Death and dying: contributions to a practice based on nursing theoretical frameworks

Abstract

OBJECTIVE

To identify nurses’ agreement on nursing conceptions with the potential to support their practice in the death and dying process context.

METHOD

An exploratory and descriptive study with a quantitative approach was carried out with 3,451 nurses from 36 hospitals in Portugal, from July 2015 to March 2016. Data collection was carried out with the use of questionnaires and data analysis was carried out by means of descriptive and inferential statistics.

Results:

Among conceptions with the potential to support practice, nurses highlighted those from Virginia Henderson, Afaf Meleis, and Madeleine Leininger. The following variables influenced the degree of agreement: region, service, gender, professional training, and length of professional practice.

Conclusion:

Considering current challenges of a practice that is mostly based on meeting needs, the relevance of nursing practices’ purposes emerges in order to facilitate experiencing death and the dying process in culturally significant ways.

Keywords:
Death; Nursing; Nursing Theory; Models; nursing

Resumo

OBJETIVO

Identificar a concordância dos enfermeiros sobre as concepções de enfermagem com potencial para sustentar a sua prática no âmbito da morte e dos processos de morrer.

MÉTODO

Estudo quantitativo, exploratório e descritivo, realizado em 36 hospitais de Portugal, de julho de 2015 a março de 2016, com participação de 3451 enfermeiros. Na coleta de dados utilizou-se o questionário e na análise recorreu-se à estatística descritiva e inferencial.

RESULTADOS

Dentre as concepções com potencial para sustentar a prática, os enfermeiros salientam as de Virginia Henderson, Afaf Meleis e Madeleine Leininger. As variáveis que afetam o grau de concordância são: região, serviço, gênero, formação profissional e tempo de exercício profissional.

CONCLUSÃO

Considerando os atuais desafios, de uma prática predominantemente centrada na satisfação das necessidades, emerge a pertinência da intencionalidade da ação dos enfermeiros, no sentido de facilitar a vivência da morte e dos processos de morrer, de formas culturalmente significativas.

Palavras-chave:
Morte; Enfermagem; Teoria de enfermagem; Modelos de enfermagem

Resumen

OBJETIVO

Identificar la concordancia de los enfermeros sobre las concepciones de enfermería con potencial para sostener su práctica en el ámbito de la muerte y de los procesos de morir.

MÉTODO

Estudio cuantitativo, exploratorio y descriptivo que se realizó en 36 hospitales en Portugal, de julio de 2015 a marzo de 2016, con la participación de 3451 enfermeros. En la recogida de los datos se utilizó el cuestionario y en el análisis se recurrió a la estadística descriptiva e inferencial.

RESULTADOS

De las concepciones con potencial para sostener la práctica, los enfermeros ponen de relieve las de Virginia Henderson, Afaf Meleis y Madeleine Leininger. Las variables que afectan el grado de concordancia son: región, servicio, género, formación profesional y tiempo de ejercicio profesional.

CONCLUSIÓN

Teniendo en cuenta los actuales desafíos, de una práctica predominantemente centrada en la satisfacción de las necesidades, emerge la pertinencia de la intencionalidad de la acción de los enfermeros, con el objetivo de facilitar la vivencia de la muerte y los procesos de morir, de formas culturalmente significativas.

Palabras clave:
Muerte; Enfermería; Teoría de enfermería; Modelos de enfermería

Introduction

In the last decade, nurses have sought to assert themselves, making use of theories to strengthen practice and systematize care. In addition to being congruent with the evolution of the subject and profession, considering the complexity of human beings from the physical, mental, emotional, and spiritual point of view, it is at least incoherent to talk about nursing care based only on a biomedical approach¹. Effectively, in spite of the need for nurses’ competence for the management of signs and symptoms of diseases, individuals’ needs, whether patients or family members, they increasingly appeal to nursing evidenced in theoretical frameworks^2-4. Moreover, based on theoretical assumptions, nursing adds social and scientific value to its knowledge and know-how, thus qualifying the care provided as well as its specific contribution in the multidisciplinary context⁴.

