INTRODUCTION

Nursing lives day by day in its practice the death of people due to a disease, within its functions it must support and help in the process of dying and how to face the transition of the death of people it cares for or patients and loved ones from this, that is why a warm, favorable, and supportive attitude is expected with the needy ¹. The importance of the academic training of future nursing professionals stands out precisely in promoting care, throughout their training students begin to observe different phenomena and are open to reflect on them, which means that when they live the first experience in front of the end of a person's life, doubts arise and a certain fear of not knowing how to act before the execution of clinical practice, causing the lack of enjoyment of the experience when providing care ².

Death is a phenomenon that results from the extinction of the homeostatic process in a living being and thus leads to the end of life; death is the permanent cessation of consciousness of the organism in all its forms, as well as the loss of the functions of the organism as a whole ³. On the other hand, Weismann makes a distinction between external and internal causes of death, noting that with age there are certain changes in the tissues that consume their functioning ending up leading to what is called normal death, or indirectly lead to death, making it unable to resist harmful pathological influences ⁴. This concept of death is seen differently by the nursing professionals, since it is directly linked to their ideas, tasks, customs, and experiences; therefore, attitudes to death are different for each person ^5,6. At present, there is rejection and denial of the issue of death, causing the health professional to put up a barrier and avoid dealing with it at all costs ^7-9; Studies show that there are attitudes that are replicated in professionals, some of them are: distancing, avoidance, break and emotional dissociation ^1,5,10.

During the development of clinical practicum, students probably do not have the necessary tools to feel sufficiently trained to face the death of a patient. (10), since it is a new and difficult event to face, for this reason the intention was given to understand the first lived experience of the student about the phenomenon of death, since the lived experiences impact on the training of the nurse in their personal and relational and academic life ¹¹.

The objective of this study was to understand the lived experience of the first contact with death in clinical practicum of nursing students.

METHOD

It is a qualitative study with a phenomenological approach. Phenomenology as a philosophy and as a research method addresses the search for meanings and essences of lived experiences ^12,13, allows to reveal the experience from consciousness, Max Van Manen takes up the concepts of Husserl's phenomenology and mentions that phenomenology as a method it is not limited solely to an approach or to a simple description or alternative, but to the search for the essence of consciousness in meaningful experiences ¹⁴, therefore and in order to understand the student's lived experiences, the methodological reference of Max Van Manen ¹⁵ was retaken, which allowed an approach to the phenomena that are essential in nursing care in the process of dying and death.

The setting of the study was a public university in the state of Aguascalientes, Mexico in the period of October 2020 to January 2021. For the selection of participants, the selection criteria were: nursing degree students who attended between third and eighth semester who stated that they had their first contact with the death of a person during clinical practicum; To select the participants, a virtual invitation was sent through a written message to the class leaders in conversational groups where the name of the research, objective, selection criteria and researchers were indicated, so the participants with the criteria contacted researchers to express their desire to participate.

An intentional sampling was carried out, obtaining a sample of seven nursing students according to the established selection criteria, reaching the saturation of information, in such a way that through the analysis, repetitive and relevant data were obtained classified in various units of meaning to understand the phenomenon of lived experience and group them into themes ^16,17. The data collection was carried out through an individual phenomenological interview (18), through the guiding question: "How was your experience of your first contact with death in clinical internships?" and using some random questions. The phenomenological interview allowed a dialogue with the participants, this in turn facilitates the encounter with the lived phenomenon by determining the characteristics of the lived experience ¹⁸.

The interviews were conducted by two student researchers who were trained to do so, and they also had the supervision of two researchers who are experts in qualitative methods after each interview, which were based on empathy on the part of the interviewers and in turn, the subordination status since they were not direct colleagues of the researchers and that no participants were taught classes. The interviews were audio recordings with the consent of the participants. The average duration of the interview was 28 minutes. Due to the COVID-19 contingency, five interviews were conducted in virtual mode through the Google Meet® platform and two in person, maintaining the security protocol issued by the Ministry of Health of Mexico.

The data collection was carried out through an individual phenomenological interview¹⁸, through the guiding question: "How was your experience lived before the first contact with death in clinical practicum?" and using some ransom questions. The phenomenological interview allowed a dialogue with the participants, this in turn facilitates the encounter with the lived phenomenon by determining the characteristics of the lived experience ¹⁸.

All the interviews were faithfully transcribed by the researchers into Microsoft Word®; Once transcribed, a first analysis was carried out by each researcher, the analysis was of an artisanal type through the phases of the phenomenological-hermeneutical method according to Max Van Manen, which consisted of three phases: descriptive (collecting the experience), interpretive (reflection on the experience) and description plus Interpretation (writing-reflecting on the experience and the creation of the phenomenological text) ¹⁹. The interviews were worked on in Tables in Microsoft Word® highlighting units of meaning, themes, and synthesis of the essence of the units. The topics were considered by consensus of the researchers.

