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Enfermería Global

On-line version ISSN 1695-6141

Enferm. glob. vol.17 n.49 Murcia Jan. 2018  Epub Jan 01, 2018

http://dx.doi.org/10.6018/eglobal.17.1.260491 

Originales

Narrative strategy for an approach to the process of death

Montserrat Guillaumet1  , Gemma Amorós1  , Adelaida Ramos1  , Beatriz Campillo1  , Mª Antonia Martínez Momblan1 

1Escola Universitària d'Infermeria Sant Pau. Adscrita a la Universitat Autónoma de Barcelona (UAB). Catalunya. España.

ABSTRACT:

Objectives

Based on teaching experience of reflective practice, we aim to explore the description about personal experiences around death in second degree nursing students. We intend to understand the environment process of death, and its importance in nursing care.

Methods

Qualitative study with a hermeneutic phenomenological approach. Participants in this study were students of “Therapeutic communication” recruited in the classroom, during the 2nd lesson of the subject. Participation was voluntary and each student could choose between 4 different topics. Data was collected using reflective writing. The texts were analyzed using qualitative content analysis with semantic approach.

Results

Several units of meaning were identified and subsequently grouped in 8 categories where 6 different topics emerged: Impact of the notice; Farewell; Evocation; Coping; Beliefs and values; Personal growth.

Conclusions

Raising awareness of own experiences in the process of death can help to define relevant aspects that may improve professional care. The recognition of the behaviors observed during the grieving process contributes to optimize the sensitive accompaniment of people in processes around death. The pedagogical chronicle, as a teaching strategy, is useful in nursing education given that allows the comprehension of the significance and impact of complex situations. Reflection on the lived experiences and contrasting them with the literature allows guiding the process of comprehensive care.

Keywords Experiential Learning; Death; Nursing Students; Reflective Practice

INTRODUCTION

The death is an inherent natural phenomenon to the human condition that shares biological, social and cultural appearances, as well as psychological and emotional 1. The western society lives it with distance, knowing that it is a universal fact, until you have to face it in first person or presents in the near affective circles. When this occurs, the experience does not leave indifferent; it reviews the sense of life, biographies, bonds or the vital experiences; emotions and feelings flow, memories are recovered and, in occasions balances and project guides are made.

The biography of the people includes losses and absences that, along the vital path, model the how to face the phenomenon of death.

Accompany the person that die and to his surroundings requires mastery. In the current context governed by the speed and by the informative saturation, has lost the sense of the accompaniment and the instruments neither the strategies to accompany to die are unknown (2. Provide an intervention of quality on surroundings to the person, in the last stretch of his life, requires having skills in the physical care, psychological, social and spiritual (3. Of the same way, requires of a deep introspective work to face the death with maturity and recognize the occasion like an opportunity for personal growth and self-knowledge, from the understanding and acceptance of the process of end of life.

In the genetic engineering era and interplanetary trips, the sanitary professionals feel uncomfortable if they have to speak with his patients of something so common like death 4. Like this, the last stretch of the life, keeps on being a professional taboo that is hide and avoids. The nursing students arrive to university being more or less conscious that they will have to face in the future emotional situations of distinct intensity 5. The boarding of the care around the death, in the Nursing Degree, requires thinking in didactic strategies that approximate the students to the complexity of the phenomenon, to the identification and management of the own emotions and to a suitable therapeutic intervention to avoid, in a future, attitudes of rejection, escaped or insecurity 1. All this turns into a formative challenge (6.

Form and educate students for a care centered in the person, requires an approach humanist from establishing the necessary and sufficient conditions to promote his deployment 7. This means that the teacher and the student elaborate a personal process based, according to Rogers, in three main attitudes: the authenticity, based in the sincerity and the congruence; the unconditional acceptance based in the appreciate and the positive consideration and finally, the empathic understanding based in listens it deep and active of the meanings that the person helped attributes him to his relate 7.

All this drives to the establishment of the therapeutic communication, indispensable in the deal and in the care of the people in next situations to the death. Likewise, it comports to go further of the interpretation reductionist of what occurs to a body and like this, consider the meanings that the person gives him to his history 8. Finally, listen the narrative of the person is to care not from the illness but from his experience, his meanings and of his priorities.

The training of the students of nursing contemplates distinct appearances of big importance, between them, the development of the critical thought, the capacity to learn to learn, and the applicability of the knowledge in his professional future. The learning like process of construction of knowledge by means of the reflection and to give sense to the experience, not only is produced in the clinical practices, but also it promotes in the classroom, from the analysis of lived experiences.