During academic and professional education, nurses are expected to develop skills in order to assume responsibility to provide care to patients throughout the whole life cycle, which inevitably includes the death time⁵. Death is part of daily life, as one more phase of the living process. However, nursing professionals are not always prepared to come across human finiteness^6-7, often choosing in patients’ dying process context for pulling away from them, limiting themselves to the execution of necessary technical procedures⁸. There are several reactions and feelings, that is, some remain silent, others seclude themselves, cry, or search for death reasons. The problem is that in all these situations, the suffering of patients and professionals is evident, as well as the negative repercussion in the way of providing care during the whole dying process experience⁹.

Increasingly common in hospital contexts, death does not make sense in professional practice, culminating in an imminently technical practice that favors the feeling of failure, and, consequently, individuals who experience it do not have access to the nursing care deserved. This is because providing care to a person facing the possibility of imminent death implies a practice congruent with the subject’s theoretical frameworks, which has not been effectively evidenced. In this context, the need for unfragmented broadened approaches is of utmost importance, which will provide an attentive look to all dimensions that involve individuals, with death among them⁶. In addition, and as defended by the authors, nursing care must be assumed and discussed based on frameworks that allow to integrate and contextualize the different events that are part of the human life cycle⁶.

Although manifestations on death and the dying process are not equally evidenced in nursing theories, some frameworks make clear allusions to this time. For Virginia Henderson, nursing is characterized by the care provided to sick or healthy individuals, in the performance of activities that contribute to health, their recovery, or to a peaceful death that they would perform unaided if they had the necessary strength, will, or knowledge¹⁰.

From the perspective of Imogene King, nursing is based on an interpersonal process of action, reaction, interaction, and transaction, whose objective is to help individuals and groups to achieve, maintain, and recover health. If this is not possible, nurses assist individuals to die with dignity¹⁰.

For Callista Roy, nursing is a science focused on human life processes and promotion of individuals’ adaptation. In this perspective, the challenge is to evaluate behaviors and factors that influence individuals’ ability to adapt to the four adaptive ways (physiological-physical, group self-concept identity, role, and interdependence) and intervene to maximize these skills and improve interaction with the environment, thus contributing to health, quality of life, or death with dignity¹¹.

From the perspective of Madeleine Leininger, nursing is focused on human care phenomena and activities such as providing care, supporting, facilitating, or enabling individuals or groups to maintain or acquire their well-being through culturally significant and beneficial ways or assist people to face disabilities or death¹⁰.

For Jean Watson, nursing is a human caring art and science, whose transpersonal processes are directed toward the promotion of “body-soul-spirit” harmony. From the development of the Human Caring Theory, Jean Watson has been constantly dedicated to its improvement. The Clinical Caritas process, as entitled by the author, includes 10 Caritas factors, one of which (element 10) particularly regards to aspects associated with spirituality, life, and death^1,12.

According to Afaf Meleis, nursing focuses on transition human experiences. In this perspective, nurses’ challenges are to understand transition processes, approach problems experienced during transitory experiences, death as an example, and develop therapies that provide support to individuals in these situations^13-14.

Although theoretical frameworks promote professional practice quality, difficulties in aligning care meaning and purpose with nursing theories have been noticeable in care practice¹. If these difficulties happen in all care types, they acquire special relevance in the death and dying process context. Therefore, being part of a broader project carried out at a national level entitled “Contextos da prática hospitalar e concepções dos enfermeiros” (Hospital practice contexts and nurses’ conceptions), the present study sought to answer the following question: Which nursing conceptions with the potential to support practice in the death and dying process context are more agreed among nurses? In this respect, the objective of the present study was to identify nurses’ agreement on nursing conceptions with the potential to support their practice in the death and dying process context.

Method

This was an exploratory and descriptive study with a quantitative approach. Although it was expected to be implemented in all hospitals regulated by the management model of public business entities, which were 38 at the time of data collection, the present study was carried out in 36 public business entity hospitals of continental Portugal because two hospitals did not agree to participate. A sample was drawn due to the impossibility to study the total population. The non-probability convenience sampling technique was used. The following inclusion criteria were defined: working at the hospital for at least six months in the medicine and medical specialties units, surgery, and surgery specialties units, or intensive care medicine and urgency units. Nurses who were on leave or vacation were excluded, as well as those who were employed for less than six months. Considering the services provided by each hospital where the study was authorized, a sample of 3,451 nurses was obtained from an available population of 10,013 nurses.

