DOCENCIA E INVESTIGACIÓN

Nursing students' reflections on the death process

Reflexiones de los alumnos de Enfermería sobre el proceso de la muerte

Hanzeliková Pogrányivá, A.^*; García López, MV.^**; Conty Serrano, MR.^***; López Davila Sánchez, B.^****; Barriga Martín JM.^***** and Martín Conty JL.^******

^*PhD student in Quality of Cares. Camilo José Cela University, Madrid; Nurse, Virgen del Valle Hospital, Toledo. E-mail: alica.hanzelik@gmail.com
^**Nurse. Graduated in Anthropology. Professor at Castilla La Mancha University Nursing College, Toledo
^****Nurse. Graduated in Anthropology. Doctor of Educations Science. Professor at Castilla La Mancha University Nursing College, Toledo
^****Nurse. Toledo Hospital
^*****PhD student of Psichology. Camilo José Cela University, Madrid; Nurse at 12 de Octubre Hospital, Madrid
^******Nurse; Associate Professor at Camilo José Cela University, Madrid

ABSTRACT

One's attitude toward and fear of death in the nursing field can determine the quality of care that a dying patient receives, which makes this topic an important one to consider and discuss.
It is necessary for one to learn to perceive death as a natural process. Healthcare workers treat dying patients, interpreting the phenomenon of death as well as death itself through their own personal lens and breadth of understanding. Training in thanatology and palliative care is scarcely and irregularly included in regular academic curricula.
The objective of this study is to analyze the contributions of 3^rd-year nursing students on the subject of palliative care upon writing a reflective journal entry about an article that surrounds a nurse's view on the process of dying.
Phenomenology was used as a methodological instrument which intended to inductively draw up a standardized explanation of the phenomenon of death through the students' expressed thoughts on the matter.
Relating to the attitudes that nurses that work with the terminally ill have towards death, the following facts stand out as impactful: lack of preparation, ineffective coping, and personal fears, values, and beliefs. Additionally, uneasiness associated with the use of life support and the care team's obstinate insistence on saving what cannot be saved is predominant.
The results emphasize a very elevated level of the nurse's emotional involvement in caring for a dying patient. Specific preparation geared toward a better adaptation in working with terminal patients has been identified as a fundamental pillar for nurses in this line of work. Personal interest and emphasis on occupational excellence also stand out as influential factors.
It is very important to analyze the problems regarding this "environment of death" and its impact on nursing students. Qualitative research in this field could be a useful tool in detecting worries and uncertainties surrounding this matter.

Keywords: death; nursing students; coping; patient.

RESUMEN

La actitud y el miedo a la muerte en enfermería pueden condicionar la calidad de cuidados del paciente moribundo, por lo que es importante abordar este tema.
Es necesario aprender a percibir la muerte como algo natural. Los sanitarios tratan a los moribundos, interpretan el fenómeno de la muerte y la muerte misma bajo su óptica y entendimiento. La formación en tanatología y los cuidados paliativos se trata de forma escasa o al menos de forma irregular en los planes de estudio.
El objetivo del presente trabajo es analizar las aportaciones de los alumnos de tercero de enfermería en la asignatura cuidados paliativos a la hora de escribir una reflexión sobre un artículo que trata la visión de una enfermera del proceso de la muerte.
Se empleó la fenomenología como instrumento metodológico, con el que se pretendió elaborar inductivamente un marco explicativo del fenómeno estudiado a partir de las expresiones de los estudiantes.
En relación a la actitud hacia el trabajo con enfermos terminales y hacia la muerte se pueden resaltar los siguientes datos: escasa preparación, afrontamiento ineficaz, miedos, valores y creencias. Predomina la inquietud relacionada con el encarnizamiento terapéutico y con la actitud obstinada del equipo de salud por salvar lo insalvable.
Los resultados ponen de manifiesto un grado muy elevado de implicación emocional de la enfermera en el cuidado del paciente moribundo. Se considera como pilar fundamental una preparación específica para adaptarse mejor al trabajo con los pacientes terminales. Destaca el interés y la preocupación por la excelencia.
Es muy importante el analizar los problemas en "entorno de la muerte" en los estudiantes de enfermería. La investigación cualitativa en este campo podría ser una de las herramientas útiles para detectar inquietudes y preocupaciones.

Palabras clave: muerte; estudiantes de enfermería; afrontamiento; paciente.

