Using the threat index to predict death anxiety, sense of purpose, and performance of hospice volunteer personnel

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Using the threat index to predict death anxiety, sense of purpose, and performance of hospice volunteer personnel
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Hospice care -- Psychological aspects   ( lcsh )
Volunteer workers in terminal care -- Psychological testing   ( lcsh )
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Thesis (Ph. D.)--University of Florida, 1993.
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Includes bibliographical references (leaves 111-124).
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by Michael Gillaspie.
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USING THE THREAT INDEX TO PREDICT DEATH ANXIETY, SENSE
OF PURPOSE, AND PERFORMANCE OF HOSPICE VOLUNTEER PERSONNEL













By

MICHAEL GILLASPIE


A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF
DOCTOR OF PHILOSOPHY


UNIVERSITY OF FLORIDA

1993


UNIVERSITY OF FLORIDA LIBRARIES












ACKNOWLEDGEMENTS

Many thanks go to Dr. Dorothy Nevill who chaired this

project and enthusiastically contributed her knowledge and

time. Thanks also go to Drs. Robin West, Martin Heesacker,

Franz Epting, and Jim Pitts who encouraged and challenged me

to excel. Finally, loving appreciation goes to my wife,

family, and friends for their forbearance and humor in

urging me to get PhinisheD. It never could have happened

without you!













TABLE OF CONTENTS


page

ACKNOWLEDGEMENTS.......................................ii

ABSTRACT.................................................

CHAPTERS

I INTRODUCTION ...................................... 1

Hospice Volunteers...............................1
Thanatological Research.........................4
Personal Construct Theory........................ 6
Hypotheses.........................................9

II REVIEW OF THE LITERATURE.........................11

Effectiveness of Hospice Programs................11
The Role of Hospice Volunteers...................16
Theoretical Origins of Death Anxiety............19
Research on Death Anxiety.......................22
Instruments Used in this Study...................26
Death Anxiety Scale...........................27
Threat Index..................................28
Purpose in Life Test...........................29
Death Anxiety and Health Care Providers.........30
Death Anxiety and Hospice Volunteers.............40

III METHOD...........................................44

Instruments......................................44
Death Anxiety Scale........................... 44
Purpose in Life Test...........................47
Threat Index.............. ....................52
Subjects.................................... 58
Hospice Trainees ...............................58
Experienced Hospice Volunteers.................59
Non-hospice Volunteers.........................60
Group Differences..............................60
Procedure...........................................67
Statistical Analyses...........................71


iii









IV RESULTS......................... ......... ...... 74

General Findings................................74
Administrative Effects ........................... 77
Demographic Effects on Test Scores...............78
Hypothesis One..................................83
Hypothesis Two..................................85
Hypothesis Three................................. 87
Summary of Findings For the Three Hypotheses.....88

V DISCUSSION...... .. ....... .......... ............ 91

Rationale for the Study........................91
Relationships Between the Test Scores............93
Using Tests to Differentiate Groups.............94
Threat Index and Volunteer Performance...........96
Using the Threat Index in Hospice Populations....98
Possible Reasons for No Group Differences........99
Limitations of the Study........................102
Future Directions...............................103

APPENDICES

A PARTICIPANT INFORMED CONSENT..................105

B DEMOGRAPHIC INFORMATION...........................106

C DEATH ANXIETY SCALE (DAS)....................107

D THREAT INDEX (PPQ, PPQ2, PPQ3)................. 108

REFERENCES ............................... ...... ....111

BIOGRAPHICAL SKETCH ............................. .....125













Abstract of Dissertation Presented to the Graduate School
of the University of Florida in Partial Fulfillment of the
Requirements for the Degree of Doctor of Philosophy



USING THE THREAT INDEX TO PREDICT DEATH ANXIETY, SENSE OF
PURPOSE, AND PERFORMANCE OF HOSPICE VOLUNTEER PERSONNEL


By

MICHAEL GILLASPIE

December 1993


Chairperson: Dorothy D. Nevill, Ph.D.
Major Department: Psychology

The present investigation examined the efficacy of

using the Threat Index to predict the death anxiety,

purpose-in-life, and caregiver performance in a sample of

144 hospice and non-hospice volunteer personnel. This study

proposed that Threat Index scores could be usefully employed

to screen and evaluate hospice volunteers.

The results of the first hypothesis indicated that the

two primary Threat Index scores (TI-actualization, TI-death

threat) could be used to predict subsequent Death Anxiety

Scale and Purpose-in-Life Test scores in the global sample

of 144 hospice trainees, experienced hospice volunteers, and

non-hospice volunteers. Two of the significant correlations

had modest predictive power. The third significant







correlation indicated that TI-actualization scores were

especially good predictors of Purpose-in Life scores.

The results of the second hypothesis indicated that

none of the scores based on the three tests could

differentiate the hospice trainees from the non-hospice

volunteers. The results of the third hypothesis indicated

that neither of the two primary Threat Index scores (TI-

actualization, TI-death threat) was significantly related to

the performance ratings of experienced hospice volunteers,

although one supplemental Threat Index score was a powerful

predictor of volunteer performance ratings.

The current investigation raised questions concerning

the feasibility and relevence of using only primary Threat

Index scores in a population of hospice volunteers. Clearly

factors other than those measured by the Threat Index are

important in the screening and evaluation of hospice

volunteers.












CHAPTER I
INTRODUCTION


Hospice Volunteers

Hospice programs in the United States have served the

multifaceted needs of the terminally ill and their families

since 1974 (Knecht, 1980) and volunteers have played an

increasingly important role in hospice's dramatic growth.

Begun as a grassroots reaction against institutionalized

medical care (Finn Paradis & Cummings, 1986; Longest, 1980),

hospice has quickly expanded nationwide and has, itself,

become a somewhat "bureaucratic" structure (Russell, 1989).

Because of its phenomenal growth, hospice has attracted

government attention in the form of federal regulations and

Congressional acts (Bayer & Feldman, 1982; Knecht, 1980).

In fact the 1983 Medicare reimbursement guidelines required

hospice to utilize volunteers as part of a patient's

interdisciplinary team (Mantell & Ell, 1985). Despite the

regulations and federal mandates, hospice strives to provide

individualized care and seeks to "maximize a comfortable fit

between dying persons and their physical and social

environments" (Mantell & Ell, 1985, pp. 86-87).

This interactionall" perspective is consistent with the

research that demonstrates that individual health and life-








stress adaptation are enhanced through social support

(Steele, 1990; Ferrell, 1985; Ell, 1984; Rando, 1984;

Gottlieb, 1983). The volunteer's role in hospice is to be

supportive of patients and families within their own

environment and to provide the foundation from which other,

professionally provided, hospice services come.

Because of the emotional demands inherent in assisting

dying patients and their families, hospice volunteers

require substantial screening and training prior to

interacting with patients. The costs incurred by hospice in

training volunteers mandate that volunteers remain active in

hospice for an extended period of time (Silbert, 1985).

Hospice administrators have a stake in seeing that

their volunteers both help terminally-ill patients and their

families and receive significant satisfaction for the work

that they do. Surprisingly, with over 1600 hospice programs

in this country (Mor, 1987), relatively few empirical

studies have been conducted on hospice programs in general

or on hospice volunteers in particular.

Volunteers are increasingly performing a wide variety

of duties in their roles at hospice, ranging from assisting

with household chores and daily living tasks to taking part

in recreational activities to counseling patients and their

families (Magnusen Hughes, 1988; De Vries, 1983).

Considering the intense and stressful nature of these

emotionally charged hospice relationships, it seems









beneficial to more closely explore the feelings and

attitudes of this population of health-care providers.

Loneliness, depression, anxiety, and fear are recurrent

themes in the literature on death and dying (Downe-Wamboldt

& Ellerton, 1986; Smith & Bohnet, 1983; Dupee, 1982;

Davidson, 1979), yet these themes have been investigated

primarily from the patient's point of view. Few empirical

studies have explored whether these or any other symptoms

are present in the volunteers who work at hospice.

According to Krant (1979), terminally ill patients

symbolize death, a universally feared concept. Perhaps

because of this phenomenon, dying patients are typically

ignored and ostracized by friends, medical staff, and clergy

(Price & Higgins, 1985; Telban, 1981; Feifel, 1969). Fear

of abandonment has long been shown to be a salient concern

of those who are dying (Davidson, 1979; Kubler-Ross, 1969).

Indeed, a sizable amount of research has shown death

anxiety to contribute negatively to the care provided by

doctors and nurses (Field & Howells, 1988; Eakes, 1985;

Stoller, 1980-81). If these negative reactions to seriously

ill patients occur because of death anxiety, to what extent

are hospice volunteers able to combat their own fears and

function effectively in their roles as caregivers? One

might hypothesize that excessive levels of death anxiety in

volunteers would negatively influence the care that they are

able to provide hospice patients.









Frequently described as "the backbone" of any hospice,

volunteers provide immeasureable support for patients and

families (Dush, 1988; Finn Paradis & Usui, 1987; Kavanaugh,

1983; Mor & Laliberte, 1983). Given the increasing

recognition that hospice volunteers have received, both by

medical and governmental bodies, anything which might

detract from, or be predictive of, their effectiveness as

caregivers would seem to be worthy of investigation.

ThanatoloQical Research

Death anxiety is a frequently debated concept whose

origins lie in the psychoanalytic notions of Freud (1926),

Rank (1912), and Stekel (1908). Phobic reactions and

cultural sublimation are two of the earliest theorized

responses to anxiety resulting from death and dying. More

recently, death anxiety has sparked interest from

researchers and has been studied quite extensively in the

literatures of psychology, medicine, and education. Not

satisfied with the nebulous "analytic" notions of earlier

theorists, later investigators devised instruments in an

attempt to operationalize death anxiety.

As the number of instruments measuring death "concerns"

increased (i.e., Bugen's Coping with Death Scale, 1980-1981;

Krieger, Epting, and Leitner's Threat Index, 1974; Templer's

Death Anxiety Scale, 1970; the Collett-Lester Fear of Death

Scale, 1969), an empirical basis was found for the long

asserted claims of analytic writers. Consistent with the








writings of early theorists, people did seem to have fears

and worries surrounding death. However, many tests

frequently exhibited only moderate correlations with each

other and some authors have suggested that significant

methodological problems continue to plague attempts to

measure death anxiety (Vargo, 1980; Dickstein, 1972).

With the continued diversity of death anxiety measures,

it is now generally recognized that this concept is much

more complex than was originally conceived. Death anxiety

is currently conceptualized to be a multi-, rather than a

unidimensional concept (Rigdon & Epting, 1985; Littlefield &

Fleming, 1984-1985; Kastenbaum & Aisenberg, 1972; Vernon,

1970). Many attempts have been made to untangle the various

responses toward death and it now appears that death anxiety

is but one component of a whole constellation of death

responses which includes death fear, death threat, and death

attitudes (Neimeyer, Bagley & Moore, 1986).

Some investigators have posited that death concerns are

present at several levels of consciousness (Feifel &

Branscomb, 1973; Feifel & Hermann, 1973). Self-reports,

projective tests, word associations, and galvanic skin

responses were some of the methods utilized to tap into

progressively deeper layers of death anxiety and fears

(Littlefield & Fleming, 1984-1985; Pollak, 1979).

Inconsistent findings using these techniques, however, gave

rise to the hypotheses that social desirability, denial, or







6

repression were responsible for skewing the results of death

anxiety research (Dickstein, 1975; Nelson & Nelson, 1975;

Durlak, 1972).

Still other investigators have found that differences

in measured levels of death anxiety and fear existed

depending upon factors such as the amount of satisfaction

obtained in life, the degree of pain experienced, or whose

death was being considered (Amenta, 1984; Trent, Glass, Jr.

& Magee, 1981; Collett & Lester, 1969).

Neimeyer, Epting, and Krieger (1984) reviewed the

fragmented literature of death and dying and concluded that

the field was in dire need of a coherent, testable theory to

conceptualize these phenomena. With so many disciplines

contributing to thanatology (medicine, sociology, education,

religion) the above authors suggest that psychology is best

equipped to provide a theoretical framework for further

empirical studies. In searching for a unifying theory to

organize thanatology, some researchers have increasingly

utilized Personal Construct Psychology, as first proposed by

George Kelly (1955).

Personal Construct Theory

According to Kelly (1955), people organize experiences

through a personally unique system of knowledge structures

called personal constructs. Shunning the more positivistic

approaches in psychology, Kelly saw individuals as "personal

scientists" who actively construed their environments








through idiosyncratic personal construct systems. People

used these knowledge structures (or personal constructs) to

create, test, and modify personal theories which helped them

organize their lives and anticipate future events.

Personal constructs can be thought of as individual

interpretive structures whereby "some things are seen as

alike and yet different from others" (Bannister & Hair,

1968, p. 489). These structures determine both a person's

perceptions of, and reactions to, their environment.

Personal constructs also enable people to interpret past

experience and to make predictions about the future.

These personal constructs, or interpretive structures,

are thought to develop over time into complex hierarchies

enabling us to order our experience through bipolar

constructs such as happy-sad, friend-enemy, male-female,

silly-serious, etc. A person's construction of reality

ultimately hinges upon a small number of "core" constructs

which are central to that person's belief system and under

which the vast matrix of other, more "peripheral" constructs

are organized.

Kelly believed that people continually modified the

secondary or peripheral constructs in response to

conflicting environmental data. However core constructs are

highly resistant to change. If the core constructs of a

person's belief system become obsolete or defective, the

whole matrix of constructs is jeopardized and previously








meaningful constructions of the world become chaotic and

indecipherable.

Kelly theorized that threat occurs when a person's

fundamental assumptions (core constructs) about reality are

seriously challenged by experience. In fact, threat was

defined by Kelly as "the awareness of imminent comprehensive

change in one's core structures" (Kelly, 1955, p. 1).