The learning experiential, developed by Kolb, based in the works of Dewey and Piaget, relates with the distinct appearances described previously 9)(10. It sustains that it is a process that allows to deduce concepts and principles from the experience, to guide the behaviour in new situations. The same author defines the learning like “the process by means of which creates knowledge through the transformation of the experience“, and describes it like a route by four successive and cyclic stages: 1) the concrete experience; 2) the reflexive observation; 3) the conceptualization and 4) the planning of future actions (9. Andresen Et al11 attributed the use of significant personal experiences like a better criteria of learning through experiences.

The nuclear idea, in the learning from the experience, supports that knowledge is achieved through the actions generated by a concrete experience. For this, is fundamental a reflexive process, an abstract conceptualization on this experience that will allow to build knowledge and, at the same time, skills from her. These new knowledge and skills will generate a continuous process of creation of new learning.

Consider from the own experience is to listen and identify the distinct symbolisms that give him felt. For the students, the four quoted stages by Kolb, can be a conductive movement to the consolidation of the learning with the purpose to be able to offer in a future an understanding care centered in the person 12.

In this context, the study pretends: explore, from a didactic experience based in the reflexive practice, the narrative on a personal experience lived surroundings to the death, of students of 2º course of Degree in Nursing; and comprise the process surroundings to the death and his transcendence in the practice of the nursing care.

METHODS

Qualitative study with an hermeneutic phenomenological approach inspired by the philosophy of van Manen. This author sustains that this approximation orients to the description and interpretation of the essential structures of the experience lived, as well as to the recognition of the meaning and pedagogical importance of this experience 13. For this, proposes empirical activities (narrative of an experience lived) and reflexive (analysis and thematic reflection) that contribute an answer in front of possible deficiencies that affect to the pedagogical theorization in general, awarding understanding to complex phenomena.

The study was carry out in the Escola Universitària d'Infermeria Sant Pau, of Barcelona (Spain) between September and October of 2015. The participants were 26 students, between 20-47 years. The criteria of inclusion were: can relate an experience related with a significant near death from an intimate and personal slope; be enrolled in the subject “therapeutic Communication”, during the 3rd semester of the career, of the course 2015-16. The participants were drafted in the classroom, in the second session of the subject. The participation was voluntary and the student chose between 4 distinct subjects. The most notable characteristics of the students were:

- Have not realized still practical clinical.

- Those that already worked in the sanitary field, not having experience neither training in the handle of complex communicative situations, from a perspective of the nurse care. His look, therefore, was without theoretical argumentation.

The didactic experience consisted in three phases: 1) narration written on the experience lived; 2) analysis of semantic qualitative content and 3) reflexive thematic session from the results obtained and of his contrast with the literature.

The data were collected by means of reflexive writing elaborated in the classroom and collected when the session ended. After his analysis, the reports returned in a personalized way, by the professor researcher.

The texts were exanimate by means of analysis of semantic qualitative content 14. It proceeded to a “floating reading”, that consisted in several readings with the end of approximation to the content and to aim hypothetical subjects, from impressions. Then, units of meaning were identified from similarities of sense, by means of signalling in the text, of sentences or groups of words with a cognitive meaning. Then, classified in categories and finally in subjects 15.

The members of the research team did a review by pairs for agree the classification. Each unit of meaning contained original fragments that constituted the unit of analysis, of which obtained the notable appearances for the care, in a first moment in an inductive way, and in a deductive way afterwards, contrasting with the literature (Table I).

Table I Experience surroundings to death. Analysis method 

The students were informed on the aim of the study and the educational strategy. It guaranteed the anonymity and the confidentiality of the information. For this, the writings were encoded with the letter E (student) and a correlated number according to the order of delivery. With the purpose of not identifying the narrations of the boys, in minority with regard to the girls, the results were presented in feminine.

RESULTS

Considering the aim of the study, the analysis of the texts allowed to identify the units of meaning that revealed the structure of the phenomenon of investigation. Later, they grouped in 8 categories, of which surfaced 6 subjects: Impact of the news; Farewell; Evocation; Facing; Beliefs and values and, personal Growth.

To continuation describe the six subjects (titles, in bold) surfaced from the categories (in the text, in bold) that, to his time built from the units of meaning.

News Impact

The initial answer, produced by the impact of the news of a death of a significant person, appears expressed verbally to split, on the one hand, of emotions and feelings (Table II) and, in a second place, by behaviours s by these, through the body.

Table II Subject: Impact of the news 

Like this, in a moment initial, discerns a defensive answer, with the negation of the reality, incredulity and emotional blockade: […] it did not want to accept his course, could not understand it, did not want to accept the reality (S6);[…] it could not it believe, he was so strong, so strong that could not be happening him (S4); […] it could not believe what finished me to say (S1); […] that remained in shock, could not react (S2, S7).

In the same stage, identify primary emotions like the sadness: […] I felt me very shattered inside(S7);[…]I felt me empty (S9,S11);[…]it felt a very big penalty (S1,S21);[…]those moments of sadness (S18).

