ARTÍCULO ORIGINAL / ORIGINAL ARTICLE / ARTIGO ORIGINAL

DOI: 10.17533/udea.iee.v33n2a13

The experience of nursing students facing death and dying

La experiencia de los estudiantes de enfermería frente a la muerte y el morir

Aline Viana Sampaio¹; Isabel Comassetto²; Ana Cristina Mancussi e Faro³; Regina Maria Dos Santos⁴; Fernanda Silva Monteiro⁵

¹RN, Resident in women's health. Universidade Estadual de Ciências da Saúde de Alagoas -UNCISAL-, Brazil. email: linevianas@hotmail.com.

²RN, Ph.D. UFAL, Brazil. email: icomassetto@usp.br.

³RN, Ph.D. Universidade de São Paulo, Brazil. email: rafacris@usp.br.

⁴RN, Ph.D. UFAL, Brazil. email: relpesantos@gmail.com.

⁵RN, M.Sc. UFAL, Brazil. email: fercell@ig.com.br.

Receipt date: March 11, 2014. Approval date: April 15, 2015.

Article linked to research: The experience of nursing students facing death and dying.

Subventions: none.

Conflicts of interest: none.

How to cite this article: Sampaio AV, Comassetto I, Faro ACME, Santos RM, Monteiro FS. The experience of nursing students facing death and dying. Invest Educ Enferm. 2015; 33(2): 305-314.

DOI: 10.17533/udea.iee.v33n2a13

ABSTRACT

Key words: students; nursing; death; attitude towards death.

RESUMEN

Objetivo. Comprender el fenómeno experimentado por los estudiantes de enfermería en sus prácticas académicas hacia la muerte y el morir. Metodología. Se realizó un estudio cualitativo, basado en la fenomenología existencial de Martin Heidegger, en una Universidad pública en Alagoas, Brasil, entre agosto y octubre de 2013. Se entrevistaron 7 estudiantes del último año de enfermería. Resultados. El análisis fenomenológico arrojó los siguientes temas existenciales: Frente a la muerte y el morir en la práctica académica, reconociendo la impotencia en el rostro de la muerte, vislumbrando la posibilidad de la solicitud, la interacción con la familia por la pérdida, y experimentar la espiritualidad antes de morir. Conclusión. De lo anterior se desprende que, durante las prácticas académicas, el tema que involucra la muerte y el morir se ha estado trabajado en forma inadecuada, pues no cumple con precisión todas las demandas de los estudiantes de enfermería durante la atención en el proceso de morir.

Palabras clave: estudiantes de enfermería; muerte; actitud frente a la muerte.

RESUMO

Objetivo. Compreender o fenômeno vivenciado pelos alunos de enfermagem em suas práticas acadêmicas frente a morte e o morrer. Metodologia. Trata-se de uma pesquisa qualitativa, embasada na fenomenologia existencial de Martin Heidegger, realizada numa Universidade pública de Alagoas, Brasil, entre os meses de agosto e outubro de 2013, foram entrevistados sete alunos do último ano do curso de enfermagem. Resultados. Da análise fenomenológica, emergiram as seguintes temáticas existenciais: Enfrentando a morte e o processo de morrer nas práticas acadêmicas; Reconhecendo a impotência diante da morte; Vislumbrando a possibilidade da solicitude; Convivendo com a família diante da perda; Vivenciando a espiritualidade diante do morrer. Conclusão. Deduz-se que durante as práticas acadêmicas a temática que envolve a morte e o morrer tem sido trabalhado de forma deficiente, não atendendo com precisão todas as demandas dos alunos de enfermagem durante a assistência no processo de morrer.

Palavras chave: alunos de enfermagem; morte; atitude frente a morte.