Death, according to Neimeyer and Chapman (1980), was just

such a threatening event to many people:

A given person would regard death as threatening to the
extent that they viewed their primary life projects as
incomplete or "unfinished." To the individual whose
central ideals remain unactualized, death threatens to
destroy those expectations that granted life its
significance; it aborts the development of a cherished
identity still unborn. In contrast, to the individual
whose major projects have been fulfilled, death is a
source of less anxiety; it appropriately punctuates a
meaningful life which has permitted the self to
approximate its chosen ideals. (p. 234)

In 1974, Krieger, Epting, and Leitner developed the

Threat Index, which is theoretically based on the Personal

Construct Theory of George Kelly. During the past twenty

years, the Threat Index has been utilized in both research

and clinical contexts and is one of the most promising death

orientation instruments in the literature today (Robinson &

Wood, 1984; Simpson, 1980).

Despite its many applications, the Threat Index has not

been administered in a hospice setting. Little is known

about the death attitudes of hospice volunteers, yet they

work intimately with terminally ill patients and families,









on a weekly, if not daily basis. Hospice volunteers would

seem to be an "at-risk" population for the debilitating

effects of death anxiety (i.e., poor patient care). Dying

patients and their families need volunteers who are

emotionally available and willing to help them physically

and psychologically during this difficult time.

The Threat Index currently can yield two primary scores

and four supplemental scores. It will be the main measure

used in this study. Two other instruments have been used

extensively in thanatological research and will also be used

during this investigation (Death Anxiety Scale, 1970;

Purpose in Life Test, 1969). The self-report responses of

hospice trainees, experienced hospice volunteers, and non-

hospice volunteers (144 subjects total) will be evaluated.

The primary purpose of this study is to show whether

the Threat Index can be effectively used in a hospice

volunteer setting to screen and evaluate hospice trainees

and hospice volunteers. To this end, three hypotheses will

be tested using the Threat Index (TI), the Death Anxiety

Scale (DAS), and the Purpose in Life Test (PIL).

Hypotheses

The first hypothesis states that significant

relationships exist between the two primary scores of the

Threat Index (TI-actualization and TI-death threat) and the

obtained scores on the Death Anxiety Scale (DAS) and the

Purpose in Life Test (PIL) in this study's sample of 144









hospice trainees, experienced hospice volunteers, and non-

hospice volunteers. This hypothesis will test whether death

anxiety or sense of purpose can be predicted using the

Threat Index.

The second hypothesis states that significant

differences in DAS, PIL, or Threat Index scores (primary and

supplementary scores) exist between hospice trainees and

non-hospice volunteers. This hypothesis will test whether

any of these tests could be used as a screening instrument

for potential hospice volunteers.

The third hypothesis states that significant

relationships exist between the two primary Threat Index

scores (TI-actualization and TI-death threat) and the

supervisory performance ratings given to experienced hospice

volunteers. This hypothesis will test whether the Threat

Index could be used as an evaluative instrument with

volunteers currently involved in patient care.











CHAPTER II
REVIEW OF THE LITERATURE


Effectiveness of Hospice Programs

In American society people typically die alone in large

and unfamiliar environments. Is this the choice of the dying

person? Is this preferable for the families involved? What

are the ramifications of treating seriously ill people in

this manner? In any given year, more than 75% of the deaths

in the United States occur outside the home despite studies

showing that 80% of the population prefers to die at home

(Hine, 1979-80). The hospice movement has evolved in this

country specifically in response to such troubling questions

and statistics.

The growth of hospice programs in this country over the

past two decades vividly demonstrates that traditional

treatment options for terminally ill patients were sadly

limited (Mor, 1987). Healthcare providers are beginning to

acknowledge that factors surrounding the death of a loved

one determine the quality of this natural experience, both

for the patients and their families.

The "death surround" was a phrase coined by Rando

(1984) to describe such things as the location of death, the

presence of loved ones, the type and cause of death, and the

degree of family preparation for death. Although the "death
11









surround" is important for the dying patient's comfort and

peace of mind, it is also seen as playing an absolutely

vital role afterwards in the family grieving process

(Steele, 1990).

Canadian researchers with the Royal Victoria Palliative

Care Unit (1976) conducted follow-up research on the

survivors of terminally ill patients who had died during a

six month period. One year after experiencing a loved one's

death, the palliative care unit's families showed

consistently fewer manifestations of grief when compared to

the control families.

Buckingham and Foley (1978) evaluated the homecare

services provided by the New Haven Hospice. Over a two year

period, anxiety, depression, and social adjustment scores of

hospice and non-hospice patients and families were compared.

Hospice patients and families exhibited lower levels of

anxiety and depression than did the non-hospice comparison

group. The hospice group also had higher adjustment levels

than those patients and families not involved in hospice

care.

Parkes (1979) interviewed the surviving spouses of

patients who had died of cancer in London. He eventually

matched 34 patients from St. Christopher's Hospice with 34

patients from other area hospitals and interviewed the

spouses of each patient. During their inpatient stays,

significantly more hospital patients suffered "severe pain








and distress" than did the hospice patients. The patients

at St. Christopher's Hospice were significantly more likely

to be "out of bed" during the majority of their inpatient

stay, and were twice as likely to know their diagnosis and

prognosis. Finally, compared to their hospital cohorts,

hospice patients endorsed "talking to other patients and

visitors" as an important facet of their treatment.

In order to understand the factors involved in

selecting an acceptable "death surround," Putnam, McDonald,

and Miller (1980) surveyed 44 patient and family pairs.

Half of the pairs chose to die at home and cited that being

with family and friends, and playing an active role in

treatment were critical determinants in their decision. The

other half of pairs chose to die in the hospital and cited

superior medical care and not burdening the family as

important factors in their decision. When given the

hypothetical situation of a nurse coming out to the home

several times per week, 60-70% of the hospital-choosing

pairs would choose to die at home.

Cameron and Parkes (1983) interviewed 40 close

relatives of cancer patients who had either died in a

Palliative Care Unit (PCU) or in other wards of the same

hospital. One year after the deaths, relatives of PCU

patients reported significantly fewer psychological symptoms

and less persistent grief than the hospital control

relatives. The relatives of the hospitalized control








patients were especially differentiated from the PCU

families in their continued irritability, hostility toward

others, and distressing memories of the patient's pain.

Kane, Wales, Bernstein, Leibowitz, and Kaplan (1984)

randomly assigned terminally ill cancer patients to hospice

and hospital treatment at a Veterans Administration

hospital. The researchers matched 250 cancer patients on

such things as age, race, occupation, and primary cancer

site. The hospice patients and their families felt more

satisfaction with the quality of care received, and families

of the hospice patients felt less anxiety than their

hospital family cohorts. The hospital-based controls were

consistently more depressed than hospice patients and no

significant differences were found between the two groups on

symptom relief or cost effectiveness.

Ferrell (1985) interviewed families of terminally ill

patients who had recently died both in hospitals and at home

under the care of a hospice. Most of the "hospital

families" interviewed expressed "serious dissatisfaction"

with the care administered to their family member prior to

death. Families enrolled in hospice programs prior to the

death felt that both they and their family member had

received "sensitive and personal attention." Ferrell

further discovered that the spouses of those who died in the

home felt less guilt, shock, confusion, and numbness than

spouses of those who died in the hospital. Lastly, the







15

"hospital spouses" also showed a strong tendency to dwell on

the negative circumstances of the death.

Using the Grief Experience Inventory (Sanders, 1979),

Steele (1990) tested 60 relatives of patients who had died,

half of whom participated in a hospice program prior to the

loved one's death. She found that the relatives of hospice

patients scored lower on the bereavement subscales of guilt,

loss of control, despair, and depersonalization when

compared to the relatives of non-hospice patients. Dying at

home was also correlated with lower subscale scores of

denial and death anxiety, regardless of the length of time

the patient and family were involved in hospice.

Although a recent phenomenon, the hospice movement is

quickly gaining acceptance among both the medical profession

and the general public. Hospice's explosive growth (Mor,

1987; Price & Higgins, 1985) seems to reflect a deep

dissatisfaction with traditional approaches aimed at caring

for terminal patients. This needy population and their

troubled families have been poorly served by years of

institutionalized medicine. Research such as the studies

cited above lends credence to hospice's assertion that

palliative care can result in a higher quality of life for

the terminally ill patient. Hospice can also play a major

role in the long-term process of recovery for survivors'

following the loved one's death.









The Role of Hospice Volunteers

According to a number of researchers (Cameron & Parkes,

1983; Krant, 1979; Williams, 1976), general hospital care is

frequently unsuited for meeting the many needs of dying

patients and families. Foremost among the problems cited by

patients and families are difficulties in communicating

fear, sadness, anger, resentment, and love (Krant, 1979). A

review of the literature suggests that volunteers at hospice

are increasingly being utilized to address the difficult

psychological demands of the terminally ill and their

families (Downe-Wamboldt & Ellerton, 1986; Caty & Tamlyn,

1983; DeVries, 1983).

Downe-Wamboldt and Ellerton (1986) investigated the

activities of volunteers interacting with 144 terminal

cancer patients. After each patient/family visit,

volunteers endorsed one of six activities: listening and

responding; socializing; providing physical comfort;

providing spiritual comfort; information exchange; and

referral. The activity most engaged in by volunteers when

interacting with patients and families was listening and

responding (58%). Although physical symptoms were cited by

patients as their most prevalent concern (51%), emotional

and social concerns were also heavily endorsed (33%). The

researchers believe that volunteers can be invaluable in

serving as liaisons between patients and medical staff.








Basile and Stone (1986-87) surveyed hospice

practitioners for the emotional, interpersonal, and

professional attributes characteristic of effective hospice

personnel. The practitioners felt that maturity, warmth,

tolerance, and a nonjudgmental attitude were the most

important traits of hospice volunteers and nurses. Having

previously experienced the death of a loved one was not

universally seen as an important screening criterion for

hospice personnel. The authors believe that hospice

administrators need to focus attention on the emotional and

interpersonal competencies of their volunteers.

Surveying 150 hospice volunteers at a midwestern

hospice, Seibold, Rossi, Berteotti, Soprych, and McQuillan

(1987) found that volunteers were engaged primarily in five

activities: palliative care; administration; bereavement;

in-home care; and community outreach. The researchers found

that 80% of the volunteers felt that their strengths and

talents were being well-utilized by hospice. However,

volunteers found palliative care the most stressful activity

and, along with bereavement, the least satisfying activities

they perform. The authors suggest that working in pairs,

offering volunteer support groups, and encouraging more

interaction with paid hospice staff might help volunteers

cope while performing these difficult activities.

Magnusen Hughes (1988) surveyed 125 volunteers from

four Wisconsin hospices to identify volunteer activities and








assess how they perceived the needs of the patients and

families that they serve. Volunteers overwhelmingly felt

that patients and families have heavy emotional (fear,

isolation, fatigue) and physical concerns (pain, nausea,

constipation). The five most frequently provided services

(and the five services seen as most valuable by volunteers)

were friendly visiting; caregiver respite; bereavement

visits; telephone contacts; and hospital visits. Volunteers

also engaged in more task-oriented services such as bathing,

transportation, shopping, and feeding. A sizeable minority

of volunteers (22%) even performed technical procedures

(wound care, oxygen therapy, and assistance in elimination).

The author claims that an intense attachment develops

between volunteers, hospice patients, and families that paid

staff cannot duplicate.

Volunteers obviously fulfill many duties in their role

as supportive caregivers for hospice patients and families.

As hospice volunteers, their interactions with patients and

families can take many forms because the needs of this

population are so diverse. Addressing the emotional and

interpersonal needs of hospice patients and families seems

to be a vital function of hospice volunteers. The heavy

emotional investment in these families by volunteers, while

very rewarding, can also be overwhelming and lead to a

premature withdrawal from the program (Finn Paradis, Miller

& Runnion, 1987; Basile & Stone, 1986-87). Death anxiety is






19

thought to negatively influence this patient-caregiver bond

(Waltman, 1990; Scanlon, 1989; Gadow, 1980; Feifel, 1967)

and to be a significant contributor to "burn-out" in the

health professions (Price & Bergen, 1977; Hay & Oken, 1972;

Vreeland & Ellis, 1969).

Theoretical Oricins of Death Anxiety

Prior to 1918, Freud (1915, 1918) maintained that death

is unimaginable to the unconscious. As a result, because of

their innate narcissism, people truly believe that they are

immortal and are unable to fathom nonexistence. People who

complained of death anxieties or fears were, in fact,

suffering from castration anxiety or separation anxiety. If

death anxiety truly existed, it would necessarily overwhelm

any psyche. According to Freud, death anxiety and death

fears were merely derivatives of more germane oedipal

phenomena.

With the end of the Great War and its terrible

destruction, Freud (1920) became more pessimistic and he

revised a number of his beliefs. Taking cues from some of

the contemporary findings in the physical sciences, he felt

that the basic aim of all life forms was to return to

simpler states. Freud felt that a basic tendency for humans

was to strive toward death. Oedipal conflicts alone were

insufficient to explain the human proclivity toward war and

mass annihilation. Freud believed that a death instinct

(Freud, 1920) must serve as the basis for a wide range of









troubling behaviors such as aggression, sadism, and

masochism.

This later view of Freud's was not well-accepted by his

analytic peers (Greenberger, 1965; McClelland, 1963;

Brodsky, 1959; Fenichel, 1945) who continued to posit that

death anxiety was merely a defensive attempt by patients to

avoid oedipal issues. Reunion with the mother, separation

from the mother, punishment for aggression, and punishment

for incestuous wishes were just some of the examples of how

these analytic writers continued to view death anxiety

(Lonetto & Templer, 1986).

Jung (1933, 1959) did not believe in such a

negativistic view of death. Instead he felt that people

could have a wide range of beliefs about death and that

these beliefs shaped people's daily lives. What was

important was how these beliefs were integrated into daily

living. He adhered to a type of developmental model of

existence: the first half of life was concerned with

preparing for life's primary activities (marriage,

parenting, careers); the second half of life dealt with

preparing for death (Lonetto & Templer, 1986).