Introduction

Though death is an inevitable end to human life, it is not often spoken of in modern society. It is necessary for us to learn to perceive death as a natural process; one that is part of our daily lives. Healthcare workers treat dying patients, interpreting the phenomenon of death and death itself through their own lens and based on their own understanding. Attitudes towards and fear of death may determine the quality of care that a dying patient receives, which is an important aspect to consider and tie into the academic formation of these workers. Education on palliative care and thanatology is only sporadically present in current academic curricula.

Nearly all nurses must face death at some point during their professional lives. Both terminal patients as well as their loved ones must be provided with emotionally sensitive care. The care that a patient receives from health care professionals is influenced by the way these caregivers understand the phenomena and processes that surround death⁽¹\ Lack or absence of preparation when facing death could lead to a certain degree of emotional impact on these professionals. Working in palliative care units is highly stressful^(2-4). Anxiety, fear, and stress can appear in healthcare workers if effective coping strategies are not developed.

Anxiety is generally characterized as being quite unpleasant on an emotional level. The individual tends to have problems and experiences feelings of peril, however is often unable to identify the root cause of this fear and cannot predict when and from where it may come. Anxiety is provoked by a fear of the unknown (the fear of "nothing in particular")⁽⁵⁾.

Fear is defined as an unpleasant, short-term emotional state that one may experience throughout his or her course of study. It is also interpreted, through one's cognitive processes, as a threatening or dangerous stimulus. In general, the individual is able to identify the source of his or her fear. While general anxiety is driven by the feeling that the future is characterized by uncertainty and peril, fear, on the other hand, is an immediate and innate reaction to actual threat or danger⁽⁵⁾.

Some authors define⁽⁶⁾ fear of death as a daily human experience that in a medically acute situation, a person's life becomes in imminent danger. It includes various components: preparing for one's own death, the dying process, and fearing the death of others.

Anxiety and fear of death is normal. They are often engrained in us since early socialization. As such, the unfavorable social and cultural atmosphere surrounding the concept of death and dying can affect one's experiences of fear and anxiety towards death. Other factors^(7,4) that affect the degree of anxiety and fear of death as well: among these are mental health and one's personal life experiences with death. Religion, culture, and personal opinion about quality of life and death can serve as influences as well.

Education and training geared toward a better understanding of death and dying can reduce fear and anxiety toward these things among university students studying health-related fields, and as such education about palliative care for nursing students should also incorporate the analysis of problems and fears surrounding death⁽¹⁰⁾.

Objective

To analyze the written contributions and analyses of third-year nursing students at the University Alfonso X studying palliative care during the academic year 2009-2010, upon reflecting on the article by Gil P.R.; Avila R, I.M.; Molero P.M.J. "A Nurse's View on the Dying Process"⁽⁸⁾.

Methodology

Qualitative study; Used as a methodological instrument, phenomenology was employed with the intent of inductively creating an explanatory framework of the phenomena expressed by the students The data was obtained through an analysis of 41 separate written reflections about the article by Gil P.R.; Avila R, I.M.; Molero P.M.J. "A Nurse's View on the Dying Process"⁽⁸⁾. This article presents the story of an oncology nurse with 21 years of professional experience, in which she explains her life experiences, the evolution of her feelings, as well as her professional development.

Using this academic subject as a portal, 4 articles related to the topics of death, the dying, and the terminally ill were distributed to the students. They were able to choose the article that most caught their attention among the 4 and were asked to create a written reflection on the article of their choosing. The article "A nurse's view on the dying process" was chosen by 38.5% (N 41) of the class (as opposed to 19.44%, 8.25%, and 34.25% who chose the other articles). Among those who chose "A Nurse's View on the Dying Process," the students' gender was reflected as such: 81% Female, 19% Male, aged an average of 24.54 years.

The data was obtained through a practice in reflective writing. Reflective writing is a complex cognitive process through which a person translates his or her ideas, thoughts, feelings, and impressions into a coherent, written discourse. This is a process which favors candid communication with the audience, thus achieving this study's desired objectives⁽⁹⁾.

Used for the study were the students' written texts. Content analysis was used as its methodological means⁽¹⁰⁾. The text itself was segmented into the following thematic pieces: the protagonist, the job, preparation, death, personal experiences, life support, emotions, coping, worries, and pursuit of professional excellence.