As a result of research in the medical area, it is known that the concept of biological death, defined as the interruption of heartbeats and breathing is an outdated concept. Thus, the criterion that is currently analyzed to define death is the brain function since, due to the technological advances, it has become possible to maintain the cardiac and respiratory functions through devices, while nothing can be done to maintain responsive brain functions.^1-3 Death is not only the end of human existence, but is preceded by different forms of losses that are part of human development. Many authors consider it as one of the few certainties in life that derives from a progressive phenomenon that starts at the moment of conception.^1-3

Therefore, death is not strictly a biological event, but a social and culturally constructed process. The concepts of death have been changing over time, it has already been considered as a natural process, as something man could master, as savage, as a cause of fear, romantic and also as a synonym of eternity. As from the 20th century, it started to be seen as something that should simply go by unnoticed, leaving aside the mourning and the farewell rituals that mainly happened in the home environment and is transferred to the hospital environment.^3-5 Consequently, in the Western society, death stopped being part of social life among people and started being hidden and denied. Hence, the exchange of experiences among people about the dying process was dissipated, furthering the hiding of the suffering that results from the loss, as death turned into something inconvenient and prohibited.^3,5

Although the feelings related to the dying process are covered up, the patients at risk of imminent death experience difficult times and need the health professionals to understand them and offer support in the end-of-life stage.⁶ Authors affirm that the health professionals are prepared to "save lives", but were not prepared to cope with the imminence of death, as it challenges the human and professional omnipotence, therefore representing one of the stressful factors associated with the health professionals' practice.^2,3,5,6 In the nurses' education process, integrality and the welcoming of patients and their relatives are discussed, as well as different other aspects of nursing care. Death gives rise to conflicting feelings though, which make the nurses retreat, possibly due to the weakness in their education to understand the human finiteness.⁷

There is a clear need for the theme of death, being extremely complex, to gain relevance in the construction of knowledge, permitting transformations in teaching and contributing to nursing education, as death is an event that is part of the work process in health. Hence, this study is justified by the fact that existing research on the research problem does not clarify the phenomenon the undergraduate nursing students experience in view of death and dying in their academic practice. As the theme is not easy to discuss and is linked to feelings of fear, anguish, anxiety, concern, loss, sadness, impotence, we believe that the academy, as an educational institution, should be concerned with the preparation of critical, reflexive and humanistic professionals who are prepared to cope with issues involving human finiteness, proposing reflections on life, care and terminality. Therefore, the objective in this study is to understand the phenomenon the nursing students experience in their academic practice in view of death and dying.

METHODOLOGY

Due to the nature of this study's concerns, a qualitative and descriptive research with a phenomenological approach was chosen, as it permits the full understanding of the nursing students' experience of death and dying in their academic practice. Heidegger's existential phenomenology served as the theoretical-philosophical support, which permitted understanding the students' experience without theories or prejudice, but considering how the experience revealed itself in its essence.⁸

The study was undertaken at Universidade Federal de Alagoas (UFAL), in Maceió, Alagoas, Brazil. The nursing students' experience of death and dying in their academic practice was the focus of investigation. The interviews were held between August and October 2013. Seven final-year undergraduate nursing students who had experienced death and dying in their academic practices were invited and accepted to participate. With the School of Nursing's authorization, the study received approval from the Institutional Review Board at UFAL, in compliance with the ethical and legal principles of Resolution 466/12, according to Opinion No. 13083813.6.0000.5013.

The students were contacted, they received explanations about the research objectives, their anonymity and the possibility to refuse were guaranteed, as well as the scientific nature of the study. After receiving and signing the Informed Consent Form, the interview started, guided by the following question: Tell me what it was like for you to experience death and dying during your academic activities? The interviews were recorded for the purpose of documentation and fully described. To preserve the students' anonymity, they were identified by the letter E (estudante in Portuguese), followed by the chronological number in which the interviews were held.

RESULTS

To achieve the study objective, the units of meaning in the interviews unveiled the structure of the research phenomenon and were grouped in five thematic categories: Facing death and dying in academic practice; Acknowledging impotence in the face of death; Glimpsing the possibility of solicitude; Interacting with the family in view of the loss; Experiencing spirituality in the face of dying. Hence, the first category that emerges from the study refers to the experience of being a nursing student confronted with death in his/her academic activities.