This life and death duality was further explored by the

works of Erik Fromm (1964). Fromm believed that all people

have vestiges of biophilia (love of life) and necrophilia

(love of death), but he was particularly interested in

necrophiliacss" who were inexplicably drawn toward death,









corpses, and decay. Fromm likened these "lovers of death"

to Freudian "anal characters" who were orderly, forceful,

emotionally cold, and ruminative. Fromm explored the lives

of characters such as Hitler and Stalin and concluded that

they were extreme necrophiliacs with a frightening capacity

and willingness to destroy.

Adler (1927) and Frankl (1955) both downplayed the

deleterious nature of death anxiety and refused to let their

patients use fear of death as excuses for unproductive

living. Adler claimed that people run away from life and

its responsibilities by "fearing death" and, as a result,

forego the rewards and fulfillment that come with living.

Frankly was a World War II concentration camp survivor who

urged his patients to seek meaning in all facets of life,

even suffering and death. Frankly believed that life was

made richer and actions were rendered more meaningful

because humans were destined to die, realized it, and could

prepare for it.

Finally, writers such as Becker (1973), Weisman (1972),

and Zilboorg (1943) viewed death denial as extremely

important, both for individuals and society as a whole. In

order to lead productive lives, people must constantly deny

death or the anxiety will become both terrifying and

overwhelming. Mental illness and societal breakdown are the

necessary outcomes of failing to effectively deny death.









No longer the sole domain of analytic and existential

writers, the study of death and its psychological impact on

humanity is now a field of inquiry in its own right.

Researchers have approached death anxiety empirically to

better understand this theorized phenomenon. The next

section will explore some of the important research findings

that have shaped current ideas about death anxiety.

Research on Death Anxiety

Religious thinkers, philosophers, dramatists, and

writers have addressed the topic of death for millennia and

have failed to agree on just what death entails or what a

healthy approach to death should be. Not until recently

have psychological researchers begun to systematically study

death and its many cognitive, affective, and behavioral

components. Predictably, few universally accepted truths

have been uncovered, but researchers have gained important

insights about death anxiety and the field has flourished.

Rando (1981), Feifel (1971, 1968, 1959), and others

have written that human thoughts and behaviors are uniquely

future-oriented and that death is the ultimate threat.

Feifel was an early pioneer in the psychological study of

death and was one of the first to demonstrate that a

person's current behavior was largely influenced by their

beliefs and attitudes about the future and their own

mortality:









The underemphasis on the place of the future in
psychological thinking is surprising because, in many
moments, man responds much more to what is coming than
to what has been. Indeed, what a person seeks to
become may, at times, well decide what he attends to in
his past. The past is an image that changes with our
image of ourselves. It has been said that we may learn
looking backward. we live looking forward. A
person's thinking and behavior may be influenced more
than we recognize by his views, hopes, and fears
concerning the nature and meaning of death. (Feifel,
1959, p. 116)

Many psychologists (Durlak, 1973; Dickstein, 1972;

Templer, 1970; Boyer, 1964; Brodsky, 1959; Feifel, 1959)

painstakingly uncovered a wealth of interesting, but

disorganized findings using empirical methods. The massive

volume of death studies in the 1970s and 1980s was the

catalyst for the creation of more specialized research and

scientific journals. One of the first "facts" uncovered was

that death had many meanings for different people.

Feifel (1968, 1959) wrote that death can represent "a

teacher of universal truths," the "gentle night," "peaceful

sleep," an "adventure," a "great destroyer," reunion with

family, loss of control, etc. Kastenbaum (1977) viewed

death from four broad perspectives: the great leveler or

equalizer; the great validator; an event that radically

alters relationships with others (either uniting or

separating); and as an end to an opportunity of achievement

and experience. Death is universal, but its meaning is

highly idiosyncratic.

One aspect of death which has fascinated poets,

Freudians, and thanatologists alike is the anxiety







24

associated with death. Even this seemingly unitary concept

has been shown to have multidimensional features (Lonetto &

Templer, 1986). Gilliland and Templer (1985-86), Ramos

(1982), Schulz (1978), Nelson (1978), and others have shown

that death anxiety can generally be conceptualized as

containing four independent components:

1. Concern about both the cognitive and emotional
impact of dying and death.

2. Anticipation and fear of the physical alterations
brought about by dying and death.

3. Awareness of the finite time between birth and
death and of the rapidity of its passage.

4. Concern about the stress and pain accompanying
illness, disease, and dying.

Researchers are convinced that these factors, either singly

or in combination, determine the level of death anxiety

present in an individual. These factors are also thought to

determine the strength of the relationship between death

anxiety and a number of other psychological variables

(Pollack, 1979-80).

Further complications regarding the understanding of

death anxiety have arisen with the finding that death

attitudes and responses to death change within an individual

and across groups over time (Rando, 1987). Feifel (1977,

1971) has even shown that people can have contradictory

attitudes about death simultaneously. Although researchers

have made huge inroads in the understanding of death

attitudes, it is quite clear that many questions remain.









One of the most troubling problems in thanatology has

been the failure to consistently delineate the difference

between death anxiety and death fear in the scholarly

literature and in various assessment instruments (Kalish,

1981). Although writers frequently use death anxiety and

death fear interchangeably, these terms are not thought to

be synonymous (Kastenbaum & Kastenbaum, 1989; Neimeyer,

Behnke & Reiss, 1983; May, 1977). Both terms imply a state

of discomfort, yet death fears are very specific and can

easily be articulated (fear of slow, painful death; fear of

being alone; fear of decomposing, etc.).

Death anxiety, on the other hand, is thought to be a

more global feeling that does not lend itself to easy

articulation (Kastenbaum & Kastenbaum, 1989). Death anxiety

is partly comprised of specific death fears, but most of its

debilitating effect comes because its source cannot be

pinpointed. According to a large number of researchers,

(Kastenbaum & Kastenbaum, 1989; Feifel, 1977; May, 1977;

Lifton, 1975; Kubler-Ross; 1969; Wahl, 1959) death anxiety

can result in psychosis, depression, fatigue, self-

destructive behavior, violence, substance abuse, and a host

of other physiological and cognitive symptoms.

Perhaps the most compelling definition of death anxiety

comes from the research of Personal Construct Psychology.

Neimeyer, Behnke, and Reiss (1983) theorized that "death

anxiety reflects the inability to understand or meaningfully








construe death" (page 249). Or put another way, an

individual does not have the constructs in place to

assimilate "death." A person is left uneasy because "pieces

do not fit." This uneasiness may necessitate some minor

adjustments in that individual's construct system. If minor

adjustments are unable to resolve the incongruence between

the way a person sees "themselves" and "death," more

comprehensive change is required and death threat is the

result. Death anxiety seems to be a natural precursor to

the more debilitating death threat.

Clearly the field of thanatology has much to learn

about humanity's attitudes about death. To a large extent,

people appear to create their own meanings about death. It

can be a terrifying, mysterious cloud on the horizon of life

or it can be a driving force which empowers people to

create, to achieve, and to love. One of the most important

findings by researchers has been that death is finally being

recognized as the complex phenomenon that it is. The

current research project was devised with this

multidimensionality in mind.

Instruments Used in this Study

The current study utilizes the two most popular

instruments in thanatology, the Death Anxiety Scale

(Templer, 1970) and the Threat Index (Krieger, Epting &

Leitner, 1974). Both tests are empirically sound and have

proven quite useful to researchers in this field. The third







27

instrument used is Crumbaugh and Maholick's Purpose in Life

Test (1969). This test is based upon Viktor Frankl's belief

that finding meaning and purpose are main motivations in

life. The three tests were grouped in a packet containing

an informed consent form (Appendix A) and a general

demographics page (Appendix B). The tests will be discussed

in more detail below.

Death Anxiety Scale

Templer's Death Anxiety Scale (1970) is the most widely

used and researched psychometric instrument in thanatology

(Kastenbaum & Kastenbaum, 1989). Templer devised this scale

as an improvement over what was probably the first death

anxiety measure, Boyar's Fear of Death Scale (1964).

Templer felt that Boyar's 18-item test had construct

validity problems and did not cover a sufficiently wide

array of life experiences. After validity and internal

consistency checks were made, Templer's 40-item, rationally-

devised, true-false test was pared down to its current 15

items (see Appendix C). In the present study, this test

will be used to measure volunteers' "unpleasant emotional

state precipitated by contemplation of their own deaths"

(Templer, 1970, p. 166).

The Death Anxiety Scale has been correlated with dozens

of physical and psychological variables, ranging from

demographic information (age, sex, race), physical health,

risk-taking behavior, depression, locus of control, to self-








concept (Lonetto & Templer, 1986; Pollack, 1979-80).

Generally speaking, high death anxiety scores are almost

invariably associated with both physical and psychological

pathology (Lonetto & Templer, 1986). This scale has also

been correlated with every other published death anxiety

scale and with most of the currently used personality

inventories. For the past 20 years, the Death Anxiety Scale

has served as the standard by which other death anxiety

instruments are measured and has served as a catalyst for

the continued refinement of our understanding of death

anxiety.

Threat Index

Second only to the Death Anxiety Scale (Templer, 1970)

in thanatological research prevalence, the Threat Index

(Krieger, Epting & Leitner, 1974) represents a significant

development in the study of death. Because of its strong

foundation in the Personal Construct Theory of George Kelly

(1955), the Threat Index represents a theoretically grounded

instrument which provides a unique format from which cogent,

testable definitions and hypotheses can be investigated.

Since its inception, this instrument has greatly contributed

to the improvement in the calibre of research in this

fragmented field (Neimeyer & Epting, 1992; Simpson, 1980;

Kastenbaum & Costa, 1977).

A number of formats for the Threat Index have been

developed in order to best understand the intensely personal







29

and varied conceptualizations of death. A number of scoring

procedures have also been reported with several more holding

promise for further exploration (Neimeyer & Epting, 1992).

Originally in a lengthy interview format, the 40 most

popular constructs of the Threat Index were transformed into

a self-administered questionnaire (Krieger, Epting & Hays,

1979) which made group administrations possible (see

Appendix D).

The Threat Index has been used to study the sick

(Robinson & Wood, 1983; Viney, 1983), health care providers

(Neimeyer, Behnke & Reiss, 1984; Rainey, 1984), the

religious (Powell & Thorson, 1991), the elderly (DePaola &

Neimeyer, 1992; Myers, Wass & Murphy, 1980), and the

depressed (Rigdon, 1983). The Threat Index has also been

used in comparing hospice patients with ill and recovering

patients (Hendon & Epting, 1989).

Purpose in Life Test

The Purpose in Life Test (1969) is an attitude scale

based upon the existential works of Viktor Frankl. This

self-administered questionnaire is protected by copyright

laws and not included in the Appendices. According to

Frankl (1969), the primary motive in life is "the will to

meaning." This uniquely human characteristic represents a

search for significance which is particularly salient in a

materialistic, mechanistic society. A person who finds

little meaning or purpose in life lacks personal identity








and experiences "existential vacuum" which may lead to

further psychological impairment (Crumbaugh & Maholik,

1981). In the present study, the Purpose in Life Test will

measure the extent to which hospice trainees, volunteers,

and non-hospice volunteers/workshop attendees feel that

their lives are fulfilled, meaningful, and full of purpose.

Used in over 110 published studies, the Purpose in Life

Test has assessed the "purposefulness" of such diverse

populations as substance abusers (Mueller, 1977),

hospitalized patients (Henrion, 1983), adolescents (Barber,

1982), the elderly (Baum & Boxley, 1983), the mentally ill

(Pearson & Sheffield, 1989), health care providers (Amenta,

1984), prisoners (Whiddon, 1983), correctional officers

(Miller & Adwell, 1984), the bereaved (Florian, 1989-90),

the religious (Stones, 1980), and the suicidal (Kukian &

Madison, 1987-88).

The Purpose in Life Test has shown significant

correlations with self-acceptance, achievement, confidence,

responsibility, and emotional stability, and has been

negatively correlated with depression, poor ego strength,

neuroticism, anxiety, and acting out behaviors (Crumbaugh &

Maholick, 1981). This test has also appeared in 13 studies

specifically exploring death attitudes and beliefs.

Death Anxiety and Health Care Providers

Researchers have long theorized that death anxiety

would necessarily have a negative impact on those people who







31

treat and care for the sick and dying. According to Howells

and Field (1982) the death anxiety of health professionals

can result in significant interpersonal stress for them and

can further isolate and alienate patients and families

coping with a terminal illness. Herman Feifel (1959) again

was an early catalyst for this area of research.

Feifel (1965) conducted a survey with professionals and

found that physicians had significantly high death anxiety

(compared to other nonmedical professionals) and that their

death anxiety was even higher than that of their patients.

Feifel hypothesized that the choice of a medical career

reflects a doctor's attempt to master a high level of death

anxiety by being in a position to combat death. Needless to

say this was a surprising discovery and led to a rash of

studies on the death anxiety of health care professionals.

Caldwell and Mishara (1972) arranged standardized

interviews with 73 practicing physicians on the topic of

death and dying. Only 13 completed the interview after

being informed that the the ten minute task was focused on

their personal attitudes and feelings regarding dying

patients. Most doctors simply aborted the interview without

further discussion, but some stated that their feelings

"interfered" with effective treatment. The authors question

how widespread this type of reaction is in the medical

profession and how prepared physicians are to deal with the








psychological and interpersonal concerns of their terminal

patients.

Schulz and Aderman (1978-79) tested the assumption that

the patients of highly death anxious physicians would

survive longer than those with low death anxious physicians.

The authors hypothesized that doctors with high death

anxiety would deny death and take heroic measures to save

the patient. The study showed that the terminal patients of

highly death anxious doctors were in the hospital

significantly longer than those with low or medium death

anxiety. The authors suggest that physicians' professional

behavior may be influenced by death anxiety with important

financial and emotional consequences for their patients and

families.

Shady, Brodsky, and Staley (1979) asked over 200

Canadian nursing students to complete a test packet

(containing Templer's Death Anxiety Scale, 1970) and report

later for a personal interview. The authors found only half

of the students willing to return for the second part of the

study (41 failed to follow through and about 50 could not be

contacted). Those students who took part in the interview

had significantly lower death anxiety scores (7.23) than

those who failed to follow through (8.05) or those who could

not be contacted (9.22). The authors concluded that the

Death Anxiety Scale accurately predicted those students who








would not expose themselves to further death-related

stimuli.