Although the process regarding authorization ranged among the institutions, the study was approved by the research ethics committees and the board of directors of the 36 hospitals involved. Nurses who worked in the departments where the study was carried out received information regarding its objectives and procedures. Nurses who agreed to participate were asked to sign an informed consent form. Confidentiality and anonymity in the use and release of data collected were ensured. A questionnaire consisting of the following two parts was used as data collection instrument: Part I - Participant’s characteristics; Part II - Nursing conceptions. For the drawing-up of the questionnaire used in a broader study at a national level^15-16, the authors focused on the following 13 nursing theoreticians at the time of literature review: Florence Nightingale, Virginia Henderson, Dorothea Orem, Hildegard Peplau, Imogene King, Callista Roy, Betty Neuman, Moyra Allen, Martha Rogers, Rosemarie Parse, Madeleine Leininger, Jean Watson, and Afaf Meleis. The choice for these theoreticians is related to the fact that, in the Portuguese context, they are approached during nursing undergraduate and graduate courses, in addition to being the most often used by nurses in the research context. Later, because some theoreticians approach the theme of death more clearly, the present study focused on the nursing conceptions of the following six theoreticians: Virginia Henderson, Imogene King, Callista Roy, Madeleine Leininger, Jean Watson, and Afaf Meleis. At the time of filling in questionnaires, nurses were asked to express their opinions about six nursing conceptions in a Likert response scale that ranged from one to five, with one referring to “totally in disagreement with my practice”, two to “in disagreement with my practice”, three to “no opinion”, four to “in agreement with my practice”, and five to “totally in agreement with my practice”. Data collection was carried between July 2015 and March 2016. The Statistical Package for the Social Sciences 22 software was used for data treatment, and descriptive and inferential statistics were used for data analysis. Considering that response (degree of agreement with the conceptions) is an ordinal qualitative variable with the purpose of identifying which sociodemographic and professional characteristic attributes affected the degree of agreement, cumulated logistic regression models were used for ordinal responses.

Results

Regarding the sociodemographic and professional profile of the participants, most of the 3,451 nurses were women (77.1%). Age ranged between 22 and 62 years and the mean age was 36.4 years (standard deviation of 8.3). The prevalent marital status was married/stable union (61.1%), followed by single (33.8%), divorced (4.7%), and widowed (0.3%). With regard to education level, there was a prevalence of the graduate degree (88.0%), followed by master degree (10.7%), bachelor degree (1.1%), and doctorate degree (0.2%). Regarding the type of professional practice, most of the participants were nurses (76.3%), followed by clinical nurse specialists (19.9%) and nurse managers (3.8%). With regard to nurses’ regional distribution, there was a prevalence of the northern region (43.2%), followed by the Lisbon and Tejo regions (24.0%), the central region (22.3%), the Alentejo region (6.2%), and the Algarve region (4.2%).

Previously to the agreement analysis regarding nursing conceptions, the hospitals were distributed by the regions of the respective regional health administrations, and later, a regional comparison of responses’ distribution was carried out. The degree of agreement was measured to present the results through the set of responses “in agreement with my practice” and “totally in agreement with my practice”, and, at the end of the analysis, conceptions that nurses characterized as “totally in agreement with my practice” were highlighted.

In the northern region, the nursing conception with the highest degree of agreement was from Virginia Henderson (89.2% responded “in agreement with my practice” or “totally in agreement with my practice”), followed by Madeleine Leininger (85.0%), Callista Roy (83.5%), Afaf Meleis (80.7%), Imogene King (58.9%), and Jean Watson (55.7%). As observed in Table 1, the nursing conceptions that were totally in agreement with nurses’ practice were from Virginia Henderson (34.6%) and Afaf Meleis (31.8%).