Facing death and dying in academic practice

In the discourse analysis, it was unveiled that, when the students perceive themselves as Beings-in-the-world of academic practice, who are launched to face death and dying in their daily activities, they discover themselves as Beings-there who are unprepared to face death and the entire context it involves. The existing gap in the academic education with regard to the theme of death is known and entails insecurity with regard to the experiences they go through in the face of finiteness. This fact gains evidence and intensity in their unplanned daily experiences, in a unique and characteristic way, which will prepare them to face the finiteness: [...] I do not feel prepared for this moment, I feel that daily reality, life, the situations that happen in daily reality are preparing me, because college does not provide preparation to face death (E1); [...] In college, dealing with death is not addressed directly [...], but the humanization the course discusses, whether you want it or not, this can be discussed better, because in the second year we are confronted with the preparation of the body and with death, still immature. What helps are our experiences (E2).

In this circumstance, the students are launched into the world in view of the facticity of the terminal condition, independently of their choice. And death, which seemed to be a distant possibility in the world responsible for their professional preparation, gains concreteness in its worldliness: Despite understanding that death is a certainty in everyone's life, it really is not easy to deal with it (E1); [...] it was not easy to experience this, first because, before being a professional, as a person, experiencing death is difficult to me, even if it's death on television or the death of relatives and friends, it is difficult to accept and reflect on the why of death (E2).

Hence, facing death and the dying process is a unique experience for the students, which goes far beyond the technical and scientific knowledge or the academic education, but involves their cultural values and life history, which will be responsible for coping with the facticity of finiteness: [...] this experience will be different for each student during the course, I think it will involve a lot of creation, it will also involve even the emotional aspect and a person's belief in some religion (E1). Independently of the cultural aspects, however, it was unveiled that, in view of the awareness about the presence of death in their academic practice, the student gains a feeling of fear, limitation and impotence in view of the struggle for life. The anguish allows the student to understand the uncertainty of human existence: [...] I felt sadness and anguish, we feel touched, I had watched his history and saw that he was a healthy man and now this. It's the weakness of life in the face of death (E2); [...] it's horrible for you to watch a person leave, it makes you reconsider many things, but it's a time when the person gets kind of sad, I am kind of cold myself, but I spent the entire day feeling sad, for me it was like that (E6).

The possibility of experiencing death and dying allows the students to get rid of the inauthenticity and find themselves, making them aware of the individuality of their existence and encouraging towards a more coherent academic practice: [...] the moments we went through made me think about the importance and how we, as professionals, are limited when we experience death. As human beings we perceive that we should always act and use the occasion to provide moments of comfort and attention to people in need at the moment of departure (E7); [...] I felt sad initially, I regretted the fact that we tried to revert the condition and nevertheless were unable to and, at the same time, I ended up conforming and understanding the situation [...] sad because we lose patience [...] but I had to conform and understand that, despite doing something to try and save here, unfortunately it was not possible, only regretting and conforming to the situation (E4). When experiencing the facticity of the terminality, the students acknowledge their limits, as unveiled in the following category.

Acknowledging impotence in the face of death

The experience of the loss in view of the presence of death provokes a reflection in the students, which entails the perception that they are unable to master it, and consequently perceive themselves as beings-in-the-world with limitations, destined to fail in the struggle against death. When acknowledging the possibility of the patient's death, feelings of weakness and the acknowledgement of impotence emerge, when they perceive that the patient does not improve and is launched to death, as a being-for-death. In Heidegger's conception, each person dies and this fact is unavoidable, simply imposed, no matter what one can do death happens. When experiencing the terminality of the human being under their care, the students can perceive their experience as a moment of failure, of losing the opportunity to permit the possibility of life and the outcome death is not accepted naturally. Nevertheless, they offer authentic care during the departure process, as discussed in the next category.