Stoller (1980-81) distributed questionnaires to 62

nurses assessing the death-related fears and the uneasiness

experienced in working with the terminally ill. Nurses

apparently utilize avoidance strategies in situations

bringing them in contact with death (i.e., avoiding a dead

body, treating the patient as an object, interacting only

when a specific nursing task is necessary). In these cases,

avoidance decreases the anxiety and uneasiness experienced

by the nurses. No such strategy was helpful when the nurse

had to interact with the patient in an "unstructured" task

(a patient approaches them about death). The author found

that death fears did affect interactions with dying patients

and that nurses were much more comfortable engaging in

depersonalized, hospital-structured tasks.

Neimeyer, Behnke, and Reiss (1984) used the Threat

Index (1974) and clinical vignettes to predict physicians'

physiological and behavioral reactions to death. They found

that, when confronted with patient death, doctors with high

levels of death threat and death anxiety significantly

utilized maladaptive coping responses (overinvolvement in

work, meticulously looking for medical mistakes, not

attending the funeral, not talking about the death, alcohol

and drug use). The authors concluded that interventions

should address the costs and benefits of these coping






34

responses and should help doctors with high death threat and

death anxiety assimilate death into their personal and

professional identities. If they could assimilate death

into their identities, doctors might be able to anticipate

and accept patient deaths more effectively.

A group of researchers in Canada (Hatfield, Hatfield,

Geggie, Taylor, Soti, Winthers, Harris & Greenley, 1983-84)

questioned over 1000 hospital staff (doctors, nurses,

chaplains, social workers, aides, orderlies) about death and

terminal care. Compared to all the other hospital groups,

physicians felt that patients and families should not share

in most treatment decisions. Physicians did not believe

that patients would want to know their prognosis, nor did

they feel that telling patients their prognosis was as

important as did the other hospital groups. Finally,

physicians were less enthusiastic about encouraging patients

to talk about their illness. The authors concluded that

physicians seem less attuned to the emotional and

psychological needs of their terminally ill patients than

other hospital employees and that death anxiety may result

in hospital staff working at cross-purposes.

Campbell, Abernethy, and Waterhouse (1983-84) mailed

out questionnaires to 25 physicians and 31 nurses at

Vanderbilt University Medical Center. Nurses consistently

viewed death more positively (birth, safety) than did

doctors (frightening, cold). Doctors saw their roles






35

primarily in terms of "responsibility" whereas nurses viewed

their roles in terms of "caring." Professional orientation,

not gender, was responsible for the observed differences in

death attitudes. The authors question whether physicians'

heavy sense of responsibility invokes a sense of blame and

failure that tinges their perceptions of death. This

emphasis on the "cure" versus the "care" may result in

emotionally-distant physicians who utilize suppression and

intellectualization to combat death anxiety.

Neimeyer and Neimeyer (1984) examined the death anxiety

of suicide counselors as it related to their ability to

respond to suicidal clients. Compared to the control group,

suicide interventionists had significantly lower death

anxiety and no relationship existed between death anxiety

and competence in handling suicidal crises. These findings

contradict an earlier study by Neimeyer and Dingemans (1980)

that showed suicide workers having higher levels of death

anxiety than comparable control groups. The authors believe

that the present results dispel the notion of Feifel, et al.

(1967) that suicide workers are merely combatting their own

death anxieties with their chosen line of work.

Eakes (1985) investigated the relationship between

death anxiety and attitudes toward the elderly among 159

nursing home staff (RNs, LPNs, nurse aides). Her hypothesis

that staff members with high levels of death anxiety would

endorse more negative views of the elderly was confirmed.









Neither death anxiety scores nor attitudes toward the

elderly differed significantly with age, race, nursing home

experience, professional position, personal experience with

death, or religious beliefs. According to the author, this

study shows that the death anxiety levels of staff members

have a direct influence on the quality of nursing home care

given to the elderly.

Eggerman and Dustin (1985) studied the relationship

between personal death orientation (as measured by the

Threat Index) and the behaviors of physicians and medical

students. They found that, compared to those with low death

threat, medical students with high death threat were less

likely to directly inform a patient of a terminal diagnosis.

This "circumspect" approach was in the form of considering

extenuating circumstances of the patient. Compared to low

death threat physicians, doctors with high death threat were

more likely to consider "psychological factors" before

speaking to a seriously ill patient about death.

Kane and Hogan (1985-86) attempted to compare the

conscious death anxiety of physicians (surgeons, internists,

psychiatrists) with a measure of repression and a projective

test (measuring covert death anxiety). Based on each

groups' exposure to death, they hypothesized that high-

repressors (surgeons) should report less overt death anxiety

but show more covert death anxiety on the projective test.

Psychiatrists were expected to be low-repressors. The







37

authors did find an inverse relationship between overt death

anxiety and the tendency to repress feelings, but the

expected inverse relationship between overt and covert death

anxiety did not develop. Those physicians endorsing many

death anxiety items did not utilize repression and had many

death references on the projective instrument. The authors

concluded that little useful information was obtained by

incorporating a measure of covert death anxiety in this

study.

Thompson, Jr. (1985-86) compared the death anxiety and

attitudes toward the dying of palliative, surgical, and

pediatric nurses. He found that palliative nurses had

higher levels of death anxiety than the other two nursing

groups, but also felt significantly less uneasy around the

dying, more useful to the patient, more emotionally

expressive, and more fulfilled in their job. The author

contends that these findings reflect primarily the influence

of the work setting on nurses, not their personal

characteristics or experience.

Field and Howells (1988) questioned graduating medical

students relative to their attitudes about dying patients

(all had experienced patient death). The authors predicted

that death anxious students would view dying patients as

more difficult and problematic, utilize more avoidance

strategies, and keep personal concerns concealed from

others. The results showed that most medical students









viewed personal interactions with dying patients as much

more difficult tasks than with other patients and most

students prefer more "structured" interactions with this

population (conducting case histories). Death anxious

students were less likely than other students to discuss the

patient's prognosis with the patient or family and were more

likely to experience more psychological problems in dealing

with dying patients.

Hare and Pratt (1989) questioned 203 professional

nurses and 106 nursing aides on their fear of death and

comfort with patients with a "poor prognosis for survival."

A significant negative relationship was found between fear

of death and comfort with poor prognosis patients. Exposure

to death played an important role in comfort levels.

Compared to nurses with infrequent exposure to death, nurses

with high death exposure had higher levels of comfort when

dealing with the dying and were less afraid of the death of

a loved one or of suffering a premature death themselves.

The authors suggest that future studies incorporate

behavioral measures into research designs to assess the

relevance of self-reports.

Cochrane, Levy, Fryer, and Oglesby (1990-91) explored

the death anxiety, behaviors, and attitudes of 99 New Jersey

oncologists. Significant positive relationships were found

between death anxiety scores and difficulties with

disclosing diagnoses to patients, difficulties interacting









with dying patients' families, and lingering doubts about

the patient's treatment. Elevated death anxiety scores were

highly predictive of maladjustment scores and general life

dissatisfaction. Death anxiety was not related to years of

experience or chosen medical field as three of the four

groups were within the high-normal range of scores.

Brockopp, King, and Hamilton (1991) explored the

differences between two types of nurses (palliative and non-

palliative) on death anxiety, death attitudes, and

perceptions of control. The study utilized two types of

non-palliative nurses (psychiatric, orthopedic). The

researchers found that palliative nurses experienced

significantly less death anxiety and more positive death

attitudes than the other two groups of nurses. No

differences between the nursing groups were found on

perceptions of control. Even though differences in death

anxiety and death attitudes exist, no effort was made to

determine the importance of such variables relative to

patient care.

Many studies have been conducted on the death anxiety

of selected medical and professional staff. In general, the

more groups are exposed to death, the less death anxiety

they report. Those with high levels of death anxiety

utilize maladaptive coping responses (Field & Howells, 1988;

Neimeyer, et al., 1983; Shady, et al., 1979; Caldwell &

Mishara, 1972), have difficulty in interacting with terminal







40

patients and their families (Cochrane, et al., 1990-91; Hare

& Pratt, 1989; Hatfield, et al., 1983-84), and endorse

negative attitudes toward the elderly and dying (Eakes,

1985; Campbell et. al, 1983-84). These studies and many

others lend credence to the claim that death anxiety plays

an important role in the care afforded to the sick and

dying.

Death Anxiety and Hospice Volunteers

Despite the major role that hospice volunteers perform

in the service of terminally ill patients and their

families, few empirical studies have been conducted on this

vital component of hospice care. The scarce research that

has been conducted on volunteers has primarily focused on

training, implementation, and utilization strategies

(Dershimer, 1988; Dush, 1988; Seibold, Rossi, Berteotti,

Soprych & McQuillan, 1987; Mantell & Ell, 1985; Buckingham &

Lupu, 1982; Dorang, 1981).

How do hospice volunteers feel about death and dying?

Do they fear death as much as the general population? Can a

volunteer with elevated death anxiety perform as an

effective caregiver to someone who is dying? Research

questions such as these have been generally neglected by

current researchers.

Amenta and Weiner (1981) administered the Death Anxiety

Scale (Templer, 1970) and the Purpose in Life test

(Crumbaugh & Maholick, 1969) to 98 hospice workers in







41

Pittsburgh (59 of whom were volunteers). The authors found

a significant inverse relationship between scores on the two

tests. Those participants who showed little death anxiety

had a higher sense of purpose in life. Amenta and Weiner

suggest using these instruments as an aid in screening

potential volunteers.

In a study of 42 experienced volunteers, Amenta (1984)

examined differences between those who withdrew from hospice

(after less than one year) and those who persisted. Both

groups had been screened for suitable personality

characteristics (empathy, expressiveness, open-mindedness,

patience) and were given the Death Anxiety Scale (Templer,

1970) and the Purpose in Life test (Crumbaugh & Maholick,

1969). Persisters showed significantly less death anxiety

and more purpose in life than their "withdrawing" cohorts.

Amenta uses her findings to support Schulz's (1978) claim

that low death anxiety (having faced the reality of one's

own death) is characteristic of effective hospice workers.

Finn Paradis and Usui (1987) examined the personality

traits of successful hospice volunteers in hopes of

identifying key traits to look for in volunteer recruits.

The results of this study confirmed other research findings

showing that hospice volunteers have higher levels of

empathy and lower levels of death anxiety than do other

volunteers (Amenta & Weiner, 1981; Newell, 1980; Gotsch,

Donaldson & Hamilton, 1979). However, using ratings







42

elicited by the volunteer coordinators, the authors found no

positive relationship between volunteers possessing these

traits and subsequent effectiveness as volunteers. Although

not useful in predicting current volunteers' performance,

the absence of these traits did accurately predict whether

volunteer recruits would complete hospice training.

Lafer (1989) investigated the personality

characteristics of 75 prospective hospice volunteers in

order to predict which volunteers would remain active after

completion of training. The group was then rated by

volunteer directors six months after training. Low death

anxiety correlated strongly with volunteers who persisted

after training. Those volunteers rated "satisfactory

persisters" exhibited the lowest levels of death anxiety,

followed by "unsatisfactory persisters" and "dropouts." The

author cited the results as corroborating support for

Amenta's (1984) belief that death anxiety can help predict

who will become a successful hospice volunteer.

Clearly the impact of death attitudes on volunteers at

hospice has received scant attention in the thanatological

literature. The limited research that has been done in this

area suggests that death anxiety (as measured by the Death

Anxiety Scale) is inversely related to purpose in life. The

few relevent studies seem to indicate that volunteers are

more likely to remain active in hospice if they exhibit low

death anxiety and high purpose in life. At the present









time, no study has utilized the Threat Index in volunteer

samples or uncovered correlations between any of these three

instruments and the ability of hospice volunteers to perform

their tasks as caregivers.

The current study will attempt to demonstrate that the

Threat Index can be used both as an effective screening

instrument for hospice trainees and as a helpful evaluative

instrument with which to measure active hospice volunteer

performance. It is further hoped that this study will be

seen as making an important contribution to the growing

literature on the efficacy of the Threat Index as a viable

thanatological research tool.

Relatively little is known about the death attitudes of

hospice volunteers, nor has the Threat Index been

administered to this population. Death attitudes, self-

actualization, and purposefulness in hospice volunteers

appear to be potentially fruitful areas of investigation

with both intuitive appeal and clinical relevance. Given

the recent nationwide emphasis on making health care more

affordable, research focusing on volunteer characteristics

might play a useful role in helping hospice obtain this

elusive goal.













CHAPTER III
METHOD


Instruments

Prior to 1970, the only empirically derived method for

assessing death attitudes was Boyar's Fear of Death Scale

(Boyar, 1964). Earlier questionnaires, checklists,

interview formats, and projective techniques used to assess

"death anxiety" were either methodologically biased or had

serious validity and reliability concerns. The measures in

this study will be the previously described Death Anxiety

Scale (Templer, 1970), the Purpose in Life Test (Crumbaugh &

Maholick, 1969), and the Threat Index (Krieger, Epting &

Leitner, 1974).

Death Anxiety Scale

The Death Anxiety Scale (Templer, 1970) is a 15-item

true-false test that has been shown to be effective in

quantifying death anxiety in a wide variety of populations

(Appendix C). Nine of the items are keyed "true" with six

items keyed "false" for a total possible score ranging from

zero (low death anxiety) to 15 (high death anxiety). The

test can be administered to individuals or to groups and the

written directions are located at the top of the one-page

form. A fourth grade reading ability is necessary to









understand the instructions and the items. Total time

required for administering and completing the scale is five

minutes.

The Death Anxiety Scale (DAS) initially had 40

rationally devised items which a panel of seven independent

judges (a clinical psychologist, two graduate students and

four chaplains in a state mental hospital) rated on a five-

point basis (1 = irrelevant to death anxiety and 5 = very

greatly associated with death anxiety). Those items

receiving an average rating below 3.0 (3 = moderately

associated with death anxiety) were discarded (nine items).