Results

Regarding the protagonist, an immense number of the students (table 1) identified with her, understood her, and could share her feelings. They felt respect and admiration for her character.

In respects to the work that she performed as an oncology nurse (table 1) one will note that this is considered a difficult, yet gratifying job. Several times in the text one will see that the way in which the nurse, who works with the terminally ill, is described as supportive, having a positive attitude, and providing a great quality of care.

It can be seen in table two how the students "shout" their requests for adequate training on how to effectively cope with the situations that may arise which involve death and dying.

Examining the death "piece," it can be observed that death is perceived as something negative. It is also clear that students differentiate between one's own death and the death of others, and also between which is more difficult to cope with. There were even students that expressed the desire to save what cannot be saved - they do not see death as a natural occurrence. Others, however, expressed that we should "let them go... let them go in peace." It can thus be concluded that there is great emotional variation regarding this piece.

Looking the life support piece, one will note, however, a uniformity of opinions among the students (table 2).

Looking at personal experiences (table 3), the students speak of pain, care, sadness, enduring difficulty, and lack of ethic on behalf of some of the nurses. Many times the frequency with which a nurse must confront death can endure and thus trivialize the experience of it.

When studying the emotions that one experiences regarding death (table 3), one finds that words such as emotional impact, pain, impotence, and sadness recur. Death, however, should not be conceived as a failure of medicine, but rather an inevitable part of life's cycle.

For nurses, daily encounters with death and suffering is like trying to struggle with an immense emotional burden while managing difficult situations, but without becoming emotionally involved nor appearing frivolous or cold. It is quite difficult to distinguish an attentive, sensitive, yet unaffected attitude from one of certain distance and coldness that often becomes routine.

Analysis of the coping piece (table 3) adds that death imposes limitations on both the human being itself as well as the professional. Coping problems often appear in relation to feelings of rejection that death produces. How a person has coped with his or her own losses will shape his or her own coping processes. As such, hospital units that treat terminal patients often organize seminars, group discussions, etc.

Relating to "worries" (table 4), in each case both personal feelings as well as preoccupations with what kind of communication should be adopted are emphasized. In the "pursuit of excellence" piece (table 4) there is a perceived interest in humanizing the care a patient receives at the time of death, without becoming oneself emotionally affected. This emotional distance is gauged inasmuch as one is able to give care that is both perceptive and sensitive to the patient's and their families' needs and demands, while not becoming emotionally involved at a personal level. This emotional distance and perceptive care grant the patient maximum benefit from the care he or she receives.

Discussion

To complete this study the focus was the interviewee's (protagonist's) world versus that of a third-year nursing student, who already knows that he or she will have to confront situations similar to those that the article's protagonist faces.

Analysis of one's attitude towards his or her work with terminal patients and death bring to light the following facts: lack of preparation, ineffective coping, and the influence personal fears, values, and beliefs. Unrest exists related to the use of life support and the health team's obstinate attitude geared to save what cannot be saved. These elements act synergistically and modulate the process of care that is given to the terminally ill.

The results of this study emphasize a very high level of emotional implication for nurses that care for dying patients. Specific preparation geared toward better adapting oneself to care for these patients stands out as a fundamental pillar in this discussion. Interest and pursuit of excellence in one's occupation are emphasized as well.

Conclusions

One's attitude towards and fear of death in the nursing field can affect the quality of care for terminally ill and dying patients. It is not only important, but also necessary, to carry out research to determine the strategies that one must incorporate into the education of palliative care. In doing so, it is possible to diminish the anxiety and fear that death provokes in nursing students. There are many existing quantitative studies on the fear and stress that death produces in nursing students, in which participants fill out questionnaires based off of numerical scales. As such, these responses are all assigned numbers to represent them. The data is then translated into percentages, averages, medians, etc., all of which may come with or without statistical representation. However, what then becomes of all the variables not encompassed by these studies, yet still remain, invisible? It is extremely important to analyze the problems "surrounding death" among nursing students. Qualitative research in this field could be one of the most instrumental tools in detecting anxiety and worry in students.

A program to "adopt and foster effective coping strategies" and an anthropological-based training about death would be very useful in the preparation of future nurses. Throughout the care process for a terminal patient, a nurse could also develop mental disorders that must be detected early on to help diminish the appearance of "burnout syndrome" and foster the acceptance of having to "live with death."

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