The research protocol was approved by the Research Academy of the Department of Nursing of the Center for Health Sciences of the Autonomous University of Aguascalientes, obtaining the AEI-09-20 code that had the basic guidelines for its development, and it was also met with the ethical criteria of the Regulation of the General Health Law on Health Research. The participants gave their informed consent, always taking care of the confidentiality of the participants, providing them with a code as identification ²⁰.

RESULTS

Considering the characteristics of the students, 57% are female and the remaining 43% male, the age range is between 20 and 31 years old, with an average age of 23 years, in addition to all Participants were in the third to eighth semester of a nursing degree. Five themes emerged with their respective units of meaning, because of the analysis, which are presented below:

1. Emotions encountered before the impact of death. These are described from the confirmation of the death of the person, when being immersed in the phenomenon of death the students expressed concern about how this news will be given, they refer that it is shocking, to such a degree that they have cried or want to do so. Participants describe that it is like being in a 'state of shock'; expressed as a “neutral situation with different emotions at the same time”, “empty”, “sadness”, “impotence”, “fear”, the latter not of death but of the process that derives from it; in addition to "despair", "frustration", a confusion of their feelings and an impact on what is perceived; As a result of this, they avoided acting spontaneously, they thought that for expressing their emotions they could be judged, making them perceive a barrier that prevents them from acting with confidence, being immature or unprepared to face death. As mentioned in the following speeches:

“I went to a corner of the room to cry for myself, for me, because even the doctors are looking strange to me, just like this one that [...] I went to the corner, because I was ashamed, I didn't want him to see me nobody crying because well, for me…, I don't know, that is, they were going to judge me" E2F.

"Eh, regarding that death, I think it was the one that impacted me the most, I think at the time, because I didn't feel prepared and mature enough to take actions like that." E4J.

"I don't know how to describe that feeling between relief and sadness, it was a shock of emotions." E5O.

“I think it all comes down to fear. Fear is the one that does not, [...] it does not let you, I feel that it is like a huge barrier that does not let you do it, as if you wanted to do it, but that would make you back [...] it was a nuisance for the lady. " E1L.

2. Uncertainty about death. It can be identified that the students were in a state of not understanding what was happening when being the first contact with the phenomenon, uncertainty arises accompanied by the impact of the event, questions began to arise when witnessing the cessation of life, about what care They had to provide the patient or the "correct" action that the situation required, likewise, they asked questions such as "Why is it happening?", "What is happening with the patient's family?", "What is happening with the staff? “Who is witnessing it?”, and “Why do they act the way they do?”; Furthermore, they indicate having noticed the reaction of health personal and some family members who witnessed the event, causing it to influence their actions. As the following speeches put it:

"Well, it was very strange, that is, for the first time I think it did affect me a lot, because it was something that I did not expect, and I was not aware of anything" E2F.

“The screaming began and everything from the relatives, the nurse was also in shock [...] she went to the bathroom to cry, […] then if you realize the impact that a death has on" E4J.

"With a certain point of uncertainty [...] What do I do now? How should I act? [...] I had a hard time assimilating that part of saying she died and now what am I going to do? or What's next?" E5O.

"I think hehe, that was one of the most difficult things in my life at that time [...] putting cotton in every hole of the human body [...] is a strange experience, to say, I remember that I had that doubt to say and “Won't it hurt?” It was a thought that I had to say and “Won't it hurt the lady? " E5O

3. The nurse-teacher-student relationship. In this topic, two opposite situations , on one hand, the student perceives how the response of the health personnel to the event was, expressing that they differ in the way the professionals acted, since they consider that the care for the deceased person is distant and this is seen by professionals as something normal but cold, likewise, they refer to the attitude of teachers, mentioning that they commented on the phrase "it will be your day to day", resulting in "normality". The following speeches express this position:

"No, the staff, they don't really explain anything to me, they just told me he's going to die, we don't want him to die on the shift and that's it" E5O.

“If the feeling came to me when I talked about it with my teacher and she told me it was normal, it was normal, I mean it was going to be part of my day today, but she did not give me time, she told me to return to the service" E6E.

In addition, there emerge on the other hand, situations on the part of the nurses in the area towards the student where, due to their actions at the time of death, the students managed to find tranquility, guidance or support and that at that moment they appeared as a guide, since They have more knowledge and experience to adequately deal with this situation, and they also pointed to their colleagues as a source of trust that helped them assimilate and control their emotions before and during the phenomenon. As demonstrated in the following speeches:

"But what shocked me the most was seeing the nurse approaching her mother saying what do you want your son to be called? And that was like, like, like a little ray of light" E2F.