The remaining 31 items were imbedded in 200 filler items

from the Minnesota Multiphasic Personality Inventory

(Hathaway & McKinley, 1943).

The resulting 231 item questionnaire was given to three

groups of university students from universities in Tennessee

and Kentucky to determine internal consistency. Only those

DAS items that had point biserial coefficients significant

at the .01 level in two out of three analyses were retained

(15 items). The probability of obtaining .01 significance

in two out of three analyses where no correlations truly

existed is .028. Relative independence of items was

determined by computing phi coefficients. No correlation

coefficients between the retained items exceeded r = .65 so

little inter-item redundancy was inferred.







46

Reliability of the 15 item DAS instrument was tested by

readministering the items to a group of college students

three weeks later. The obtained Pearson product-moment

correlation coefficient of .83 and the obtained Kuder-

Richardson correlation coefficient of .76 demonstrated

reasonable internal consistency.

The DAS was also tested for a response bias toward

over-agreement with the items. No significance at the .05

level was found suggesting that an agreement response set

accounts for little, if any, of the DAS score variability.

The Pearson correlation between the DAS and the Marlowe-

Crowne Social Desirability Scale also failed to reach

significance (r = .03).

Construct validity of the DAS was established in two

separate procedures at a Kentucky State Hospital. First,

psychiatric patients with high death anxiety (those who had

spontaneously verbalized a fear or preoccupation with death)

were matched with a control group of psychiatric patients

with low death anxiety in terms of diagnosis, sex, and age.

Mean DAS score of the death anxious patient group was 11.62

compared to the control group mean of 6.77. This result was

significant at the .01 level (two-tailed t of 5.79).

A second attempt at establishing DAS construct validity

involved administering the DAS to college undergraduates at

two Kentucky universities and correlating each students'

score with obtained scores on the Fear of Death Scale







47

(Boyer, 1964), a death association task, and the MMPI scales

of anxiety. A correlation coefficient of .74 was found

between the DAS and the Fear of Death Scale resulting in

significance at the .01 level. Scores on the DAS were also

significantly correlated (at the .01 level) with the

Manifest Anxiety Scale (r = .39), the Welsh Anxiety Scale (r

= .36), and with the number of emotional words elicited by

the death association task (r = .25; p < .05).

Although the DAS has no formally established normative

data, extensive research was conducted (23 groups, 3600

subjects) during the test's construction and validation

(Templer, 1970). According to Templer and Ruff (1971), mean

DAS scores for nonpsychiatric subjects typically range from

4.5 to 7.0 with a standard deviation of 3.0. Females

consistently score higher on the DAS than do males and

psychiatric populations obtain higher scores than do

nonpsychiatric populations (Templer & Ruff, 1971). A major

study comparing the scores of 2500 subjects between the ages

of 18 and 85 (Templer, Ruff & Franks, 1971) found no

significant relationship between age and DAS scores.

Purpose in Life Test

The Purpose in Life Test (Crumbaugh & Maholick, 1969)

is a 20 item, Likert scale test that purportedly measures

the degree of meaning and purpose that each respondent

feels. All 20 questions are scored on a "1" to "7" basis,

resulting in a range of scores between 20 140. Higher







48

scores reflect a stronger sense of purpose and meaning. The

Purpose in Life Test (PIL) can be administered both to

individuals and groups without lengthy explanation or

elaboration. A fourth grade reading ability is necessary to

comprehend the items and the instrument typically takes less

than ten minutes to administer and complete.

The PIL has its origins in the existential theory of

Viktor Frankl (1969) and was developed to measure the degree

to which respondents view their lives as full of purpose and

meaning. Frankly claimed that one of the unfortunate

consequences of a highly mechanized society is loss of human

initiative and personal meaning. He hypothesized that lack

of purpose (i.e. existential vacuum, noogenic neurosis) is a

universal trait in modern times and present, to varying

degrees, in all people (not just the psychotic or abnormal).

However, the incidence of lack of purpose would be expected

to be higher in psychiatric populations.

Crumbaugh (1968) administered the PIL to nearly 1200

subjects (six psychiatric groups and four nonpsychiatric

groups) in an attempt to assess the construct validity of

this instrument. He was able to correctly predict the order

of mean PIL scores for the ten groups. The difference

between the psychiatric mean (M = 92.60, SD = 21.34) and

nonpsychiatric mean (M = 112.42, SD = 14.07) yielded a

significant t value (two-tailed) at the .001 level.









A significant difference in score variability between

psychiatric and nonpsychiatric groups (at the .01 level) was

taken by Crumbaugh (1968) as confirmation of the logotherapy

hypothesis that psychiatric patients would experience an

overall wider range of PIL scores than would nonpsychiatric

subjects.

Concurrent validity of the PIL was evaluated in two

ways. First, therapists were to estimate each of their

clients' responses to the PIL. These scores were then

correlated to each clients' (N = 50) actual PIL responses.

The Pearson product-moment correlations between patient and

therapist scores was .38.

In a related study, ministers completed the PIL for

each of their parishioners (N = 120) based on the purpose

and meaning exhibited by each church member. Each church

member also completed the PIL and the Pearson product-moment

correlations between both groups' scores was .47. Both

studies are in line with the level of criterion validity

typically demonstrated from a single measure of a complex

trait.

Split-half reliability of the PIL was found to be .81

in a group of 105 nonpatients and 120 patients (Crumbaugh &

Maholick, 1964). Using the Spearman-Brown procedure, the

researchers corrected this figure to .90. In 1968 Crumbaugh

obtained a split-half reliability of .85 (Pearson product-









moment) for 120 Protestant parishioners and the Spearman-

Brown procedure corrected this figure to .92.

Crumbaugh and Maholick (1964) correlated the PIL with

an informal questionnaire used by Frankl (1958) to estimate

the presence of existential vacuum in 136 patients and

nonpatients. They quantified the questionnaire and found a

Pearson product-moment correlation of .68 between the two

instruments.

Crumbaugh (1968), Elmore and Chambers (1967), Nyholm

(1966) and Crumbaugh and Maholick (1964) have tested various

groups of undergraduates and outpatients and have found

negative correlations between the PIL and the Depression

scale of the MMPI in the range of -.42 to -.65. These

researchers have also correlated the PIL with the MMPI K

validity scale (.39), Psychaesthenia scale (-.44), and the

Social Isolation scale (-.45). Crumbaugh (1968) and Elmore

and Chambers (1967) both tested college students and found

negative correlations between the PIL and separate measures

of anomie in the range of -.32 to -.51.

Snavely (1963) found an initial correlation of .57

between the PIL and the Crowne-Marlow Social Desirability

Scale. Afterwards, subjects were randomly assigned

"acceptable" and "unacceptable" scores, and a retest

indicated correlations between the two measures had dropped

to .36 with little or no movement in the unacceptable

group's scores. The author suggested that the PIL and the






51

Crowne-Marlow Social Desirability Scale were responding to

social desirability in qualitatively different ways. He

concluded that the PIL was not highly influenced by social

desirability. The author does caution against the use of

the PIL in competitive situations where social desirability

may be aroused.

Other studies using nonpsychiatric populations

(Crumbaugh, Lozes & Shrader, 1968; Nyholm, 1966) have found

significant positive correlations between the PIL and a

number of subscales of the California Personality Inventory,

the Cattell 16 Personality-Factor Test, and the Gordon

Personal Profile (achievement, emotional stability, self-

acceptance, self-control, responsibility). Significant

negative correlations were found on such things as anxiety,

insecurity, neuroticism, and suspiciousness. These authors

failed to find any significant correlations between the PIL

and empathy, intelligence, sex, age, or education.

Crumbaugh (1968) determined that a cutoff score of 102

(out of 140 total) with a standard deviation of 19 was an

appropriate estimate of mean purpose-in-life for most

groups. He suggested that raw scores ranging from 92 to 112

on the PIL are suggestive of "average" purposefulness and

are not easily interpretable. Raw scores of 113 and above

suggest the presence of high levels of purpose and meaning,

while raw scores 91 and below suggest the lack of clear

purpose and meaning in life.









Threat Index

The Threat Index (Krieger, Epting & Leitner, 1974) is

arguably the most methodologically sound instrument used in

death and dying research. Psychometric and administrative

modifications have continued since its inception until today

it is widely recognized as a model in the field (Simpson,

1980; Kastenbaum & Costa, 1977).

The self-administered Threat Index (Krieger, Epting &

Hays, 1979) that is used in this study contains 40 of the

most popular bipolar constructs (e.g., empty vs. meaningful;

pleasure vs. pain; calm vs. anxious) elicited by the older

interview format Threat Index. These 40 dimensions are

printed on three test pages (Appendix D) and respondents are

to circle the end of each bipolar dimension that corresponds

to "self" (page 1), "ideal self" (page 2), and "own death"

(page 3). The Threat Index takes 15-30 minutes to complete.

Discrepencies on "self-ideal self" dimensions (or

splits) are regarded as a quantified measure of the

"actualization" that the respondent feels on a 0-40 point

scale (Neimeyer & Chapman, 1980). Low scores (few splits)

reflect a strong sense of actualization in the respondent

and high scores indicate that little actualization is

present. Likewise, discrepencies between "self-own death"

ratings yields a 0-40 point score that quantifies the extent

to which a respondent has integrated "death" into his world

view. Again, as splits increase, so does the estimated









level of death threat. Thus, the traditional method of

scoring the Threat Index results in a TI-actualization score

and a TI-death threat score. Normative data for these two

primary scores of the Threat Index have been published

(Krieger, Epting, & Hays, 1979) with 20 TI-actualization

splits and 20 TI-death threat splits approximating average

levels of self-actualization and death threat.

In addition to the above traditional method of scoring

the Threat Index, the current study will also explore an

additional Threat Index scoring procedure recently devised

by Pritchard, Epting, and Beagle (1991). Using construct

responses from all three pages of the Threat Index

simultaneously, four supplemental scores can be generated

for each subject based upon whether the person considers

themselves and death in a positive or negative manner.

These four supplemental scores are the Death-accepting

score, the Death-threatened score, the Depressed score, and

the Death-attracted score. The four supplemental scores

could each conceivably range from a score of 0 40, but the

sum of all four scores has to equal 40. Each of the

supplemental scores are described below.

The Death-accepting score is characterized by having

"self," "ideal self," and "death" along the same positive

pole of a construct (e.g., happy vs. sad; meaningful vs.

empty). High scores reflect both a positive view of the

self, and of death. This score is hypothesized to be







54

positively related to optimal functioning (Rigdon & Epting,

1985).

The Death-threatened score is characterized by having

"self" and "ideal self" along the same positive pole of a

construct and "death" identified with the opposite end of

the construct (e.g., self and ideal self = meaningful; death

= empty). High scores reflect a positive view of self, a

negative view of death, and are thought to be predictive of

those variables commonly associated with death threat

(Neimeyer, 1988).

The Depressed score is characterized by having a split

between "self" and "ideal self" (e.g., self = empty; ideal

self = meaningful) along with a negatively-valenced

construct pole for death (e.g., death = empty). High scores

reflect a negative view of both self and death and is

thought to be related to a number of depression correlates

(Rowe, 1983; Beck, 1967).

Lastly, the Death-attracted score is also characterized

by a discrepency between "self" and "ideal self" constructs.

However, "death" is viewed with the positively-valenced

construct pole (e.g., self = sad; ideal self = happy; death

= happy). This profile is thought to be related to suicidal

preoccupation (Neimeyer, 1985; Beck, 1967).

These four supplemental scores from the Threat Index

will complement the two primary scores discussed earlier

(TI-actualization, TI-death threat). In contrast to the







55
primary scores, no normative data have been established for

the four supplemental Threat Index scores.

Internal consistency of the traditional method of

scoring the Threat Index was demonstrated on college

students and mixed adults by a number of independent studies

(Moore & Neimeyer, 1991; MacInnes & Neimeyer, 1980; Krieger,

Epting & Hays, 1979; Krieger, Epting & Leitner, 1974).

Split-half and Cronbach's Alpha correlations ranged from .88

to .96.

Test-retest reliabilities on college students by the

aforementioned authors and two other research groups (Rigdon

& Epting, 1985; Rainey & Epting, 1977) were performed over

periods of four to nine weeks. Correlations on all of the

studies ranged from .64 to .90 indicating that the Threat

Index yields scores which are stable over one and two month

periods of time.

Three separate studies demonstrated that the Threat

Index is largely free of social desirability bias and

extreme attempts to appear well-adjusted (Moore & Neimeyer,

1991; Dattel & Neimeyer, 1990; Krieger, et al., 1979).

Discriminant validity correlations between the tests had

values ranging from -.01 to -.08 for populations of college

students and mixed adult samples.

Convergent validity between the Threat Index and a

number of commonly used death and dying measures was

demonstrated in eleven studies from 1977 to 1990 (Neimeyer &









Epting, 1992). In varying populations (high school and

college students, crisis workers, adults, ministers, and

community agency groups) the Threat Index showed convergent

validity correlations of .21 and .58 with eight frequently

utilized tests of death and dying.

Construct validity concerns were addressed in eleven

studies dating between 1977 and 1989. College students,

medical and hospice patients, physicians, medical students,

death pre-planners, and students of death education courses

scored in the predictable direction based on religious

orientation (Tobacyk, 1984), disclosive behaviors (Eggerman

& Dustin, 1985) severity of illness (Hendon & Epting, 1989),

presence of denial (Neimeyer, Behnke & Reiss, 1984),

occupation (Rainey & Epting, 1977), and after exposure to

threatening situations (Lantzy & Thornton. 1982).

Unlike the Fear of Death Scale (Collett-Lester, 1969)

and the Death Anxiety Scale (Templer, 1970), the Threat

Index has shown no consistent gender differences on death

attitudes (Neimeyer & Epting, 1992). In fact, the Threat

Index has been utilized as a tool to allow researchers to

explore potential reasons why females obtain higher death

anxiety/fear scores than males on most tests.