Table 1:
Agreement’s numerical and percentage distribution with nursing conceptions in the northern region. Portugal, 2017

Nursing conceptions	Totally in disagreement with my practice		In disagreement with my practice		No opinion		In agreement with my practice		Totally in agreement with my practice		Total
	n	%	n	%	n	%	N	%	n	%	n	%
Virginia Henderson	6	0.4	49	3.3	107	7.2	814	54.6	516	34.6	1,492	100
Imogene King	8	0.5	207	13.9	399	26.7	686	46.0	192	12.9	1,492	100
Callista Roy	3	0.2	36	2.4	208	13.9	899	60.3	346	23.2	1,492	100
Madeleine Leininger	5	0.3	39	2.6	179	12.0	949	63.6	320	21.4	1,492	100
Jean Watson	20	1.3	200	13.4	441	29.6	647	43.4	184	12.3	1,492	100
Afaf Meleis	9	0.6	42	2.8	236	15.8	730	48.9	475	31.8	1,492	100

• ^Source:
  Research data, 201715

Regarding the central region, the nursing conception with the highest degree of agreement was from Virginia Henderson (92.4%), followed by Madeleine Leininger (82.0%), Afaf Meleis (81.2%), Callista Roy (80.5%), Imogene King (54.7%), and Jean Watson (54.0%). As shown in Table 2, the nursing conceptions that were totally in agreement with nurses’ practice were from Alaf Meleis (35.0%) and Virginia Henderson (33.9%).

Table 2:
Agreement’s numerical and percentage distribution with nursing conceptions in the central region. Portugal, 2017

Nursing conceptions	Totally in disagreement with my practice		In disagreement with my practice		No opinion		In agreement with my practice		Totally in agreement with my practice		Total
	n	%	n	%	n	%	n	%	n	%	n	%
Virginia Henderson	1	0.1	11	1.4	47	6.1	451	58.5	261	33.9	771	100
Imogene King	1	0.1	65	8.4	283	36.7	327	42.4	95	12.3	771	100
Callista Roy	0	0.0	12	1.6	139	18.0	426	55.3	194	25.2	771	100
Madeleine Leininger	0	0.0	11	1.4	128	16.6	443	57.5	189	24.5	771	100
Jean Watson	1	0.1	82	10.6	271	35.1	328	42.5	89	11.5	771	100
Afaf Meleis	0	0.0	10	1.3	135	17.5	356	46.2	270	35.0	771	100

• ^Source:
  Research data, 201715

In the Lisbon and Vale do Tejo regions, the nursing conception with the highest degree of agreement was from Virginia Henderson (93.4%), followed by Callista Roy (86.9%), Madeleine Leininger (84.1%), Afaf Meleis (79.7%), Imogene King (64.3%), and Jean Watson (63.2%). As observed in Table 3, the nursing conceptions that were totally in agreement with nurses’ practice were from Virginia Henderson (40.2%) and Madeleine Leininger (31.6%).

Table 3:
Agreement’s numerical and percentage distribution with nursing conceptions in the Lisbon and Vale do Tejo regions. Portugal, 2017

Nursing conceptions	Totally in disagreement with my practice		In disagreement with my practice		No opinion		In agreement with my practice		Totally in agreement with my practice		Total
	n	%	n	%	n	%	N	%	n	%	n	%
Virginia Henderson	2	0.2	11	1.3	42	5.1	441	53.2	333	40.2	829	100
Imogene King	3	0.4	63	7.6	230	27.7	423	51.0	110	13.3	829	100
Callista Roy	1	0.1	15	1.8	93	11.2	529	63.8	191	23.0	829	100
Madeleine Leininger	3	0.4	12	1.4	117	14.1	435	52.5	262	31.6	829	100
Jean Watson	2	0.2	91	11.0	212	25.6	398	48.0	126	15.2	829	100
Afaf Meleis	1	0.1	19	2.3	148	17.9	472	56.9	189	22.8	829	100

• ^Source:
  Research data, 201715

In the Alentejo region, the nursing conception with the highest degree of agreement was from Virginia Henderson (86.4%), followed by Madeleine Leininger (82.2%), Callista Roy (79.3%), Alaf Meleis (77.5%), Imogene King (64.8%), and Jean Watson (56.8%). As shown in Table 4, the nursing conceptions that were totally in agreement with nurses’ practice were from Virginia Henderson (36.2%) and Madeleine Leininger (26.8%). Finally, in the Alentejo region, the nursing conception with the highest degree of agreement was from Alaf Meleis (95.3%), followed by Virginia Henderson (91.8%), Callista Roy (91.1%), Madeleine Leininger (89.1%), Jean Watson (60.9%), and Imogene King (35.6%). As also observed in Table 4, the nursing conceptions that were totally in agreement with nurses’ practice were from Virginia Henderson (38.4%) and Madeleine Leininger (37.0%).

