Death distress constructs: A preliminary empirical examination of the Farsi form in nurses: A brief note

Abstract Aim Death distress can increase mental health problems. The aim of the present study was to develop a measure of death distress and evaluate the reliability of this Death Distress Scale‐Farsi (DDS‐F) among nurses. The hypotheses were that death distress has three components and that the DDS‐F would have desirable psychometric properties. Design A descriptive cross‐sectional study. Methods A convenience sample of 106 Iranian nurses from two hospitals at Tehran city, Iran was recruited. They completed the Death Anxiety Scale (DAS), the Death Depression Scale (DDS) and the Death Obsession Scale (DOS). Results Cronbach's α for the DDS‐F was 0.71. As expected, the DDS‐F had three independent components: death obsession, death depression and death anxiety. A principle component analysis with a varimax rotation of the DDS‐F items identified three factors accounting for 66.13% of the variance. Factor 1 was labelled “Death Obsession” (31.3% of the variance), Factor 2 was labelled “Death Depression” (21.9% of the variance), and Factor 3 was labelled “Death Anxiety” (12.8% of the variance). Discussion Death distress has three components: death obsession, death depression and death anxiety. The DDS‐F which measures these has good psychometric properties, and it can be used in hospital settings to assess death distress among Iranian nurses.

Nurses who care for dying patients may experience death distress. Various factors can impact on the level of death distress in nurses . One of correlates of death distress is cultural religious spiritual issues (Jong et al., 2018). For example, some findings found among English sample (Maltby & Day, 2000a), Muslim Lebanese (Abdel-Khalek, 1998a), Saudi Arabia sample (Almostadi, 2012) and Iranians (Dadfar, Bahrami, Sheybani Noghabi, & Askari, 2016;Dadfar & Lester, 2017a;Mohammadzadeh, 2015;Mohammadzadeh & Najafi, 2010. To screen nurses and other hospital staff for their sensitivity to death and dying and to evaluate death education programmes for hospital staff, it would be useful to have a brief screening instrument to assess their sensitivity to death and dying. Many scales to measure attitudes towards death have been developed, and previous research has indicated that there are three major components: death anxiety, death depression and death obsession. To administer all three Death Anxiety Scale (DAS), Death Depression Scale (DDS), and Death Obsession Scale (DOS) involved a total of 47 items and the goal of the present study was to develop a brief measure of these three components using a brief 9-item scale.

| PROB LEM IDENTIFI C ATI ON
The aim of the present study was to devise a Death Distress Scale-Farsi (DDS-F) for nurses to measure three components of death distress: anxiety, depression and obsessive thoughts.

| ME THODS
A convenience sample of 106 Iranian volunteer nurses was selected from different wards of two hospitals in Tehran, Iran: Hazrat-e Rasool General Hospital affiliated with Iran University of Medical Sciences and the Khatom-Al-Anbia General Hospital. Inclusion criteria were as follows: nurses working in the wards and an educational level of bachelor's degree or higher. Exclusion criteria were as follows: having medical diseases and mental disorders and receiving individual or group psychoeducational or psychological interventions.
The nurses' participation in the study was voluntary, and anonymity was ensured. The objective of study was explained to the nurses.

| Data analysis
For determination of the normality of the data and equality of variances, the Kolmogorov-Smirnov test and Levene's test were used, respectively. The data were analysed with descriptive statistics (mean, standard deviations) and a principal component factor analysis to identify the number of factors to be retained. The criterion of eigenvalues greater than or equal to 1.0 was followed, and the varimax orthogonal rotation of axes was adopted. The SPSS/WIN 26.0 program was used.
The mean total score on the DDS-F was 9.62 ± 3.72. Cronbach's α was 0.71 for the DDS-F, denoting high internal consistency. These 9 items were gain subjected to the same factor analysis (a principal component extraction with a varimax rotation). Three factors were identified (accounting for 66.13% of the variance), confirming the structure of the DDS-F. Factor 1 (3 items) accounted for 31.3% of the observed variance and was labelled "Death Obsession." Factor 2 (3 items) accounted for 21.9% of the observed variance and was labelled "Death Depression." Factor 3 (3 items) accounted for 12.8% of the observed variance and was labelled "Death Anxiety." There was no item which loaded on two factors (Table 1).

| D ISCUSS I ON
The purpose of the present study was to develop a brief screening instrument for death distress to be used for screening nurses and for evaluation death education programs designed to reduce death distress in nurses and other hospital staff. A 9-item scale was developed to measure death anxiety, death depression and death obsession. Three components were identified for death distress by previous researchers (see Mohammadzadeh, Ashouri, Vahedi, & Asgharipour, 2018). The study showed Cronbach's α was 0.71 for the DDS-F as a whole. Researchers can use the total score for the DDS-F or, if they wish, measure each component of death distress separately.
For obsession and depression, it is suggested to cut some of items from the DOS and the DDS, because some of them seem more to do with anxiety. The best three items were chosen from the first factor of each of the factor analyses, taking into account content.  Note: Items of high loadings (> 0.50) are given in bold to more clearly differentiate the factors.

| CON CLUS ION
The DDS-F was developed to assess death distress with its three components (death anxiety, death depression and death obsession).
It has good psychometric properties, and it may be useful in hospital settings to assess death distress among Iranian nurses and other staff and to evaluate death education programmes.

CO N FLI C T O F I NTE R E S T
The authors declare that there is no funding for the study, and they have no conflict of interest regarding the publication of this paper.

AUTH O R CO NTR I B UTI O N S
All authors have agreed on the final version and meet at least one of the following criteria [recommended by the ICMJE (http://www. icmje.org/recom menda tions /)]: substantial contributions to conception and design, acquisition of data or analysis and interpretation of data; and drafting the article or revising it critically for important intellectual content.