"The teacher [...] has a little more experience of knowledge before these scenes, [...] he was the one who was telling us: do this, he calmed us down" E4J.

4. Sense of professionalism in the face of the phenomenon. Students are described from a professional nursing perspective; Guiding themselves through their values ​​such as: respect, empathy, confidentiality and acting with humanism, they indicated feeling satisfaction and emotion for the interventions carried out at the end of life, they highlighted their own and nurses' attitudes towards the deceased patient and family members that they are living a grief or the "pain of loss" that was of great moral contribution making them feel in a certain way comfort and relief when they see something positive in everything they have experienced and / or find resignation for the loss. As the following speeches put it:

"Talking with her and being close ... this ... hers [...] mmm made me feel good, that is, I was not really alone if her family member was missing [...] I felt that in a way I was there with her" E6E.

"When I wear the uniform, I do believe in myself, I try to believe in myself a lot, that I am a nurse and ... I have to help patients or make them strong" E1L.

“I felt very satisfied for the person because I knew that I was treating him with a lot of respect, I knew that I was doing it for a good [...] more than anything than with all those good emotions that I had, with all that motivation to make it feel good" E7A.

5. Memorial reflection of the phenomenon of dying. Sharing their experiences made them reflect on being able to improve their actions and that nursing has given them courage to face the situation. In addition, they refer that the fact of remembering made them transport themselves to the moment and relive the feelings that invaded them in said event, they narrate that living this experience left something significant; highlighting that what they most remembered of that moment was the shrouding process, the actions of the person before his death and the way in which the family reacted. They indicate that the situation changes "from one second to another", that that moment was "fast”, and they could not act or respond to it. This is expressed in the following speeches:

" What marked me the most was this was the before and after because I had to shroud her [...] it was the impact, it lasted as I don't know how two weeks dreaming of the lady because it was my first contact with her" E6E

“Seeing a person who has, in a few minutes he has just been fine, well alive and with vital signs and suddenly see what he no longer has, like from one second to another you realize that everything changes in a second, right?? Nothing is guaranteed" E1L.

"That moment was quick, it was instantaneous and at that moment I couldn't do anything afterwards that was when I intervened, uh, shrouding [...] that was my intervention maybe" E6E.

"In fact, I'm a little shaking, because they reminded me of a very strong experience [...] I'm talking with, with feelings, with what I really felt and well, right now they made me transport myself to that day" E7A.

DISCUSSION

The experience lived by the students in front of their first contact with the death of a patient is given in the first place by an impact on the news of the cessation of life since this process causes the professionals and nursing students in particular an impact that influences in his acting and his professional life ⁶.

This first impression affects the way they feel concern about how this news will be given and their actions in this situation, since it is not known how to react to it because during the transition from life to death the nursing staff adopts different mechanisms of response. defending, such as justifying death with the age of the person; when it comes to the death of an older adult, this reaction is usually present ⁵.

Regardless of this, when you are inexperienced you react spontaneously with different emotions that come together in the impact produced, getting to position yourself as one more spectator of the phenomenon when trying to have an explanation of what is happening. This first reaction begins by configuring the experience and contact with the lived reality, it generates in the student a special attention, since it is a phenomenon that impacts.

Students experience a series of more specific reactions, such as a blockage due to not knowing how to intervene, due to the fact that death provokes endless emotions and feelings; some of them as fear, anguish, uncertainty and suffering ²¹; The students express an emotional encounter, a feeling of uncertainty and with this they try to respond to the fear that invades them due to the various reactions, which interferes with the care of the patient and their relatives, by not being able to express words and perform actions of support. Some of these reactions are unexpected when witnessing death, there is denial of the lack of response from the staff, since they act in a normalized way that in turn strengthens indifference, self-absorption, and dehumanization ²².

Students differ with the way of acting of the nursing professional, since some exercise care towards the deceased patient marked by a distance, the literature indicates that this can be an emotional barrier to the situation ¹; However, strategies are needed to support both the nursing staff to face these situations with a sense of humanism, since the students learn from the daily dynamics in which they are involved, so the actions of the nurses are perceived by them .

All of the above is combined in the student, who, being her first approach, seeks how to face the phenomenon of dying, but it is one more challenge for him. On many occasions, students do not have the necessary tools to face the death process, stating that the study plans are scarce in subjects related to death ^6,23,24, which is why insecurity arises because they believe that they could be judged for expressing their emotions and for perceiving themselves unprepared to face death. This lack of preparation may not be generalized in the study plans, but it does emphasize the need to review them and include tools and strategies on death, how to face it and how to manage it, not only focusing on post-mortem care.