Glimpsing the possibility of solicitude

Despite the feeling of loss, satisfaction is expressed when the students overcame their own expectations and successfully delivered nursing care. The feeling of "being able to do something" is evidenced when care occurs as planned, this possibility which is called authentic care in Heidegger's thinking: I left very satisfied that day [...] I was really able to overcome myself in terms of my attitudes towards the death situation and I delivered all care (E4).

In view of death, a feeling of satisfaction is perceived, when the fears that accompany terminality are overcome, a barrier is broken and the student progresses towards the conquest of integral care. In view of this experience, the possibility to promote welcoming blossoms, when being-with the being-for-death, thus glimpsing a wide activity area for the nurses with the patients who are dying and their relatives.

In their statements, the students reported that the human side should never be dissociated from the professional side and that the search to grant the patient who is about to die moments of comfort ends up causing an emotional burden for the professional, not always of sadness or suffering, but also of satisfaction: As a professional, at that moment, for me, I did not feel bad, because I was able to deliver all possible care to him, [...] for me, I am unable to separate the professional side from the human side that much [...] but when we do the work that has to be done we get happy, not because of the end, but because you can grant a dignified end, because that is the least everyone wants (E6). When acquiring an authentic way of being, the students start to glimpse the valuation of solicitude in the entire context of academic practice in nursing, always attempting to act to relieve the other beings' suffering: [...] the fact of death [...] made me think of using all moments [...] grant all my attention and deliver all care with love, mainly for my fellows, and putting in practice all knowledge to relieve the pain, suffering and also give attention to the people who need it (E7).

Authentic care stands out and turns into something inherent in nursing care at the time of death, making it fundamental to consider the other as a being who deserves respect and attention: The condition of being-for-death is rather complex to be accepted and experienced, causing suffering in view of the loss and arousing a reflection to cope with death in its rational and emotional dimensions, in the search to understand its meanings. Experiencing the death of the patient under their care arouses feelings of loss, sadness and anguish, difficulties to cope with the family also appear in situations of finiteness, as observed in the next category.

Interacting with the family in view of the loss

While unveiling the phenomenon the students experienced, the difficulties experienced during contact with the patient's family in the dying process were strongly manifested. The relatives' expressions in view of their patient's dying process emerged in the student's experience as a cause of discomfort and apprehension: [...] the family joined, it was close to visiting hours and the family's commotion touched me a lot so that I could not attend them at that moment, I left the family there, we placed a screen and the family stayed there, and I also calmed down, breathing deeply, getting things together to be able to continue the care for the body (E1); Well, when I saw the patient dying for the first time I got scared. And first I thought of the family, of how to deal with the family, that was what made me feel most apprehensive, because we had already done everything for the patient [...] (E5).

The lack of preparation to deal with the death situation, linked to the inexperience in care for the family members who experienced the loss caused anguish and affliction, out of fear of not being prepared to satisfactorily play they role in care for the relatives who are experiencing the loss: [...] dealing with family, in daily life we already deal with family, now, in death it's more difficult, you really need to be prepared (E3). They are aware that it is the nurse's duty to holistically attend to the patient, whether in life or death, and this precept include care for his family, which was appointed as a fundamental part of nursing care: There were family members who stayed with the patient until the final moment, we were there taking care of the patient and observed that she was tired, but she was there so, as soon as the patient died we knew that now it was the family who needed our care (E1); But at the same time we need to give support to the family, not all professionals do that, we need to look for the professional's human side as early as in academic education (E2).