The sadness, to his time, expresses with distinct intensity; like this, it observes the impotence: […] never I felt me with so much impotence (S8, S10, S26); and l abandonment: […] I felt me abandoned (S15); the solitude: […] as of solitude, in spite of being surrounded of so many people (S13); […] I felt me alone (S11, S18) or the depression: […] like a species of depression (S5).

The second primary emotion expressed, in the initial moments to know the news, is the anger, expressed with distinct intensity: […] it felt ire, anger (S12); […] I went in rage (S19); […] it felt me raging and angered (S24).

The fear, as third primary emotion expresses also with distinct strength: […] have fear to go back to suffer (S10). […] It was so distressed (S9, S15).

Finally it appears the joy, manifested in terms of release: […] I felt joy, after what had suffered (S25); I felt a mix of sadness and release because it had left to suffer she and the family (S17).

Some students show how, in the course of the time, the feelings transformed, perceived combined or appeared of new. Like this, it identifies the fault, related with the sadness: […] I seat me guilty of not to have it accompanied during his last days (S10); and the frustration, the anger and the car reproach, related with the anger: I remember my penalty that now has turned into anger, impotence and frustration (S24); […] today I regret not having gone more visiting (S15); Still I have the spine nailed by have not cried in the moment, when they said it to me (S20).

The impact of the news generated behaviours linked like emotional expression through the body (Table III). In this sense, distinguish distinct demonstrations focused on the body: […] it seated me like a slap (S8); […] it screamed, it cried while it struck the frame of the door (S18); […] only see him the face, already thought that something had happened (S2); […] it could not leave to cry (S5, S9); […] I arrived with the trembling legs (S1).

Table III Subject: Impact of the news 

Farewell

Giving the last goodbye is one of the appearances that the students experienced like taking of consciousness of the loss. His narratives show how the rituals of farewell approximated them to said connection: […] him did a kiss and said him: “always you will be with me” (S18); it did not want to die alone and went to fulfil his wish (S23); I took him the hand strongly and approached him his favourite photo (S17).

The not being able to sack comports expressions of pain: […] it does a year and today even, hurts me have not been there and not being able to sack me of her (S6).

Like this, they perceive feelings polarized in this category. While those who could sack felt tranquillity, satisfaction, gratitude or calm, those that could not do it, expressed fault, frustration or pain.

Evocation

The experience of a process of death induced to the students to the reflection, through the evocation of distinct appearances, any of them reiterative, like the concretion in the chronology of the facts, remembered in distinct formats: […] happened 3 years ago (S6); […] 17 October 1986. Memory when I received a telephone call with an unexpected message that she had died (S9); […] they were the 00:30h of 8 February (S22); […] it was between Christmas and kings (S3).

Another of the appearances significant remembrances, described in the narratives, is the review of the experiences shared with the person died: […] know that you will not be able to share more moments neither experiences with him, that will not be able to neither do a so simple thing like going to buy the bread (S2); all those moments in which it had answered badly, with ugly words, screaming him (S8).

Also it emerges the memory of concrete appearances of the deceased: […] already it has happened almost six months and always remember it raising the head in high, like a soldier (S1); […] today even I admire his strength in the last moments of the life, and remember it happy, as he was (S22).

Facing

In relation to this subject, the stories reveal appearances related with the personal management, from the introspection. reveals An individual adaptive answer in front of facing of the loss; like this it perceives isolation: […] it did not want to know at all of anybody and happened almost a month shut home (S1); and duel complicated and acceptance: […] I could not do a process of suitable duel. Till lately, I could not manage it and now I thrill me, but it is distinct, do not have that weigh that had and that did not leave me face the death like a natural process of the life (S2); Know that you will not be able to share more moments; change of priorities: […] from that day changed. At the beginning it did not eat, I did not sleep, it did not care about me. My smile disappeared and matured of hit. I did not have time to be teenager (S7).

Beliefs and values

The stories transmit transcendence through expressions that show beliefs sustained in the hope, through a spiritual connection with the died: I Know that he is very (S12); […] God decided to carry it to his side (S18); I Know that it always will be with me protecting me (S6); […] after so many years, follow dreaming with him and in all the dreams ask him pardon (S8).

Personal growth

Finally, some narration allude to purposes of change and future projects, after living the experience of a significant death: […] From that moment changed my way to act with my family (S14); The fact to study Nursing arose of this experience (S16, S4); […] I value really the important things of the life (S5).

In the Table I, shows the relation between the subjects obtained and the authors with which were contrasted in the third phase of the didactic experience with the students.

DISCUSSION

The results of this study show that the students, in front of an experience surroundings to a death, especially felt when bursting into in his near circle, transit by a process of duel with big emotional fluctuation 16)(17)(18)(19. The distinct mood states mutate like the same life and each person transit of particular way and no predictable 2, from the initial impact of the loss until the adaptation to her 20. In the professional field, the identification of the events felt allows to the nurse comprise the experiences. His intervention bases in the respect to the privacy, facilitate the emotional expression and to his time respect the silences, accept the changes of humour and encourage the expression of the loss 20).