Table 4:
Agreement’s numerical and percentage distribution with nursing conceptions in the Alentejo and Algarve regions. Portugal, 2017

Nursing conceptions	Totally in disagreement with my practice		In disagreement with my practice		No opinion		In agreement with my practice		Totally in agreement with my practice		Total
	n	%	n	%	n	%	N	%	n	%	n	%
ALENTEJO
Virginia Henderson	0	0.0	7	3.3	22	10.3	107	50.2	77	36.2	213	100
Imogene King	0	0.0	18	8.5	57	26.8	108	50.7	30	14.1	213	100
Callista Roy	0	0.0	6	2.8	38	17.8	114	53.5	55	25.8	213	100
Madeleine Leininger	1	0.5	4	1.9	33	15.5	118	55.4	57	26.8	213	100
Jean Watson	2	0.9	18	8.5	72	33.8	89	41.8	32	15.0	213	100
Afaf Meleis	1	0.5	2	0.9	45	21.1	112	52.6	53	24.9	213	100
ALGARVE
Virginia Henderson	0	0.0	2	1.4	10	6.8	78	53.4	56	38.4	146	100
Imogene King	0	0.0	14	9.6	80	54.8	51	34.9	1	0.7	146	100
Callista Roy	0	0.0	0	0.0	13	8.9	82	56.2	51	34.9	146	100
Madeleine Leininger	0	0.0	3	2.1	13	8.9	76	52.1	54	37.0	146	100
Jean Watson	1	0.7	15	10.3	41	28.1	71	48.6	18	12.3	146	100
Afaf Meleis	0	0.0	0	0.0	7	4.8	116	79.5	23	15.8	146	100

• ^Source:
  Research data, 201715

With the purpose of establishing which characteristic attributes significantly affected the degree of agreement, a cumulated logistic regression model for ordinal responses was adjusted for each conception, since response (degree of agreement) is an ordinal qualitative variable. These models allowed to conclude which characteristic attributes effectively influenced the degree of agreement with each conception and in which sense. In all conceptions, elimination of the variables’ model whose estimated parameter was not statistically significant was carried out for selection of the explanatory variables to retain in the model, by means of “backward” selection based on the Wald test.

Therefore, in Virginia Henderson’s conception model, estimate results showed that the explanatory variables to retain in the model, that is, those that effectively determined a greater agreement in this conception, were region and professional practice. In Imogene King’s nursing conception, the estimate results indicated that the explanatory variables that determined a greater agreement in this conception were region, service, professional practice, and length of professional practice. In Callista Roy’s nursing conception, the estimate results showed that the explanatory variables that determined a greater agreement in this conception were region, service, gender, professional practice, and length of professional practice. Regarding Madeleine Leininger’s nursing conception, the estimate results showed that the explanatory variables to retain in the model, that is, those that effectively determined a greater agreement in this conception, were region, service, gender, and professional practice. In Jean Watson’s nursing conception, the estimate results indicated that the explanatory variables that effectively determined a greater agreement in this conception were region, service, gender, and professional practice. At last, in Alaf Meleis’ nursing conception, the estimate results showed that the explanatory variables that determined a greater agreement in this conception were region, service, professional practice, length of professional practice, and education level.

Figure 1 summarizes nurses’ sociodemographic and professional characteristics that determined a greater agreement with the nursing conceptions in analysis.

Figure 1:
Nurses’ sociodemographic and professional characteristics and agreement with nursing conceptions.

Discussion

As a result from the analysis of the sociodemographic variables and in accordance with the nursing professionals’ profile in the national context, most nurses who participated in the study were women (77.1%) and presented a mean age of 36.4 years. Regarding professional practice, most participants were nurses (76.3%), followed by clinical nurse specialists (19.9%), and nurse managers (3.8%). With regard to the agreement expressed by nurses concerning nursing conceptions, those that presented the potential to support practice in the death and dying process context were from Virginia Henderson, Afaf Meleis, and Madeleine Leininger. Therefore, regarding the theme in study, nurses focus their role on patient care, activities that contribute to a peaceful death, facilitation of processes and transitory human experiences such as death, as well as assisting, supporting, and patient training activities to help them face disabilities or death in culturally significant ways.