Experiencing spirituality in the face of dying

Experiencing death from a religious perspective end up making it more acceptable, as the spiritual explanations indicate that, even after death, the forms of life still continue, that is, the end of the physical body does not mean the end of life, as living goes beyond concrete matter, it implies the spirit and the soul. The belief in the existence of the spirit appeared as a point of comfort after the patient's death: In the belief that the most important part of the human being is the spirit, when seeing her already dead, it seems unbelievable but it was easier, it was easier to face [...] (E1). Coping with death, mourning and loss becomes easier when one believes in God. Faith and the belief in spirituality are points of support for the students in their experience of death: For me the most difficult is for you to bear it, so you'll miss that person independently of being a relative or not, when a person dies someone will miss her, but if you believe in God, I think that that makes all of the difference (E5); [...] the thing of dealing with death really, the mourning, the loss, it's spiritual! (E5).

Another important phenomenon that emerged in the students' discourse was that death is considered as a loss of bodily function, but not of spirituality. This belief evidences the hope of family members, friends and the professionals themselves: [...] Death? There's the change of phase, [...], because it's unknown, because we do not know what comes in the afterlife, I believe in spiritual life (E7). In view of the subjectivity of the meanings of death, understanding it in a spiritual dimension permitted the students' better acceptance, understanding it as a start of a new life, and is therefore considered as something positive.

DISCUSSION

The hospital dynamics of the incessant struggle for life does not leave room for questioning, talking and thinking of death. In addition, the psychosocial aspects of death are not included in the Nursing programs' curriculum and, when addressed, the discussion is superficial and non-systematic.^4,10,11 Dying is a phenomenon that should be understood existentially in a privileged sense and, therefore, it needs to be analyzed and delimited more closely.⁸ The focus on health professionals' education about the theme death should be sought, with a view to turning into new knowledge and skills and strengthening these professionals' social commitment to enhanced clinical practices, not restricted to the obstinacy of cure.¹²

Therefore, it is considered that death in learning situations is a matrix that produces conflicts but, on the other hand, it can grant conditions that provide the students with a more humanized education. To make death tangible in this context, one needs to understand its meaning for the people who experience it.¹³ The feelings of frustration, impotence and guilt often derive from the lack of preparation and inadequacy of the staff in view of situations involving dying.¹⁴ The students feel uncomfortable when they are confronted with death in their daily life, as this experience remits them to their finiteness, giving rise to feelings of impotence that arouse feelings predisposing to the assessment of the care delivered.¹⁵ Even if death is part of human development, the proximity of the dying process arouses issues in people that involve their experiences and reflect their existential anguish, permeated by feelings that are not always clear and conscious.⁴ As the nurses are the professionals who are always present at the patient's side, this can trigger affective involvement. As a result of death, the bond is interrupted, causing suffering and feelings of loss. Thus, the loss is faced as a probation the students have to go through.^16-19

Death is revealed as a loss, a loss felt by the beings who stay, but a physical loss, as the existential death can only be felt by the person who dies. In that same sense, Heidegger affirms that the loss is felt by the people who stay, as the loss of the people departing is unknown.⁸ Relieving the suffering or helping a person to die is one of the hardest tasks for nursing professionals. Not being able to cure does not mean failure, but an acknowledgement of the limits of the technique.¹ In the Health area, despite being subject to daily experiences of death episodes, the nurses in general are not properly prepared to cope with these situations. Talking about death means talking about what one is doing, about what one did not do, about plans, dreams, about what is left; that is what one escapes from and what one is afraid of confronting.¹⁰

In Heidegger's phenomenology, the term feeling should be understood as a disposition, which is the way in which the dasein reaches himself. When translated in that manner, the feeling turns into an experience of facticity, which allows the dasein to feel the world in other ways. The facticity allows him to perceive himself when being launched to the feeling.⁸ The dasein reveals himself in the anguish, which is ontological, its source is death as such. Not being anywhere, the anguish is the actual possibility-of-being-in-the-world and that is where the dasein reveals himself as a facticity in his being in the world. Hence, the essence of human anguish is the extinction, as man is the only live being who is aware of his finiteness, which then entails the fear of death.⁸ The essence of human motivation is the search for a meaning for life, suffering and death.²

