Problem-Based Learning in Teaching of Thanatology in Undergraduate Nursing Program

Objectives: To report a methodological experience of learning-based on problems in the discipline of Thanatology. Method: Experience report of professors of the baccalaureate degree in nursing using problem situations influenced by the methodology of questioning and problem-based learning. Results: The elaboration of three problem situations broadened the development of the formative process in Thanatology, favored reflections during the program of the discipline and approached the theory of real situations experienced by the students. Conclusions and implications for practice: This methodology was assessed as a viable and low-cost strategy in promoting empowerment on issues of death and dying. In addition, students self-assessed as reflective agents and builders of their own personal and professional growth.


INTRODUCTION
Thanatology is an interdisciplinary science that focuses on the study of death and dying.In recent years, we have studied the process of death and dying, but it is still a challenge to accept the theme with naturalness and resilience.In addition, the phenomenon is influenced by age, physical problems, psychiatric conditions, ethnicity, religiosity, personalities, sociocultural experiences and beliefs. 1 Nursing is a profession that cares for the human being throughout the life cycle and is also present at the time of death, whether in home care, hospital care or in emergencies.However, nurses have difficulties in attending patients with reserved and terminal prognosis, since the proximity of their death can generate impotence and guilt in the professional involved in the care.Death proves to be a failure, generating reactions and dysphoric feelings, such as sadness, deception, nonconformity, dissatisfaction, guilt, anxiety, depression, fragility, self-doubt, low self-esteem, injustice, helplessness, failure, impotence, anger or frustration. 2ursing programs offer little space for discussion of Thanatology, leading to an incipient practice.Professors report a gap during the academic training and perpetuation of this practice due to the lack of theoretical preparation and small workload in the disciplines, with prioritization of nursing techniques and the care of the physical body, evidencing the need to approach the subject in an interdisciplinary and/or directed way, through complementary discipline. 3hanges in the paradigm of nursing education imply the requirement of professionals who, besides the technicalscientific knowledge, have the skills to deal with their own feelings and use them with humanized attention to the care provided to the patient and their family.
For this, the academy and health institutions need to develop skills in students and health professionals, not only in technical aspects, but in issues related to emotion, focusing on the terminality of life and the development of intervention that provokes changes in the relation of the subject with aversive changes of the environment and, consequently, adjustments for the confrontation of stressors associated with treatment of death. 4,5Critical thinking is one of the most important criteria related to the development of skills, which are intrinsic to the improvement of nursing professional practice. 1n Brazil, the Guidelines for Basic Education (Diretrizes de Bases da Educação) have been guiding changes that can make education more flexible, critical, reflective, constant and responsive to the health care challenges of the population and professional training.They point to the need to train professionals with competence to act with social responsibility, in addition to exercising the role of health promoters, based on the principles of the Brazilian Healthcare Reform (Reforma Sanitária Brasileira) and the Unified Health System (SUS -Sistema Único de Saúde). 1 In order to reach humanization in the practices related to death and dying, valuing the subjects involved, as recommended by the Brazilian Humanization Policy (PNH-Política Nacional de Humanização), and a care of excellence, nurses need to articulate knowledge, to add them to their own life experiences, and face personal barriers (fear, anguish, trauma) and imposed by the system (overcrowding and lack of resources).This preparation should be started, still, in the undergraduate education, by discussions in group about this reality and the best way to face it and/or necessary referrals for logotherapy, etc. 6 Knowing how to deal with the feelings of death is the starting point of this preparation, for as long as the theme is neglected from the real dimensions and meanings, it will be considered as something distant until the moment of confrontation with the finitude of oneself or of loved ones. 7The nurse, when he/she is confident of his/her emotions, recognizing limits and potentialities, is better prepared to deal with the suffering of the other, demonstrating sensitivity, support and identity of the role, without suffering by this conduct.
Faced with the need to train the critical, humanized nurse, confident about personal and professional emotions, the question arose: how to improve teaching in the discipline of Thanatology?Considering that it is a theoretical and practical learning, it was sought to use active learning methodologies for the development of skills in the student and the construction of the student's learning.Thus, this study aimed to report a methodological experience of learning based on problems in the discipline of Thanatology.
The use of Problem-Based Learning (PBL) 8 in the teaching of Thanatology can boost critical thinking, teamwork and reflection on the performance in the different settings of practice, as well as facilitate the discussion of various issues with comfort, palliative care, family and, consequently will contribute to more active, autonomous and dialogic training.