Although nurses evidence difficulty in supporting their practice in nursing theoretical frameworks, the results of this study constitute a challenge for paradigm’s change. In fact, it is of utmost importance that nurses know and make use of theoretical frameworks concerning the subject, in order to actively participate in the care provided to patients during the dying process^1,17. In the imminence of death, patients’ possibility of receiving help from nursing professionals, who, in addition to managing signs and symptoms, listen, understand, and meet their needs, is essential so patients are able to more easily experience the dying process⁷.

Different theories have different perspectives and meanings; however, in nursing practice, they play a key role in the purpose of care provided¹⁸. In addition, the nursing profession, without its disciplinary bases, may be easily guided by hospital culture and pressure to be subject to a medicalization view and clinicalization¹⁹, which will hinder the death and dying process experience.

From the analysis of frameworks with the potential to support nurses’ practice in the death and dying process in the hospital context, the results obtained from the different regions of the country evidence the existence of two groups. One group made up of the northern and central regions, whose theoretical frameworks with potential to support practice are from Virginia Henderson and Afaf Meleis, and another group made up of the Lisbon and Vale do Tejo and the Alentejo and Algarve regions, whose theoretical frameworks that most suit practice are from Virginia Henderson and Madeleine Leininger. Approaches on the subject’s theoretical frameworks in different nursing schools have proved to be a determining factor in the option of nurses, thus potentially justifying the differences found¹⁵.

Nurses’ agreement regarding nursing conceptions indicates that, in addition to assisting patients in meeting their basic human needs, nurses recognize the importance in acting with the purpose of understanding and facilitating transitions experienced by individuals¹⁵. The uniqueness of human beings makes the dying process an individual experience that can be distinctly experienced by every individual, depending on their social, historical, and cultural context²⁰. In Madeleine Leininger’s view, nursing focuses on the recognition and understanding of similarities and cultural differences, and on the use of this information to provide culturally congruent nursing care to individuals from different cultures¹⁰, which is an aspect that must be appreciated by nurses in the dying process context.

Although, in the sequence of the results obtained from the present study and other studies^15-16, nurses evidence a practice predominantly focused on the assumption of “assisting patients in doing what they are not able to do”, in the perspective of Virginia Henderson, resulting from the relevance of a practice focused on “doing with patients” in their transition process context, they must develop therapies able to assist individuals in living experiences in end-of-life situations more consistently.

The main characteristics of transition experiences focus on patients’ possibility of being aware of the change and difference in what they experience^13-14, which justifies the degree of agreement with the Afaf Meleis’ conception being higher among nurses who work in medicine/medical specialties and surgical/surgical specialties units when compared with those who work in intensive/urgency medicine units, which are contexts where patients’ conditions more often hinder transition awareness.

Regarding Madeleine Leininger’s conception, agreement is also higher in nurses who work in medicine/medical specialties units and surgical/surgical specialties units. Emphasis on a practice focused on transcultural care demands a systematic professional aid and highly focused on the valorization of cultural differences in the dying process context, unfortunately common in the abovementioned services⁸.

In addition, it is worth mentioning that the agreement of nurse managers regarding the different theoretical perspectives translates their concerns about creating key conditions to nursing care provision coherent with the subject’s theoretical frameworks, thus meeting the commitment to keeping dignity and uniqueness of the one-being-cared for⁴. Although nurses’ agreement is more significant regarding the theoretical frameworks of Virginia Henderson, Afaf Meleis, and Madeleine Leininger, contributions from other theoretical perspectives should not be disregarded. The dying process and the death of others arouse feelings of sadness, defeat, fear, anger, impotence, becoming more often related to loss and separation than to a natural life process, which, like others, demands adjustment. It is in this context that the theoretical framework of Callista Roy may be essential, as it will strengthen individuals’ preparation and adjustment in end-of-life situations.