Likewise, the students referred to a type of "normalization" of death and although the process of dying is normal, they reported that the teachers expressed to them that it was something that would always occur, but they perceived it as a distant message; Not so much, with the knowledge and resources they have at their disposal, they found support Figures in the staff or teachers who serve as support, providing confidence and emotional support, based on their experience and knowledge.

Likewise, sometimes teachers do not provide the necessary support and behave apprehensively, because they do not have the necessary training to talk about death¹, this is relevant in the sense that the teacher is the Figure formative of the student and is the one who provides the basis and support, not only academic, but also personal and human, so it is imperative to address these situations in teachers and that they transmit to the student confidence and an attitude of respect and reflection before the process die. On the contrary, some students referred to the teacher's support, which, added to that of some nurses, sustains the experience lived in an environment of trust, security, hope and comfort.

It is necessary to consider training in death that includes students and teachers in a dynamic relationship of learning about the process of dying ²⁵, even so it is referenced that the teacher continues to be a Figure that can support in understanding the end of life of the student (2,24), for this reason it is imperative that both learn and reflect in clinical practice about this phenomenon and that they can generate meanings that lead to interventions in favor of the deceased person, the family and themselves.

Even when students are involved in various emotions, they try to act with professionalism through what they learned during their training, they seek to offer care in the transcendence between life and death, according to Orozco-González, they act with humanism, respect and confidentiality, granting dignified care ¹⁰; Likewise, with their knowledge there are actions that contribute to finding comfort or satisfaction in what has been done, in the same way, it gave them hope to carry out better care in the future; because professionals use their knowledge from their social experiences to face complicated situations such as death ²⁶.

The whole phenomenon of death, although it is experienced from a lack of preparation, is also perceived as a learning experience in the student that leads them to reflect on it and what triggers sharing it, stating that they do not feel capable of providing support to family members or to the patient himself during the dying process, this is already a reflective process of the needs felt by the student, for which a better preparation to possess knowledge and attitudes based on ethical principles would be useful ¹⁰.

Finally, they assured they had being involved in a time that they do not conceive of understanding in the face of the reaction of the dying process, which is why nursing needs more preparation to be able to understand how ineffable the transcendence of life-death is and to be able to provide spiritual care, because Without a doubt there will be incomprehensible doubts about what this process generates ²², but despite this perception, undoubtedly, students are left with great learning based on humanism and the approach towards the deceased person, as well as the family.

The results focus on the lack of training on the one hand that triggers a series of emotional situations ²⁵, however, the student is also a human being endowed with a reflective capacity, which allows him to face the process from a human perspective , where affection, humanism and human dignity are the source of learning about care at the end of life and death ², for this reason it is necessary that, as evidenced in the speeches, the student has a space to reflect on death and what it requires in your training to face this process.

Phenomenology allows addressing that essence of consciousness regarding a lived experience, conFigures it and endows the student who experienced it with a representation about what was lived, the phenomenon of death in the first clinical practicum without a doubt conFigures the academic life of the student ¹¹, but also from his teachers, the deceased patient in his dignity as a person and the family who at that time will go through a difficult time. The student is also conFigured as a human being with a sense of humanism that will surely reflect in his future experiences.

The phenomenon of death in the first lived experience highlights the lack of preparation and knowledge about death, but also the opportunity to grow as people, signifying death and the process of dying.

The limitations of the present study were that due to the COVID-19 pandemic it was not possible to carry out face-to-face interviews, however, it is also a strength since the use of digital media for its realization and the rich information obtained is evidenced. Another limitation is that the results cannot be generalized, but they do create a reflective point to consider that the teaching of dying and death does not focus only on care after the event or on only theoretical concepts, but on reflective spaces throughout the training of the patient. student.

CONCLUSION

The experiences of nursing students show that they have difficulties in coping with death and that throughout their experience they present a feeling of blockage, accompanied by emotions, highlighting fear as the main obstacle in caring for the deceased patient and the patients relatives; but despite this, it is not an impediment to provide the necessary quality care, because nursing has empowered them to want to cope.

The continuous reasoning about the experience of death made them think that it goes beyond something intangible; For this reason, it is considered that a deeper preparation on what to do before the process of dying, can be favorable for their acting as a professional; also recognize the pedagogical importance of the students' experiences in the phenomenon, observing and understanding the needs of future nursing professionals to initiate the improvement of thanatology training and care in the dying process of the patient. In addition, it is recommended that educational institutions or programs include psychological support for students, along with training in these contents.