METHOD
It is an experience report of professors of the baccalaureate degree in nursing of a federal public university, using problem situations, influenced by the Methodology of Questioning and the PBL, adopted in the discipline of Thanatology, which is optional, with a workload of 32 hours divided into 16 meetings, addressing the contents: Spirituality and Mourning; History of death and Thanatology; Bioethics; Psycho-Oncology; Palliative care; Communication of bad news; and Suicide.
The discipline proposed the minimum gist of PBL: 1) the student as the core; 2) resolution of real-life problem situations; 3) learning process involving self-directed study and selfassessment; 4) curriculum composed of problems-content appropriate to the program; 5) professor as facilitator of the learning process; 5) group learning.
Nineteen students of the nursing program and one of the Psychology program held it in the first half of 2014.The teaching staff was made up of three professors of the nursing

Teaching Thanatology in Nursing Education
Sampaio CL, Neri MFS, Araújo MAM, Caetano JA, Eloia SMC, Souza AMA undergraduate, with the participation of a master's degree graduate program in nursing.
The planning of the learning process used in the program of Thanatology began in the year 2014.The group of professors met to discuss what should change in relation to the syllabus of the discipline and how could be implemented the necessary changes to adhere to the strategy of learning with problem situations.During the planning meetings, situations experienced were discussed by the master's student in the specialization in Activation of Processes of Change in Higher Education of Health Professionals, a program held in 2013, whose proposal was to work on problem situations in which students/professionals started to conduct autonomously the process of learning during the professional life, to exercise proactivity in the necessary changes, with critical sense, decision, humanistic vision and ethics. 2,9The experience of the masters in this specialization brought principles of the PBL methods and Questioning that collaborated with the transformation of contents of theoretical classes of Thanatology in problem situations.
The situations were elaborated with the objective of approaching challenges posed by the world of work, bringing regional cultural characteristics, elements of the unit's routine, interpersonal relations and participation of the multiprofessional team and the family in the hospital environment.
The problematic situations incorporated the questioning, allowing to analyze the characteristics by the Maguerez's Arch Method: observation of the reality (problem), attainment of key points, theory, hypotheses of solution and application to reality (practice); and the PBL method that allowed to work intentionally with problems elaborated by a team of professors to cover all the essential knowledge of the curriculum and explored the student participation and self-assessments of knowledge and abilities. 10eaching strategies involved more than just "doing", but associating it with critical and reflective thinking in the face of learning situations.The key concept of this pedagogical model is to learn by doing, comprising an overlapping of "action-reflectionaction" on the traditional binomial theory/practice in the development of knowledge.This model integrates the current basic and clinical cycles, through the questioning, guiding the search for knowledge and skills that base the interventions, and working with the presented issues, both from the point of view of clinical and collective health. 1 An advantage of the implementation of problem situations is the low cost for application, when compared to other commonly used active methodologies such as website, simulation, among others.
The experience of using problem situations as learning strategies for care in nursing in Thanatology is presented below.The processes of implantation of the problem situations are described, as well as the group discussion on the themes that have awakened the need for theoretical and reflexive subsidies.