Some gaps in nursing education have produced professionals who are hardly apt to deliver this care in a more comprehensive manner to people who experience their finiteness, as well as their relatives. This lack of preparation can favor the escape from a situation of confrontation with their own fears, making them limit the care to the body that dies in most cases, and not to the human being who dies.¹⁹ The professionals need contents that offer skills to facilitate the management of situations involving death and dying, considering the cultural diversity and sociodemographic characteristics.²⁰ The supply of theoretical support about finiteness in undergraduate programs was proven relevant to guarantee appropriate care in the dying process.²¹ Putting in practice humanized attitudes in nursing care demands a good relation between the nurses and the patients and their families. Therefore, the theme humanization needs to be discussed in academic education.²²

In humanized care, religion reveals to be a possibility nursing has to offer access to the spiritual dimension of patients who are dying.²³ Religion has always contributed to explanations of the death phenomenon, strengthening the idea that life is not useful and does not end. Consequently, religions have granted society and individuals support, providing a framework of reality to death, so as to assimilate and validate the expressions of emotion inherent in mourning. On the other hand, many people who find support in religious beliefs picture death as a passage and not as the end of life. This conception provokes the emergence of fierce defense against coping with death.²⁴ In the students' perception, life consists of a mortal physical body with an immortal soul. This is strengthened by most religions and spiritual schools that believe in the concept of immortality and the indestructability of the soul.¹⁷ This view of death as a passage was supported by the results of a study involving nursing professionals, which indicated that they tend to associate death with the meaning of transcendence.²⁴

In conclusion, based on the unveiling of the phenomenon the nursing students experience in view of death, in their academic practice, the nursing students are unprepared to face the situations involving the dying process. This lack of preparation derives from insufficient academic education to discuss such a relevant theme to achieve excellent care delivery with a view to a dignified death. The lack of preparation was revealed in the students' psychosocial reaction when they were exposed to this experience, in the form of a painful phenomenon that is hard to accept, at the same time as it furthered reflections on their own finiteness. In their experience, they expressed feelings of anguish and impotence in view of the terminality. The support from religion was used to overcome the feeling shared with the patient and his family and, thus, they constructed meanings for the complex process of dying.

Humanization in care during finiteness was emphasized as a fundamental nursing care practice, as it demonstrates respect for the patient who is dying and his relatives, in the attempt to relieve the suffering. The need for a space for dialogue is highlighted, where the theme of death and dying is discussed in its entire context, so as to contribute to the nursing professionals' academic education and to attend to the demands of the being-for-death, as well as his relatives, in a safe and humanized manner. Thus, the difficulty to understand the meanings of the phenomenon involving death was perceived, which made the students experience intense feelings. In view of this subjectivity of the meanings of death, understanding it within a spiritual dimension permitted a better acceptance, as it acted as a point of relief for the suffering experienced as a result of the finiteness.

It should be mentioned that the theme of death can contribute to the academic education of nursing professionals, suggesting the need for these professional to get familiar with death since their undergraduate program, with a view to the students' personal and professional development.

Finally, it is important to register this study's limitation, firstly because of the research design, which demands some time to mature the reflections the authors did not have, besides the anchorage of a theoretical framework, which a qualitative scientific initiation study could not bear. In addition, the involvement of a small number of subjects can be considered as a limitation, whose discourse captured in an in-depth interview was exhaustively explored, one by one, until being able to identify, between the lines, the meanings they attributed to the experience of the death of someone they were taking care of and which put them face to face with a complex and difficult phenomenon that, if not addressed properly, can be devastating. Another limitation refers to having joined students from a single teaching institution, at a single hospital unit in the small group of subjects. Therefore, further studies on the phenomenon are suggested, in circumstances that permit a broader base to recruit the subjects, which may turn into a multicenter study, unveiling other nuances of the phenomenon that were not discussed here, such as the influences of culture, religion and even the type of sector where the death happens, in the students' reactions when experiencing patients' death.

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