In the perspective of Imogene King, perceptions, needs, goals, and values of nurses and patients influence the interaction process established by themselves. In addition, patients have the right to participate in decisions that influence their lives, and they may either accept or reject care, especially because the goals of professionals and care receivers may not be congruent¹⁰, which is an aspect that must be considered in end-of-life situations.

The needs of individuals who are experiencing the dying process transcend the physical and often highlight the spiritual dimension. The search for the death meaning in spirituality is common in many religions. Therefore, understanding the difficulty in ignoring individuals’ spiritual needs in the dying process²⁰, nurses must be prepared to support their practice in guiding principles of theoretical frameworks such as the Jean Watson’s perspective¹⁷. According to Clinical Caritas, nurses must meet patients’ urgent needs without diverting to care only focused on the physical dimension¹.

Due to death institutionalization, nurses who work in hospitals are increasingly susceptible to providing care to patients in dying processes, and studies carried out in these contexts evidence that they do not always feel prepared^5,7-9. In addition, feelings of loss and failure experienced by nurses are often exacerbated, because nursing schools train professionals with theoretical and practical support to preserve life, with death and dying issues little or even not approached or discussed at all^6,9. The problem is that superficiality and trivialization of the few discussions regarding death and the dying process do not allow a broader understanding of this phenomenon as an event that is part of the life cycle⁶.

Since care provided in the death and dying process context have to be grounded in nursing theoretical frameworks, the present study is believed to be an important contribution to ensure the quality of nurses’ professional practice. Considering that the experience to deal with death and dying is acquired during professional career⁵, often by trial and error⁷, where nurses learn to deal with situations at every new experience in the face of a death episode⁹, the inclusion of this theme in the academic education is of utmost importance in order to promote the development of skills in future nurses, thus preparing them to be more effective in assisting patients experiencing death and the dying process⁸.

In addition to the acquisition of knowledge on death and dying within the educational context, the promotion of reflexive practices and clinical supervision in the professional environment will have a key role in nurses’ preparation to deal with terminal patients, simultaneously reducing the probability of these professionals to express anxiety, stress, and burnout⁷. Group discussions and backing in frameworks that comprise the death phenomenon as a comprehensive part of the living process are pointed out as strategies to discuss this theme, both in theoretical and practical environments⁶. Although it is not easy to broaden the understanding on death and the dying process, it is important to ensure that nurses are able to recognize, not only biological aspects but also psychosocial and spiritual implications of this experience on patients and families under their care⁴.

Conclusion

Increasingly common in hospital contexts, death and the dying process require a practice congruent with the subject’s theoretical frameworks from nurses, which effectively does not always happen. Therefore, even assuming as a limitation that the sampling technique was not probabilistic, which determines the possibility of the profile of participating nurses influencing the results, the present study provides the opportunity to reflect on nursing conceptions with the potential to support practice. Therefore, it is an important aspect for the development of the subject and the profession, as well as for the quality of nurses’ professional practice in the care for individuals in all their dimensions and throughout their whole life cycle.

In spite of the lack of studies on the theme having hindered the discussion of the results from the analysis carried out, the present study showed that, in the five regions of the country, nurses identified the conceptions of Virginia Henderson, Afaf Meleis, and Madeleine Leininger as totally in agreement with their practice, being these the theoretical frameworks with potential to support nurses’ practice in the face of death and dying processes. In this context, it was clear that, at a national level, in light of the theoretical framework of Virginia Henderson, nurses evidence concern in meeting patients’ needs. However, meeting current challenges, it is of utmost importance to deconcentrate the attention of a practice mostly focused on meeting basic human needs on behalf of a care based on experiences lived by individuals in the face of the imminence and inevitability of life finiteness, with potential to culminate in a dignified and peaceful death. Therefore, in the education context, the adoption of teaching-learning strategies enhancing the appropriation of the theoretical frameworks with the potential to support nurses’ practice in the face of death and dying processes is of utmost importance. In practice, the need for promoting a more qualified professional approach to patients and their families during the experience of death and dying processes emerges. Further qualitative studies should be carried out with the purpose of identifying factors that facilitate or hinder a practice congruent with the subject’s frameworks.

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Publication Dates

• Publication in this collection
  18 Feb 2019
• Date of issue
  2019

History

• Received
  13 June 2018
• Accepted
  23 Oct 2018