The operation of problem situations
From the reading of the problem situations, the participants were invited to express previous knowledge, capturing the problem of the situation (first stage of the learning process).The group was encouraged to formulate hypotheses and/or explanations on the problem (second stage) and to elaborate learning questions aimed at checking and/or substantiating the hypotheses raised (third stage).Individual search and group discussion would allow the construction of new meanings based on the skills profile (fourth and fifth stages). 11The process was concluded by assessing the set of all these learning stages.
Thus, a text was read, opening the problem situation, then the students attained the key points and elaborated the learning issues, which consisted of a guiding question that contemplated all the participants.The students rehearsed a number of questions, until they reached agreement on an issue that covered all the key points listed.This moment motivated the participation of the group to research what was of interest, making learning meaningful.
In the second meeting of each problem situation the students shared how they performed the search and what they sought, developing theory on the subject.The facilitator had the role of instigating them to follow a line of reasoning that would lead to the answer of the question, preferably, by means of questions.Encouraging everyone to participate was essential.The professor moved from investor to activator and continued to coordinate the discussion to form a subsidy to elaborate a text covering the answer of the learning issue.
In the last class on each problem situation, the closing was accomplished, which consisted of complementing the previous discussion, clear and objective response of elements that responded to the synthesis, retrieval of the concepts learned and assessment of the closure of the problem situation.This assessment consisted of the students' speech about the acquired learning.They also delivered the syntheses that answered the learning issues, which were read and returned next class, with observations on the content and the exchange of information in the classroom.
In these meetings, students' experiences and facilitators emerged that allowed the visualization of the theoretical application in practice and personal lives, whether personal or professional.Research and discussion provided students with an understanding of what the mourning process is, how professional counseling should be, as well as the historical evolution of the concept of death and meaning for different cultures, professional practice in suicide care and palliative care.Thanatology, therefore, shows relevance in the nursing care in any field of care, since death and mourning are part of the care network as a natural consequence of life.The programs need to take place not only in the curricular educational process, but also as part of the orientation for the health team members and as permanent education in the institutions. 4eaching Thanatology in Nursing Education Sampaio CL, Neri MFS, Araújo MAM, Caetano JA, Eloia SMC, Souza AMA

Building knowledge
The problem situations were denominated by "Experiences of Mariana", "The internship of Cláudio" and "The project of Amanda and Sara", according to Figure 1.
The first problem situation brought the experience of a young Brazilian woman who was in Germany, through the Sciences without Borders program, and came across the cultural differences that govern a funeral.The students had an approximation to the Thanatology, examining cultural factors that influence the phenomenon of death, brought by them in the first contact.Yet, there is limited research in nursing that examines cultural and religious factors and their influences on the event of death along with comparative approaches among cultures. 4ach brought the aspect of the problem situation that stood out and sought to respond to the concerns (Chart 1).The stages of mourning and the differentiation of normal and pathological mourning were the best aspects seized by all involved, some students also brought interesting cultural particularities, individual experiences of losses and other subjects were worked on the following approaches.This emphasis can reduce the culture of death as a taboo for health professionals and enhance the quality of communications and thus perceptions of care among health professionals and patients and family members. 4efore starting the second problem situation, a visit was made, in loco, to two cemeteries of the city, one ancient and one more modern.The visit provided students with a knowledge of the rituals of death, relating to the history of death, the stages of mourning and spirituality, as well as the history of the city and the economic and artistic aspects.On the day of the last visit, in a comfortable place, the students were asked to draw and write what they would have written on the tombstone.The difficulty of recognizing themselves dead was almost general, at that moment they sensitized themselves to a reflection on their own finitude.
The second problem situation dealt with the experience of a student of the last semester of nursing undergraduate program who took care of a patient that tried suicide, with a reserved prognosis (Chart 2).The problem situation brought about quite complex aspects, but there was already a thematic approach with the discipline of Ethics and Legislation in Nursing.The students were then able to relate the disciplines and to deepen the practical aspects, mainly through the reporting of situations experienced by professors and students.At that moment, multidisciplinarity was presented through the rescue of the disciplines: Ethics, Epidemiology, Adult Care, Mental Health, besides the main focus, professional approach to suicide (Epidemiology, Risk Factors, Prevention and Conduct), demystifying the popular ideals.Also discussed were the concepts of euthanasia, dysthanasia, orthothanasia, social euthanasia and communication of bad news.
The ethics, emphasized in the Brazilian Curriculum Guidelines (Diretrizes Curriculares Nacionais) for nursing programs, must be understood through real and direct experiences, experienced in the daily services, permeating the development of curricular contents and establishing a dialogical relationship between students and professors. 1 The last problem situation dealt with the care of patients with cancer carried out in the extension project with two students, one of nursing and one of psychology (Chart 3).Finally, the necessary skills for professional action were discussed with patients and families in the process of death and dying.The link and the ideal therapeutic relationship for care were widely debated.
During the third problem situation, after formulating the learning issue, the students were interviewed in the Laboratory of Alternative Health Practices, with adequate lighting, environment and sound, in which they adopted the role of companion and family member who receive the communication of bad news.At the moment of expressing the feelings about the experience, the emotion arose.The role of the sick was better accepted than that of the family by the majority.Particular situations with relatives, fears and anxieties were revealed and the group assumed the proper function of a therapeutic group, providing listening and support, as well as empathy and understanding of the pain of the loss.
These discussions are essential for the training of nurses, professionals who deal with daily death and who must meet the health needs of the population.However, professors and students, in fact, distance themselves from dialogue, from understanding the difficulties of the other, from completeness in the relationships established in the training process. 12