The Threat Index was used to test for emotional versus

cognitive responses to death stimuli (Lantzy & Thornton,

1982) and to test for gender differences in "emotional

expressiveness" (Dattel & Neimeyer, 1990). Thus far, the









results have been inconclusive but suggest that other

factors (i.e. locus of control) may account for the obtained

gender differences in scores (Neimeyer, 1988).

The Threat Index has been correlated to traditional

Judeo-Christian religious orientations in some studies

(Ingram & Leitner, 1989; Tobacyk, 1984) but studies have

largely ignored alternative religious beliefs (i.e. Muslim,

Hindu). Other researchers are even focusing on strength of

religious (or atheist) belief as the key predictor of death

threat (Moore & Neimeyer, 1991; Ingram & Leitner, 1989).

Furthermore, researchers (Neimeyer, Bagley & Moore, 1986)

seem to be moving away from simply assessing the positive or

negative valence of death beliefs and are moving toward

using the Threat Index to explore more qualitative research

questions such as, "What is the actual structure of this

individual's death beliefs?"

The Threat Index has also been utilized to assess the

sense of self-actualization that respondents feel.

Researchers (Wood & Robinson, 1982; Neimeyer & Chapman,

1980) have correlated high TI-actualization scores on the

Threat Index (few self-ideal self splits) with the Death

Anxiety Scale and to three of the four subscales of the

Collett-Lester Fear of Death Scale. Results from later

studies using both TI-actualization and TI-death threat

scores (Robinson & Wood, 1983; Neimeyer, 1985) showed that

using both scores did not appreciably add to the prediction







58

of death attitudes (although both were significantly related

to different aspects of death anxiety).

Subjects

Three distinct, naturally occurring groups composed of

144 people participated in this study. Group 1 consisted of

38 hospice trainees. Group 2 contained 73 experienced

hospice volunteers and Group 3 was composed of 33 non-

hospice volunteers.

Hospice Trainees

Thirty-eight hospice volunteers-in-training comprised

the first grouping in this study and were defined as those

people currently attending hospice training workshops for

the purpose of becoming hospice volunteers. Hospice of

North Central Florida recruits volunteers through media

advertising, outreach programs, and word-of-mouth, and

conducts monthly volunteer training workshops at various

locations in northern Florida. Typically trained in classes

of 10 25, trainees first complete application forms and

are personally interviewed to assess motivation, emotional

maturity, and philosophical compatibility.

Hospice trainees are educated over an extended period

of time using audiovisual, didactic, and experiential

methods. They are taught the hospice philosophy, as well as

the physical and psychological issues involved in caring for

the terminally ill. Somewhat surprisingly, only 6 of 38

hospice trainees in this investigation cited salient









personal experience with death (i.e., cancer diagnosis,

death of family member) as a factor in their decision to

become hospice volunteers (15.8%).

Experienced Hospice Volunteers

Seventy-three experienced hospice volunteers made up

the largest grouping in this study. These experienced

hospice volunteers were operationally defined as those

volunteers with at least one year of patient care experience

and at least one patient served. As a group, a wide

spectrum of hospice experience was represented with the

number of patients seen varying from 1 to 80 and length of

service up to 10 years. The median values were six patients

seen and two years of service. Two-thirds of this group had

been hospice volunteers for less than four years.

Only those volunteers whose work was familiar to both

the hospice volunteer coordinator and assistant volunteer

coordinator were used in this study. Hospice of North

Central Florida currently has over 200 trained volunteers to

serve the terminally ill from 11 counties in northern

Florida. At any one time, roughly half of them are active

within the hospice system.

Volunteers are assigned one primary patient and work as

part of a hospice team (nurse, social worker, chaplain,

bereavement counselor) in providing services to that patient

and family. Thirty-five of 73 experienced volunteers in

this study cited salient, personal experience with death as







60

a precipitating factor in their decision to become involved

with hospice (47.9%).

Non-Hospice Volunteers

The final group was a general community volunteer group

of 33 people who served in non-hospice related agencies and

who attended hospice-sponsored presentations. Hospice is

frequently invited by community agencies to present

educational information pertaining to terminal illness,

bereavement, and support resources. This group of

volunteers attended these hospice presentations.

These non-hospice volunteers provide services to

citizens who are sick, shut-in, or recently bereaved. They

were selected to participate in this study based on the

shared similarities of clientele and volunteer activities

with the hospice volunteers. The non-hospice volunteer

group served primarily as a control group for hospice

trainees.

Group Differences

The groups were compared on a number of non-test score

variables (test administration differences, demographic

differences) to assess for any significant group differences

that potentially could confound the test results. First,

comparisons were made between the groups on test

administration method.

Data from these three subject groups were collected

between April 1992 and March 1993 incorporating both group









administrations and bulk mailings of the test packets.

Group administrations took place at various locations in and

around Gainesville, Florida. Table 1 describes the three

groups of research participants, the data collection dates,

the number of subjects taking part in each procedure, and

the administrative method used to collect the data.


Table 1

Subject Groups and Methods of Test Administration

GROUPS (subgroups) N METHOD

Hospice Trainees
Gainesville Training (4/92) 19 Group
Gainesville Training (3/93) 5 Mail
Palatka Training (4/92) 6 Group
Satsumo Training (6/92) 8 Group
Total Hospice Trainees 38

Experienced Hospice Volunteers
Mailouts (8/92) 46 Mail
Gainesville Volunteer Meeting (4/92) 12 Group
Keystone Heights Meeting (4/92) 8 Group
Satsumo Volunteer Meeting (5/92) 7 Group
Total Experienced Volunteers 73

Non-Hospice Volunteers
Lake City Medical Club (7/92) 8 Group
Lake City Hospital Group (7/92) 6 Group
Meals on Wheels-Gainesville (8/92) 10 Mail
Widowed Persons-Gainesville (6/92) 9 Group
Total Non-Hospice Volunteers 33



A large discrepency in the method by which data were

collected was noted between the three groups. Whereas the

majority of experienced hospice volunteers (46 out of 73)

were sampled by mailed test packets (63.0%) rather than in a

group situation, only 5 out of 38 hospice trainees (13.2%)







62

and 10 out of 33 non-hospice volunteers (30.3%) were sampled

by mail.

A Chi-square procedure was performed comparing the

three groups on test administration rates. The resulting

'2(2, N = 144) = 28.4, p < .001 indicated strong evidence

that test administration differences were associated with

the three groups. Compared to hospice trainees and non-

hospice volunteers, significantly more experienced hospice

volunteers responded to mailed test packets rather than

group-administered test packets.

As noted previously, hospice trainees and experienced

hospice volunteers appeared to differ in the percentage who

cited personal death experience as a key factor in the

decision to become involved with hospice (hospice trainees =

15.8%; experienced hospice volunteers = 47.9%). No attempt

was made to assess non-hospice volunteers on this issue.

The resulting )2(1, N = 111) = 11.1, E < .001 indicated that

group membership was significantly associated with how

important prior death experience was in deciding to become

involved with hospice.

Using a demographic information page (see Appendix B),

seven demographic variables were obtained from each research

participant: marital status; gender; household income;

education level; religiosity; age; and occupation.

Descriptive statistics were computed for each group to

determine whether any obvious group differences existed









on any of these seven variables. The simple frequencies and

percentages for all demographic variables except age and

occupation are included in Table 2.


Table 2

Descriptive Group Demographic Information

VARIABLE GROUP 1 GROUP 2 GROUP 3
N % % %
Marital Status
Married 19 50.0 42 57.5 19 57.6
Divorced 4 10.5 7 9.6 1 3.0
Single 12 31.6 10 13.7 0 0.0
Widowed 3 7.9 13 17.8 13 39.4
Totals 38 100.0 72 98.6 33 100.0

Gender
Female 33 86.8 65 89.0 25 75.8
Male 5 13.2 8 11.0 8 24.2
Totals 38 100.0 73 100.0 33 100.0

Household Income
< $10,000 5 13.2 11 15.1 4 12.1
$10 $19,999 5 13.2 12 16.4 9 27.3
$20 $29,999 7 18.4 11 15.1 7 21.2
$30 $39,999 11 28.9 13 17.8 6 18.2
$40 $49,000 2 5.3 9 12.3 1 3.0
> $50.000 7 18.4 12 16.4 2 6.1
Totals 37 97.4 68 93.1 29 87.9

Education Level
< 12 years 7 18.4 19 26.0 10 30.3
13 -16 years 20 52.6 33 45.2 17 51.5
> 16 years 11 28.9 20 27.4 5 15.2
Totals 38 99.9 72 98.6 32 97.0

Religiosity
Yes 20 52.6 46 63.0 24 72.7
No 17 44.7 24 32.9 8 24.2
Totals 37 97.3 70 95.9 32 96.9



As can be seen from the data given above, the modal

research participant, regardless of group, was female,

married, college-educated, and religious. In fact,









household income was the only variable that did not have

consistent modal values across the three groups.

Modal household income for hospice trainees and

experienced hospice volunteers was between $30,000 -

$39,000. The modal household income for non-hospice

volunteers was between $10,000 and $19,000. Although the

groups appeared to have generally similar modal values,

group differences on these five variables were statistically

assessed using a Chi-square procedure.

Five Chi-square tests were performed between the groups

on each of the five demographic variables listed above to

check for statistical independence. With a ~)((6, N = 143)

= 22.25, p < .01, only marital status showed a significant

effect indicating that, of the five variables checked,

strong evidence existed that only marital status differences

were associated with group membership.

However, large group discrepencies were readily

apparent with the other two demographic variables (age and

occupation). To test for apparent group differences in age,

z test statistics comparing the groups' mean ages were

performed, with each of the three group comparisons showing

significant group differences. Table 3 depicts the mean

ages for the three groups, standard deviations, group

comparisons, Z scores, and R values.









Table 3

Mean Ages for Groups and Z Score Comparisons

GROUP AGE MEAN SD COMPARISON Z SCORE p VALUE

1 40.0 14.2 1 vs. 2 -4.90 .0001

2 54.2 14.9 2 vs. 3 -6.67 .0001

3 69.3 7.8 3 vs. 1 10.93 .0001



Average age for the hospice trainees (Group 1) was 40.0

with a SD of 14.2. The experienced hospice volunteers'

(Group 2) mean age was 54.2 with a SD of 14.9. The non-

hospice volunteers' (Group 3) mean age was 69.3 with a SD of

7.8. The group comparisons all attained significant E-

values (R < .0001) indicating that there were significant

differences in the mean ages of each group. The non-hospice

volunteers were significantly older than the experienced

hospice volunteers who were, in turn, significantly older

than the hospice trainees.

As mentioned earlier, the occupational status of the

144 participants in this study also showed obvious group

differences. Self-reported occupations from the sample's

144 respondents were merged into four broad occupational

categories: employed; full-time student; retired; and

homemaker. Simple frequency counts and percentages were

then computed for each group. Included in Table 4 are the

frequencies and percentages of occupational categories for

each of the three groups.









Table 4

Descriptive Group Occupational Information

OCCUPATIONAL STATUS GROUP 1 GROUP 2 GROUP 3
N % N % N %

Employed 26 68.4 29 39.7 5 16.1

Full-Time Student 6 15.8 5 6.8 0 0.0

Retired 2 5.3 23 31.5 22 71.0

Homemaker 4 10.5 16 21.9 4 12.9

Totals 38 100.0 73 99.9 31 100.0



The modal occupational category of Group 1 (hospice

trainees) and Group 2 (experienced hospice volunteers) was

employed (68.4% and 39.7% respectively). However, the modal

occupational status for Group 3 (non-hospice volunteers) was

retired (71%). In fact, 32.6% of the total sample were

retired (47 out of 144) compared to 71% of the non-hospice

volunteers (Group 3) and 5.3% of the hospice trainees (Group

1) identified as such.

Group 3 (non-hospice volunteers) was the only group to

have no identified students. Group 2 (experienced hospice

volunteers) also had the largest percentage of their members

identified as homemakers (16 out of 73, 21.9%). It seems

probable that significant age differences between groups

contributed to these group occupational differences.

A Chi-square test was performed between group and

occupational status to check for statistical independence.

The resulting %2(6, N = 144) = 41.61, R < .001 indicated









strong evidence that a person's occupational status was

associated with group membership.

To summarize, group membership was significantly

associated with test administration methods, the importance

of prior death experience in the decision to become involved

in hospice, marital status, and occupational status. In

addition, significant differences were found in the mean

ages for each of the three groups. The effects of

administration method and demographic variables on

subsequent test scores will be explored in Chapter IV.

Procedure

All participants in this study were administered a

packet containing an informed consent form, the Death

Anxiety Scale (DAS), Purpose in Life Test (PIL), the Threat

Index, and the previously described general demographics

page. The entire package was typically completed in 25 40

minutes. These test packets were either mass-administered

in meetings or mailed individually to all participants.

In all, four primary test scores were generated with

each completed test packet (DAS, PIL, TI-actualization, and

TI-death threat). In addition, four supplemental scores

from the Threat Index were computed (Death-accepting, Death-

threatened, Depressed, and Death-attracted). The scoring

criteria for each test were outlined earlier in this

chapter.









Hospice trainees were screened and invited to

participate in regional training workshops. The training

involved a commitment of six consecutive Tuesday evenings

from 6-9 p.m. Test packets were group-administered during

the first workshop evening prior to any hospice training.

During the spring and early summer of 1992, every trainee

from three different training classes completed the packet

(total of 33). Because the primary investigator was no

longer living in Gainesville, a fourth training group during

the spring of 1993 was given 12 test packets during the

first training session and requested to mail them back at a

later date. Five test packets were returned (41.7%). The

hospice trainee group consisted of 38 members.

Experienced hospice volunteers can attend semi-monthly

patient care meetings sponsored by hospice staff in various

locations. Agency information, volunteer activities, and

patient concerns are shared during these informal meetings.

The test packet was group-administered to the 27

participants who attended three separate meetings. Every

volunteer who attended the three meetings completed the

questionnaire.

