships between levels of death anxiety, negative memories, and potentially harmful consequences.

Using online survey methodologies might present difficulties in obtaining responses from older adults who do not have internet access. The convenience and snowball sampling methods used may affect the study’s external validity and make the findings less likely to be generalizable. Potential confounders were overlooked in the current mediation model. In the future, mediation and moderation studies may establish the possible paths of mediation and confounding variables in the presence of psychiatric symptoms such as depression and social isolation. Future studies may also consider other clinical constructs in explaining death anxiety and self-transcendence, such as social support and loneliness.

From a clinical perspective, reminiscence interventions are not used as therapeutic techniques in Jordan at present. Policymakers may encourage health care practitioners to adopt clinical standards and practice policies incorporating reminiscence-based interventions into care for older adults and those living with dementia (Van Bogaert et al., 2016). From a research perspective, this study’s findings highlight the need for further empirical evidence on the mechanisms via which “Bitterness Revival” mitigates psychological distress, aiding in predicting how successful reminiscence interventions will be with Jordanian older adults. Future studies may include tracking why Jordanians reminisce throughout their lives and undertaking longitudinal studies to draw definitive conclusions about the impact of personal and environmental factors on reminiscence functions, especially during such unprecedented times.

Relevance to Clinical Practice

Research on reminiscence functions, death anxiety, and self-transcendence has important practical implications for psychiatric nurses in improving older adults’ mental health. According to the study findings, increased “Bitterness Revival” frequencies are positively related to higher levels of death anxiety. This effect is significantly mediated by the person’s level of self-transcendence. This coincides with previous studies showing that self-transcendence was found to have both an inhibitory and a buffering influence on death fears (Soriano & Calong Calong, 2021). Understanding the relation between death anxiety and self-transcendence to patterns/frequency of reminiscence among older adults is essential to developing therapeutic reminiscence sessions (Jo & An, 2018).

Drawing on the Theory of Self-Transcendence (Reed, 1991) as a theoretical framework may support the development of effective therapeutic reminiscence sessions. These sessions can extend healthy personal boundaries intrapersonally (through introspective reminiscence), interpersonally by listening and interacting with others, and temporally through reflecting on one’s past life and planning for the future (Abu Khait et al., 2020; McCarthy et al., 2017; Stinson & Kirk, 2006). Through these sessions, older adults can protect themselves from emotional distress caused by grief and despair throughout their lives, allowing them to broaden healthy personal boundaries and buffer against death anxiety (Fiske, 2019; McCarthy et al., 2017).

According to the National Institute for Health and Care Excellence (NICE, 2018), reminiscence is a standard nursing practice implemented in community clinics, nursing homes, rehabilitation centers, community mental health centers, and long-term care facilities. This intervention helps older adults suffering from neurocognitive disorders, complicated grief, depression, anxiety, disturbed sensory perception, social isolation, fear, low self-esteem, and disturbed thought processes improve their mental health (McCarthy et al., 2017). To affect such interventions for those with varying categories of mental illness, psychiatric nurses can use reminiscence therapy to (1) help people feel more connected to their communities, (2) provide an emotional outlet, and (3) overcome stressful situations. In the initial assessment, psychiatric nurses can motivate patients to talk about traumatic experiences and incorporate reminiscence therapy into the multidisciplinary treatment planning process. By using sensory memory triggers relating to sight (photos, maps, flags, symbols), sounds (songs, animal sounds), words (place names, famous people, stories, proverbs, poems), tastes (food, drink), and smell (perfume, make-up, cleaning agents, herbs, spices) in the initial assessment, nurses may prompt communication to reveal different aspects of mental health not regularly covered.

Over time, nurses may work to tailor the treatment by tracking individuals’ reminiscence frequency and building/sustaining a working relationship with these individuals. Active listening can help nurses recognize negative thought patterns and more constructively reframe negative emotions. If individuals reminisce negatively, psychiatric nurses may consider further interventions to reform negative thinking into positive thinking. Screening for and preventing potentially harmful effects of negative memories, encouraging patients to talk about traumatic experiences, and validating memories can help them recognize negative thought patterns and replace them with more positive ones.

The current study’s findings will assist nurses in understanding how cultural and sociological contexts form these functions of reminiscence in an Arabic-speaking community. Understanding how reminiscence functions are universally similar or different across cultures is necessary to design and deliver culturally sensitive nursing interventions. It is more important now than ever, as the growing Middle Eastern population emigrates outward toward Europe and North America, that reminiscence interventions become more culturally sensitive (Butcher et al., 2018).

In fact, reminiscence may not always be helpful if cultural and contextual factors are not taken into account (Hofer et al., 2017). By giving their patients a more nuanced perspective on the past, especially when it comes to traumatic memories, and centering their care on adaptive reminiscence (e.g., integrative and instrumental reminiscence), psychiatric nurses can help older Arab adults who suffer from death anxiety due to Bitterness Revival cope with these flashbacks.

This study provides primary data (personal and contextual factors) that impact how an older adult will respond to reminiscence. Psychiatric nurses, responsible for directly handling the identification and management of mental health issues in at-risk older adults, must be aware of these contextual factors when dealing with reminiscence and assessing negative memories. These negative memories could develop into negative thoughts, contributing to depressive symptoms. To help prevent this, psychiatric nurses may apply reminiscence as an independent nursing intervention to expand self-transcendence and ease death anxiety. Using reminiscence to solidify identity may stimulate the search for meaning in life and reach a sense of calm when thinking about the end of life (McCarthy et al., 2017; Stinson & Kirk, 2006). In reviewing their lives, they may emphasize positive past events and reconcile negative memories to increase self-worth and determine their future direction (Hallford et al., 2018). They also enhance positive feelings by planning, sharing past experiences, and bringing unresolved conflicts to conscious awareness.

Conclusion

This study provides the first set of empirical data about the mediating effect of self-transcendence on the relationship between “Bitterness Revival” and death anxiety in a sample of Jordanian older adults. This study offers evidence that although unfortunately death anxiety is ubiquitous among older adults who rely on “Bitterness Revival,” self-transcendence may help this group overcome these fears. Assisting older people to consolidate and improve their meaning in life may heighten their self-transcendence and further ease death anxiety. Structured reminiscence group interventions could address death anxiety by understanding death anxiety among older adults and help families and psychiatric nurses promote mental health. Older adults who experience death anxiety due to “Bitterness Revival” reminiscences require the attention of psychiatric nurses to control these unpleasant reminiscences by providing a balanced view of the past, particularly about painful memories, and focusing on adaptive reminiscence (e.g., Problem-Solving).

Footnotes

Author Roles

All authors contributed to the conception or design of the study or to the acquisition, analysis, or interpretation of the data. All authors drafted the manuscript, or critically revised the manuscript, and gave final approval of the version that was submitted for publication. All authors agree to be accountable for all aspects of the work, ensuring integrity and accuracy.

Declaration of Conflicting Interests

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

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Ethics

The study was reviewed and approved by the Research Ethics Committee at the Hashemite University.

ORCID iDs

Abdallah Abu Khait

Austin Menger

Theodora Moldovan

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