Self-assessment and group assessment
At the end of the signature, they were asked to write a farewell letter.Some intended the letter to family, friends, lovers or both and others did not specify the recipient.Some did as if death were in the present moment and others in the distant future.Again, it was pointed out that there is no way to determine this day and that the sign of detachment is to write it as it were today.
The assessment was carried out through a portfolio, encompassing: expectations and choice of discipline; the report of how the construction of each learning issue, the search in the literature, the elaboration of the individual synthesis and the group sharing and debate; understanding and applicability of each learning issue to other disciplines; individual synthesis; assessment of each problem situation; individual, group and facilitator assessment; assessment of the discipline.The portfolios brought the path of the discipline, with particular reports of confrontation, more complete syntheses, taking into account the suggestions of the facilitator, photos, drawings, and new perspectives on Thanatology, presenting life and interest, but recognizing limitations, due to the need for continuous study, and absence of experiencing a certain situation.

Teaching Thanatology in Nursing Education
Sampaio CL, Neri MFS, Araújo MAM, Caetano JA, Eloia SMC, Souza AMA Bonding, fear of being emotionally involved, therapeutic relationship, fear of death, palliative care, suffering/finitude, meaning of life, hope, age to die.
What should be the therapeutic relationship of health professionals with critically ill patients?Source: Created by the authors.
There is difficulty in teaching Thanatology, due to numerous classes, small hours, and little age of students.However, the challenge faced with the number of students enrolled and the proposal different from what they were used to has been overcome, and the objectives have been achieved in a pleasurable way, corroborating with other publications that affirm that learning through active methodologies adds similar knowledge However, the student's performance in relation to the skills and attitudes is superior, as well as the greater satisfaction on the part of the academic ones, considering that the use of practical cases provides a greater relation with the reality, facilitating the fixation of contents and promoting critical thinking. 4

FINAL CONSIDERATIONS
The teaching of Thanatology is a real necessity in the professional practice of nursing.students sought discipline for diverse interests, curiosity, personal need, credit to be met, and demonstrated interest, participation, commitment, and maturity in issues of death and dying.
This methodology was approved by the students, who assessed reflective agents and builders of personal and professional growth.The horizontality used provided moments of productive discussions and skills development, such as speech and listening, thus providing therapeutic moments.
It is also worth noting the satisfaction provided to the teachers when observing the individual growth of each student and the recognition of a successful practice.