The emotiveness, can accompany of corporal demonstrations like the tears, the gestural language, embraces, agitation, expressions of rage or perceptions of corporal changes, that complement the intensity of the feeling 2)(18)(20. The corporal expressivity becomes because it goes further of the words 2. The humanists nurse include the presence, the compassion, as well as the mastery in the no verbal communication: the gestural language, the look, the touch or the corporal movements during the accompaniment 2)(18)(21.

The farewell plays an essential paper in the loss of a be wanted. It is a symbolic act of gestures and words that ritualize the universal (2 transfer. It allows to seal a relation, a stage and to his time take full consciousness of a separation. It is a painful act and to his indulgent time that relates closely with the symbolic universe of values and beliefs, with meanings sociocultural and with personal paths 20).

The understanding care allows to give space for the ritual of the farewell, accommodate and provide comfort, respect the symbolic expressions without judging, offer privacy and expertise in the art of the therapeutic communication 18 adapt the surroundings for an intimate and only experience 22.

The process surroundings to the death generates evocation; remember is a duty, since without memory, there is not identity 2. They evoke objects, dates, experiences shared, words, facts; all this purchases a particular meaning. The memory allows reconstructing what has lived; it provides structural order ordering and retaining the lived 17. The memory connects with the loss and accompanies the adaptive process; it drives to the vital review, to the reflection and also to strengthen the facing. This, to his time, can be difficult when it denies the death to social level, included the sanitary professionals, that require a double effort in the attention to the next people to the death 21.

The competent nurse that identifies the demonstrations observed and that shows sensitive to the vital experience of those who accompanies can provide more elements to improve the quality of life through the care holistic 19)(20. Know accompany is not leaving only to the that does not wish to be only, situate and respect the rhythm of the another, share silences as well as have a good command of the expressive capacity and receptive and a correct emotional management 2. Being present does not only consist in being with another, but in being in the another this contributes to that the physical presence transcend to emotional presence 2; a presence that accompany and reassure, and that was not, as it occurs sometimes, an invasion of the another 22.

The succession of stages in the time, comports introspection and transcendence. The beliefs, religious or spiritual, orient and sustain the hardship 17)(19. They allow looking for again a sense to follow the vital course 2. The nurse respects the singularity of each person and comprises his frame of reference from the way in which it understands the life 20. The care of people in process of duel generates in the own nurse the confronter his look of the world, his finitude and his beliefs and values 20; a similar circumstance to the experienced by the students during the didactic experience presented.

In this sense, Smith sustains that to ensure the learning does not suffice the experience, but this has to go accompanied of a process of personal reflection in which it builds meant from the experience 23.

An overwhelming experience, like the related, does not leave indifferent. Over time, they produce changes in the factors related with the personal realization 20. They arise projects and purposes as a result of the introspection and of the balance of the personal biography.

Comprise the phenomena linked to the duel allows to provide cares to the people that transit any stage of the process, with an approach humanist. Nurse with a vision of wide spectrum means to comprise and respect the answers disperse, and sometimes shoot, that present the people attended; in this sense, the intervention nurse heads to cover the specific needs of the people in each stage facilitating the traffic by the duel, from the respect to the autonomy 22. The pedagogical relate allows to sensitize to the students of the importance of the therapeutic communication and of the integral approach centered in the person, when illustrating the complexity of the cares 24.

The analytical introspection, from the discussion and of the confrontation with the literature, contributes to the student the taking of consciousness and the sensitivity to the care in complex stages. These cognitive processes produce thanks to that the narrative pedagogy puts in the center the collective thought, the dialogue for the interpretation of the experiences from multiple perspectives in the practical nurse, with the purpose to discover new meanings, arrive to consensus and conclusions 25. The narrative, like the affective learning, can improve the acquisition and application that facilitates the development of meaning shared between the students and, therefore can increase the competition of the knowledge and of the praxis 24.

CONCLUSION

Take consciousness of the own experiences during a process surroundings to the death, allows to identify significant appearances during the experience of loss that can enrich the stage of professional care.

Recognize the behaviours observed in front of the impact of the news of a loss, value the importance of a farewell, consider the expressions of facing in the distinct phases of the process, comprise the stories from the evocation of some facts, respect the beliefs and values in front of a loss and identify expressions that denote transformation and personal growth, sustains the sensitive accompaniment of the people in processes surroundings to the death.

The implementation of the pedagogical relate is useful in the training nurse since it makes possible the understanding of meanings and of the impact in front of complex situations and personal transitions. The reflection on the experiences and the contrast with the experts, allows to guide the process of the understanding care.

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Received: June 06, 2016; Accepted: August 30, 2016

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