However, not all experienced hospice volunteers

attended the semi-monthly patient care meetings. Thus, 76

mailouts were sent to volunteers not attending the patient

care meetings and 48 completed questionnaires were returned

(63.2%). Two of the returned test packets were from very









recent volunteers who were not well-known to either the

hospice volunteer coordinator or to his assistant and were

not included. Altogether, 73 experienced hospice volunteers

were included in the current study.

The majority of non-hospice volunteers received the

test packets during regularly scheduled monthly volunteer

meetings. Several community organizations (e.g., Lake City

Medical Club, Lake City Hospital Group, Widowed Persons

Support Group) had invited hospice to give presentations to

their volunteers on hospice services, distribute educational

materials, and answer relevant questions. All participants

in the meetings completed the questionnaires (total of 23).

In addition, the Meals-on-Wheels group was given 25 test

packets prior to making their appointed delivery rounds and

10 completed forms were later returned to the Meals-on-

Wheels supervisor (40% return rate). A total of 33 non-

hospice volunteers were included in this study.

A volunteer coordinator (Supervisor A) and an assistant

volunteer coordinator (Supervisor B) supervise the volunteer

program at the Hospice of North Central Florida. Both were

interested in the current project and were enthusiastic

about the prospect of correlating a thanatology instrument

with volunteer caregiver performance. The volunteer

coordinators claimed that the Hospice of North Central

Florida had no systematic method of evaluating volunteers









and both felt strongly that participating in this project

had positive ramifications for their program.

The two volunteer coordinators were provided a list of

the 75 experienced hospice volunteers who had completed the

questionnaires. To be included in the study, both volunteer

coordinators had to be familiar with each of the experienced

volunteer's work at hospice so that two performance ratings

could be generated for each volunteer (one from each

volunteer supervisor). The vast majority of experienced

hospice volunteers who completed the test packets were well-

known to both coordinators (73 out of 75) and included in

this phase of the study.

The volunteer coordinators were then instructed to

independently rate the caregiver performance of these 73

volunteers on a five-point ordinal scale based upon their

personal knowledge of each volunteer's performance as a

hospice caregiver. These were obviously very general and

highly personalized ratings. The volunteer coordinators

needed only a working knowledge of each volunteer's hospice

performance and an awareness that a "5" rating represented

superior performance with each lower rating representing

progressively lower performance.

To ensure a broad range of scores, each coordinator was

given the additional instruction to evenly distribute the

volunteer ratings so that nearly equal numbers would be

found under each global rating (top 20% were given a "5"







71

rating; next 20% = "4"; middle 20% = "3"; next to last 20% =

"2"; and last 20% = "1"). This format was used to decrease

the tendency to rate all volunteers as 4's or 5's and

ensured an equal distribution of rating scores. This format

also seemed to assuage the coordinators' fears of evaluating

any volunteer as "a poor performer" since all five ratings

could be considered gradations of adequate performance.

Without conferring with one another, or knowing the

test results of experienced hospice volunteers, the

volunteer coordinators rated the experienced volunteers,

placing them in a distribution of approximately 15

volunteers per rating (5 ratings for 73 members). A

significant Spearman correlation was found between the two

sets of volunteer coordinators' ratings (rho = .5881, R <

.0001).

Although the Spearman correlation was statistically

significant, only 34.5% of the variance of one coordinator's

ratings was associated with change in the other's. This

degree of association was not high enough to allow a merging

of the two ratings (need to account for at least 50% of the

variance), so the coordinators' ratings were kept separate.

As a result, each volunteer had two scores (one from each

volunteer coordinator) ranging from one to five.

Statistical Analyses

The first hypothesis states that significant

relationships exist between the two primary scores of the







72

Threat Index (TI-actualization and TI-death threat) and the

obtained scores on the Death Anxiety Scale (DAS) and the

Purpose in Life Test (PIL) in this sample of 144 hospice

trainees, experienced hospice volunteers, and non-hospice

volunteers. To test the first hypothesis, Pearson

correlations were performed between the TI-actualization

score and the DAS, the TI-actualization score and the PIL,

the TI-death threat score and the DAS, and the TI-death

threat score and the PIL for the entire sample of 144

subjects.

The second hypothesis states that significant

differences in the DAS, PIL, and Threat Index scores exist

between hospice trainees and non-hospice volunteers. To

test the second hypothesis, t tests were used to look for

significant differences in DAS, PIL, TI-actualization, TI-

death threat, and four supplemental Threat Index scores

between the hospice trainee group and the non-hospice

volunteer control group.

The final hypothesis states that a significant

relationship exists between the two primary Threat Index

scores (TI-actualization and TI-death threat) and the

performance ratings given to experienced hospice volunteers

by their supervisors (A and B). To test this hypothesis,

Spearman correlations were computed between TI-actualization

scores, Supervisor A's ratings, and Supervisor B's ratings

and between TI-death threat scores, Supervisor A's ratings,







73

Supervisor B's ratings. All of the above analyses were

conducted using the Statistical Analysis System (SAS

Institute, 1982).













CHAPTER IV
RESULTS


General Findings

Means, standard deviations, and score ranges were

computed for every variable to ensure that scores and values

were appropriately encoded and accurately reflected the

possible range of values. Spot checks were also made

between raw data and computer-inputted data to ensure that

reliable transformation of test protocols took place. Test

results for the entire sample are contained in Table 5.


Table 5

DAS. PIL. and Threat Index

VARIABLE N

DAS 144
PIL 144
TI-actualization 135
TI-death Threat 133
Death-accepting 130
Death-threatened 128
Depressed 128
Death-attracted 128


Test Results of the Entire Sample

MEAN SD RANGE

4.79 2.54 0 13
113.87 15.54 37 140
2.58 3.15 0 20
9.23 9.19 0 36
26.32 10.59 0 40
8.00 9.23 0 36
1.02 1.53 0 6
1.52 2.34 0 15


The means, standard deviations, and ranges of scores on

the Death Anxiety Scale (one score), the Purpose in Life

Test (one score), and the Threat Index (six scores) were

within expectations for this sample of 144 hospice trainees,









experienced hospice volunteers, and non-hospice volunteers.

Compared to the previously cited DAS and PIL normative data

in Chapter III, this global sample endorsed a low average

amount of death anxiety (DAS M = 4.79, SD = 2.54) and a high

sense of purpose (PIL M = 113.87, SD = 15.54).

Results from the two primary scores on the Threat Index

(TI-actualization, TI-death threat) also seem to suggest an

overall high sense of actualization (M = 2.58 splits) and

low death threat (M = 9.23 splits). Krieger, Epting, and

Hays (1979) suggested that scores of 20 would be good

approximations of normal levels of these traits. This

global sample's splits were well below expectations

(extremely well-adjusted).

Means of the four supplemental Threat Index scores

(Death-accepting, Death-threatened, Depressed, Death-

attracted) for the entire group generally seem to reflect a

strong sense of death-acceptance, a moderate degree of death

threat, and minimal depression or death-attraction.

Clearly, this sample of hospice and non-hospice personnel

has a number of positive attributes.

DAS, PIL, and Threat Index mean scores for each of the

three groups were also calculated separately. The summary

statistics for hospice trainees, experienced hospice

volunteers, and non-hospice volunteers have been recorded

below in Table 6.









Table 6

DAS, PIL. and Threat Index Results for the Three Groups

GROUP (TESTS) N MEAN SD RANGE

Hospice Trainees
DAS 38 5.34 2.61 0 11
PIL 38 113.32 13.44 63 134
TI-actualization 38 3.13 3.76 0 20
TI-death threat 38 9.39 7.81 0 31
Death-accepting 38 26.95 7.64 7 39
Death-threatened 38 7.45 7.90 0 30
Depressed 38 1.08 1.36 0 5
Death-attracted 38 2.13 3.21 0 15

Hospice Volunteers
DAS 73 4.48 2.26 0 9
PIL 73 116.44 13.75 72 140
TI-actualization 69 2.19 2.89 0 12
TI-death threat 67 8.67 9.39 0 36
Death-accepting 67 26.69 11.06 0 40
Death-threatened 65 7.63 9.35 0 34
Depressed 65 0.89 1.63 0 6
Death-attracted 65 1.20 1.79 0 7

Non-Hospice Volunteers
DAS 33 4.88 3.00 0 13
PIL 33 108.82 20.11 37 139
TI-actualization 28 2.79 2.83 0 10
TI-death threat 28 10.32 10.56 0 36
Death-accepting 25 24.36 13.08 0 40
Death-threatened 25 9.80 10.85 0 36
Depressed 25 1.24 1.51 0 4
Death-attracted 25 1.40 1.96 0 7



At first glance, the eight test scores showed very few

obvious group differences. Consistent with the total

sample's test results, each of the three groups showed

average levels of death anxiety and an average to above

average level of purposefulness. Again, all three groups

were highly actualized, had moderate levels of death threat,

were generally death-accepting, and had negligible levels of







77

depression or death-attraction. These three groups appeared

to be much more alike than different when comparing the

scores from the three tests.

Administrative Effects

As was noted in Chapter III, the groups showed

significant differences in how they were administered the

test packets. T score (small group inference) and Z score

(large group inference) comparisons were performed on each

of the three groups (hospice trainees, experienced hospice

volunteers, and non-hospice volunteers) and on the entire

sample to determine whether mean test score differences were

present between those subjects who were mailed the tests and

those who were mass-administered the tests.

The only administrative effect found was on the TI-

actualization scores of hospice trainees (Group 1). The

resulting t(36) = 1.96, **R < .05 indicated that hospice

trainees who were mass-administered the test packets tended

to endorse more actualization splits (feel less actualized)

than those who were mailed the test packet (mass-

administered group M = 3.45, SD = 2.72; mail group M = 1.0,

SD = 1.22). Although this represented a statistical

difference, both groups of hospice trainees were highly

actualized (had few TI-actualization splits).

None of the other comparison groups (experienced

hospice volunteers, non-hospice volunteers, or the total

sample) showed any significant differences in test scores









between those administered the tests in groups and those

receiving the tests in the mail. On the whole, there was

little evidence that administrative method had any

meaningful effect on the mean test scores of the groups or

of the entire sample.

Demographic Effects on Test Scores

Before addressing the three hypotheses, demographic

effects on the eight test scores (DAS, PIL, TI-

actualization, TI-death threat, four supplemental Threat

Index scores) were analyzed using Pearson correlations (age

effects), Spearman correlations (education, household

income), and t tests (gender, marital status, religiosity).

Two of the eight Pearson correlations for age and test

score were found to be significant. Table 7 includes the

test scores significantly correlated with age.


Table 7

Significant Correlations Between Demographics and Tests

VARIABLES CORRELATION PROBABILITY

Age TI-actualization -.2249 .0095
Age Death-attracted -.2398 .0071



Table 7 illustrates that TI-actualization and the

Death-attracted score of the Threat Index were significantly

correlated with age. Both correlations were negative and

indicated that, as people's ages increased, fewer TI-

actualization splits (stronger sense of actualization) and









lower Death-attracted scores occurred (less hypothesized

suicidality). These associations were quite weak, with only

5.06% of the variance in TI-actualization scores and 5.75%

of the variance in Death-attracted scores associated with

changes in age.

Spearman correlations were computed between the eight

test scores and the ordinal variables of education (3

levels) and household income (6 levels). The Education -

Death-accepting Spearman correlation was the only

significant value found out of of 16 possible correlations

(rho = .1795, E = .0314). This positive correlation

indicated that higher death-acceptance was associated with

more education. Although statistically significant, only

3.22% of the variance in Death-accepting scores was

associated with changes in education.

Finally, t test comparisons were used to determine

whether gender, marital status, and religiosity had any

effect on test scores. Significant gender differences were

noted only on the PIL with t(21.9) = 2.23, **R = .0365).

Females endorsed higher PIL scores (PIL M = 115.49, SD =

13.37) than did males (PIL M = 102.90, SD = 25.29). None of

the 48 comparisons between the eight test scores and marital

status (4 levels) were found to have significant

differences. Marital status did not appear to have a marked

effect on test scores.







80

Religiosity did have a widespread effect on test scores

as six of eight t tests comparisons revealed significant

differences. Table 8 describes the tests, T values, df, and

p values for the variable of religiosity.


Table 8

T-Test Comparisons of Religiosity's Effect of Test Scores

TEST SCORE T-VALUE DF P-VALUE

DAS -2.5793 137 .0109

PIL 4.2073 137 .0001

TI-actualization -2.1356 137 .0344

TI-death threat -3.2936 137 .0012

Death-accepting 0.5612 133.2 .5756

Death-threatened -2.8491 90.8 .0054

Depressed -1.2335 137 .2194

Death-attracted -2.1726 137 .0315



As can be seen in Table 8, all of the primary test

scores used in this study (DAS, PIL, TI-actualization, TI-

death threat) and two of the supplemental Threat Index

scores (Death-threatened, Death-attracted) showed a

significant religiosity effect.

The DAS t(137) = -2.5793, **p < .0109 was significant

and indicated that those who were religious (H = 90) scored

significantly lower on the DAS (DAS M = 4.43, SD = 2.43)

than those who did not identify themselves as religious (H =

49, DAS M = 5.54, SD = 2.58). Although a statistical









difference was found between the two groups, both the

religious and the non-religious appeared to have generally

low levels of death anxiety (as measured by the DAS).

A significant t value on the PIL of t(137) = 4.2073,

**p = .0001) indicated that those who were religious scored

significantly higher on the PIL (PIL M = 117.81, SD = 13.92)

than those who did not identify themselves as religious (PIL

M = 106.72, SD = 17.40). The religious tended to have a

very high sense of purpose (as measured by the PIL) compared

to the average levels of purposefulness endorsed by the non-

religious.

A significant t value on the TI-actualization score of

t(137) = -2.1356, **R = 0.0344 indicated that those who were

religious had fewer TI-actualization splits (TI-

actualization M = 1.92, SD = 3.05) than those who did not

consider themselves religious (TI-actualization M = 3.07, SD

= 3.27). However, both groups clearly showed high levels

self-actualization (few TI-actualization splits).

The significant t value on the TI-death threat score of

t(137) = -3.2936, **E = .0012 indicated that those who were

religious had fewer TI-death threat splits (TI-death threat

H = 6.54, SD = 8.25) than those who did not consider

themselves religious (TI-death threat M = 11.61, SD = 9.98).

This statistical difference between the religious and the

nonreligious also appeared to have some clinical utility,

with the nonreligious mean TI-death threat score (11.61







82

splits) representing one of the highest Threat Index scores

obtained in this entire sample.

A significant t value on the supplemental Death-

threatened score of t(90.8) = -2.8491, **R = .0054 indicated

that those who were religious had fewer Death-threatened

splits (Death-threatened M = 5.26, SD = 7.95) than those who

did not consider themselves religious (Death-threatened M =

9.91, SD = 10.30). As expected, this supplemental Threat

Index score closely mirrored the results of the TI-death

threat score and appeared to reflect an important difference

between these two groups.

The final significant t value found was on the

supplemental Death-attracted score. The resulting t(137) =

-2.1726, **p = .0315 indicated that those who were religious

had fewer Death-attracted splits (Death-attracted M = 0.91,

SD = 2.20) than those who were not religious (Death-

attracted M = 1.78, SD = 2.50). This finding is of little

apparent clinical usefulness as both groups had minimal

levels of death-attraction (hypothesized suicidality).

Two t test comparisons yielded no significant

differences between the religious and nonreligious on the

supplemental Death-accepting or the Depressed scores of the

Threat Index.

Of note, the majority of demographic variables assessed

(age, education, household income, and marital status) had

few, if any, significant associations with the eight test









scores. When significant relationships were found, they

accounted for little of the variance in scores.

The PIL was shown to have a gender and a religiosity

effect that resulted in easily observed, meaningful

differences in test scores. Clearly the highest PIL scores

were obtained by females and by the religious. Religiosity

also appeared to have a clinically meaningful effect on two

of the eight Threat Index scores (TI-death threat, Death-

threatened). The effect of religiosity appeared to have

more of an impact on test scores than any other demographic

variables. The test results specifically addressing the

three hypotheses will now be addressed.

Hypothesis One

The first hypothesis stated that significant

relationships exist between the two primary scores of the

Threat Index (TI-actualization, TI-death threat) and the

obtained scores on the Death Anxiety Scale (DAS) and the

Purpose in Life Test (PIL) for this global sample of hospice

trainees, experienced hospice volunteers, and non-hospice

volunteers.

These two Threat Index scores proved to be significant

predictors of DAS and PIL scores as Pearson correlations

were computed and three of four correlations were found to

have significant r values. Table 9 describes the four test

score comparisons, r values, and p-values.









Table 9

Correlations Between the Threat Index. DAS. and PIL Scores

TEST COMPARISONS r p

TI-actualization DAS .2231 .0093

TI-actualization PIL -.4889 .0001

TI-death threat DAS .3004 .0004

TI-death threat PIL -.1400 .1080



As can be seen in Table 9, three out of four test

comparisons resulted in significant correlations. TI-

actualization showed a positive correlation (r = .2231, p =

.0093) with the Death Anxiety Scale (DAS). As TI-

actualization splits increased (lower self-actualization),

so did DAS scores (higher death anxiety). This correlation,

although statistically significant, was a weak one with only

4.98% of the variance in the DAS scores associated with

changes in the TI-actualization scores.

TI-actualization showed a significant negative

correlation (1 = -.4889, E = 0.0001) with the Purpose in

Life Test (PIL) indicative of an inverse relationship

between these two scores. Few TI-actualization splits (high

self-actualization) were associated with high purpose in

life. This correlation represented a robust relationship

between these two test scores, with 23.90% of the variance

in PIL scores associated with changes in the TI-

actualization scores.








TI-death threat showed a significant positive

correlation (I = .3004, p = .0004) with the DAS. High death

threat (many splits) was associated with high death anxiety.

This correlation was also a relatively weak association with

only 9.02% of the variance in DAS scores associated with

changes in the TI-death threat scores.

Finally, TI-death threat was not significantly

associated with PIL scores (r = -.1400, R = .1080).

Hypothesis Two

The second hypothesis stated that significant

differences in DAS, PIL, and the six Threat Index mean

scores exist between hospice trainees and non-hospice

volunteers. This hypothesis tested whether any of these

three tests could identify traits that would discriminate

hospice trainees from non-hospice volunteers. It was hoped

that one of the tests would be effective in screening

potential hospice volunteers.

Using t test procedures, the two groups were compared

on the Death Anxiety Scale (DAS), Purpose in Life Test

(PIL), and the Threat Index (two primary scores and four

supplemental scores) and shown to have no significant

differences in mean scores on any of the measures utilized

in this study. Table 10 describes the t test results of

Group 1 (hospice trainees) and Group 3 (non-hospice

volunteers) on each of the eight test scores.









Table 10

T-Test Comparisons Of Test Scores of Group 1 and Group 3

TEST t df p

Death Anxiety Scale .6960 69 .4888

Purpose in Life Test 1.0905 54.5 .2803

TI-actualization .4087 64 .6842

TI-death threat -.4101 64 .6831

Death-accepting .8940 34.9 .3774

Death-threatened -.9961 61 .3231

Depressed -.4398 61 .6616

Death-attracted 1.1237 60.7 .2656



To summarize, t test comparisons of the hospice trainee

and non-hospice volunteer mean scores on the DAS, PIL and

the Threat Index were ineffective in discriminating between

these two groups.

In ancillary analyses, t tests were also used to

compare Group 1 (hospice trainees) and Group 2 (experienced

hospice volunteers) and Group 2 (experienced hospice

volunteers) and Group 3 (non-hospice volunteers) on these

eight test scores. No significant t values were obtained on

any of the sixteen t test comparisons. These three tests

were clearly unable to effectively discriminate any of these

three groups of subjects.









Hypothesis Three

The third hypothesis stated that significant

relationships exist between the two primary Threat Index

scores (TI-actualization, TI-death threat) and the

performance ratings given to the experienced hospice

volunteers by two volunteer coordinators (Supervisor A and

Supervisor B). This hypothesis tested whether the Threat

Index might be useful as a measure of performance for

existing hospice volunteers.

A Spearman correlation procedure was performed between

the volunteer coordinator ratings and the two primary Threat

Index scores to assess the relationship between these

variables. The correlation between the two volunteer

coordinator's ratings reached statistical significance (rho

= .5881, R = .0001), but was not large enough to justify

merging the ratings. As a result, each set of ratings was

separately correlated with the test scores with the rho

values and probabilities included in Table 11 below.

Table 11

Spearman Correlations Between Supervisors and Threat Index

VARIABLES RHO P-VALUE

Supervisor A Supervisor B .5881 .0001

Supervisor A TI-actualization -.1477 .2125
Supervisor A TI-death threat -.1563 .1867

Supervisor B TI-actualization -.2042 .0831
Supervisor B TI-death threat -.2108 .0734









As can be seen in Table 11, neither the TI-

actualization score nor the TI-death threat score was

significantly associated with supervisory ratings

(Supervisor A or B). However, an ancillary analysis

correlating the performance ratings with the four

supplemental Threat Index scores resulted in significant

correlations between the Death-accepting score of the Threat

Index and both raters (Supervisor A Death-accepting rho =

.5634, p = .0001; Supervisor B Death-accepting rho =

.4359, R = .0001).

Although the performance ratings of experienced hospice

volunteers were unrelated to TI-actualization and TI-death

threat scores, one supplemental Threat Index score (Death-

accepting) had a significant positive correlation with both

raters. These correlations were also of some clinical

relevance as 31.74% of the variance in Supervisor A's

ratings and 19.00% of the variance in Supervisor B's ratings

were associated with changes in the Death-accepting score.

Those experienced hospice volunteers rated highly by the

volunteer coordinators were likely to have high death-

acceptance.

Summary of Findings for the Three Hypotheses

Results of the first hypothesis showed that TI-

actualization and TI-death threat scores of the Threat Index

were significant correlated with the DAS and the PIL scores

on three of four test comparisons in this global sample of








144 hospice trainees, experienced hospice volunteers, and

non-hospice volunteers. TI-actualization scores were

significantly related to scores on the DAS and the PIL and

TI-death threat scores were significantly related to DAS

scores.

As the number of TI-actualization splits increased

(lower self-actualization), DAS scores increased (more death

anxiety) and PIL scores decreased (lower sense of purpose).

As the number of TI-death threat splits increased (more

death threat), DAS scores increased (more death anxiety).

Of the three significant test correlations, the TI-

actualization score was best able to predict PIL socres,

with 23.9% of the variance in PIL scores associated with

changes in the TI-actualization scores.

Results of the second hypothesis indicated no

significant differences in DAS, PIL, and Threat Index mean

scores were found between hospice trainees and non-hospice

volunteers. None of the eight test comparisons (DAS, PIL,

TI-actualization, TI-death threat, or four supplemental

Threat Index scores) showed significant t results. In fact,

none of the three groups were found to significantly differ

from each other on any of the test scores.

Results of the third hypothesis also showed that

neither the TI-actualization nor the TI-death threat score

was significantly correlated with the performance ratings of

experienced hospice volunteers. However, ancillary analyses







90

did uncover a significant correlation between both sets of

experienced hospice volunteer ratings and the Death-

accepting score on the Threat Index (supplemental Threat

Index score) indicating that death-acceptance among

volunteers tended to increase as performance ratings

increased.












CHAPTER V
DISCUSSION


Rationale for the Study

Hospice provides an important service to terminally ill

patients and families (Steele, 1990; Ferrell, 1985; Cameron

& Parkes, 1983) and seems destined to play an increasingly

larger role in health care delivery in the years ahead (Mor,

1987; Hine, 1979-80). Hospice volunteers are widely

recognized as valuable members of the hospice team (Basile &

Stone, 1986-87; De Vries, 1983), yet very little is known

about their views on death, their sense of purpose, or the

impact of their attitudes on subsequent caregiver

effectiveness (Lafer, 1989; Amenta, 1984).

The research that is available on the death attitudes

of "professional" health care providers seems to indicate

that caregivers who are overly anxious about death or who

deny its impact have difficulties responding appropriately

to the emotionally-charged needs of terminally ill patients

and families (Field & Howells, 1988; Eakes, 1985; Neimeyer,

Behnke & Reiss, 1984). Death anxiety obviously detracts

from a healthy "death surround" (Rando, 1984) seen by

hospice as so critical in facilitating the coping of a

patient and family facing inevitable death. To what extent









is death anxiety a problem with "nonprofessional" hospice

volunteers?

Many hospice administrators recognize that carefully

exploring the feelings that volunteer trainees have about

death is important and most programs currently have formal

candidate interviews prior to training. However, a review

of the literature found few, if any, attempts to develop

screening instruments for potential hospice volunteers or to

investigate the link between the death attitudes of hospice

volunteers and subsequent caregiver performance (Finn

Paradis & Usui, 1987). The current study was conducted

primarily to address these shortcomings in the literature.

The Threat Index and two other popular thanatological

instruments (Death Anxiety Scale, Purpose in Life Test) were

used in this study to explore three primary hypotheses. If

found to be helpful in addressing the basic research

questions of the current study, it was hoped that the Threat

Index might prove to be a useful tool in the hands of

hospice administrators seeking to put the best candidates in

these stressful and demanding caregiver roles.

The present investigation has examined whether the

Threat Index (based on the Personal Construct Psychology of

George Kelly) could be used as an effective screening and

evaluative measure for both hospice trainees and volunteers.

The Threat Index was chosen because it had the strongest

theoretical grounding of any thanatological instrument









(Neimeyer & Epting, 1992) and it was constructed with an

inherent sensitivity to the fact that an individual's

notions of death are highly idiosyncratic (Rando, 1987;

Feifel, 1968; Jung, 1959).

The primary investigator also hoped that the present

study would meaningfully contribute to the growing

literature of thanatology. Thanatology is a field marked by

multiple journals, contributing disciplines, and research

foci. Yet it is also a field apparently in need of a

unifying theory with which to understand past findings and

to efficiently explore new research directions. Personal

Construct Psychology (Kelly, 1955) has been viewed by some

(Neimeyer, Epting & Krieger, 1984) as best suited to perform

these tasks and the Threat Index is one of its primary

tools.

Relationships Between the Test Scores: Hypothesis One

Three of four Pearson correlations between the three

tests were found to be significant. These findings

indicated that significant relationships exist between the

primary Threat Index scores (TI-actualization, TI-death

threat) and the scores on the Death Anxiety Scale (DAS) and

the Purpose in Life Test (PIL) obtained from this sample of

144 hospice trainees, experienced hospice volunteers and

non-hospice volunteers. These three instruments do seem to

measure some common aspects of death anxiety and sense of

purpose.









A high sense of actualization (few TI-actualization

splits) was correlated to low death anxiety (DAS) and a high

sense of purpose (PIL). A high degree of death threat (many

TI-death threat splits) was correlated to high death anxiety

(DAS). No significant correlation was found between TI-

death threat scores and PIL scores. Although statistically

significant, the three correlations had weak predictive

power with roughly 5%, 24%, and 9% of the variance in one

score associated with changes in the other score

(respectively). Clearly, scores on the DAS and PIL were

largely associated with factors not directly measured by the

Threat Index.

The few studies that have been conducted with hospice

volunteers have shown that scores from the Death Anxiety

Scale and the Purpose in Life Test have a significant

inverse relationship (Amenta, 1984; Amenta & Weiner, 1981).

The results of the current study closely mirrored the above

findings. However, as was the case in prior studies, the

current investigation also obtained correlations with weak

predictive power and will probably do little to silence

critics who claim that serious methodological problems

continue to confound attempts to measure death anxiety

(Vargo, 1980; Dickstein, 1972).

Using Tests to Differentiate Groups: Hypothesis Two

This study found that no significant differences in

DAS, PIL, and the six Threat Index mean scores exist between