Meaning of the death / dying process for entering nursing students

Abstracts

Trata-se de uma pesquisa qualitativa, embasada na fenomenologia existencial heideggeriana, com o objetivo de desvelar o significado do processo morte/morrer para acadêmicos ingressantes no curso de enfermagem, realizada numa universidade pública do Noroeste do Paraná, Brasil, entre os meses de agosto e outubro de 2010, quando se entrevistaram 33 graduandos do primeiro ano do curso de enfermagem. Da análise fenomenológica, emergiram as seguintes temáticas existenciais: "Entendendo a morte como um processo difícil de ser compreendido"; "Compreendendo a morte como um processo natural"; "Vislumbrando a morte como uma passagem para outra vida". Por este estudo, compreendeu-se que o saber e a morte estão enredados na temporalidade e historicidade de cada ser, sendo necessária uma compreensão científica, filosófica e ética do fenômeno morte/morrer para que o acadêmico possa se preparar para o cuidado humanizado ao doente e sua família.

Morte; Ensino; Estudantes de enfermagem

ORIGINAL ARTICLE

Meaning of the death / dying process for entering nursing students

Significado del proceso muerte/ morir por los estudiantes que entran en el programa de enfermería

Gabriella Michel dos Santos Benedetti^I; Kézia de Oliveira^II; William Tiago de Oliveira^III; Catarina Aparecida Sales^IV; Patrícia Chatalov Ferreira^V

^IRN. Specialist in Family Health. Graduate of the Master's Program in Nursing of the State University of Maringá (UEM) – Maringá – Paraná – Brazil

^IIRN. Specialist in Family Health and UTI Neonatal. Professor of the University Center of Maringá (CESUMAR). Graduate of the Master's Program in Nursing of the State University of Maringá (UEM) – Maringá – Paraná – Brazil

^IIIRN. Specialist in Management of Nursing Services at the State University of Londrina (UEL). Professor of the Faculty Ingá - Uningá. Graduate of the Master's Program in Nursing of the State University of Maringá (UEM) – Maringá – Paraná – Brazil

^IVPh.D. in Nursing. Professor at the Nursing Graduate Department of the State University of Maringá (UEM) – Maringá – Paraná – Brazil

^VNursing undergraduate (4th year). Holder of a Scientific Apprenticeship Grant (PIBIC). Nursing Department. State University of MaringᖠParaná – Brazil

Author's address

ABSTRACT

This is a qualitative study, based on Heidegger's existential phenomenology, with the purpose of revealing the meaning of death / dying for freshmen students of the nursing program. The study was developed in a public university in the northwest of Paraná, Brazil, between August and October 2010, and 33 entering students from a Nursing program were interviewed. The following existential themes emerged from the phenomenological analysis: "Understanding death as a difficult process to be understood"; "Understanding death as a natural process"; and "Perceiving death as a passage to another life". The present study allowed to understand that knowledge and death are entangled in the temporality and the historicity of every being, which requires a scientific, ethical and philosophical understanding of the death / dying phenomenon so that the scholar may prepare for the humanized care of the patient and his/her family.

Descriptors: Death. Teaching. Nursing undergraduate students.

RESUMEN

Se trata de una investigación cualitativa, basada en la fenomenología existencial heideggeriana, con el objetivo de revelar el significado de la muerte / morir por estudiantes de primer año en el programa de enfermería. Realizada en una universidad pública del Noroeste de Paraná, Brasil, entre agosto y octubre de 2010, fueron entrevistados 33 graduandos del 1° año del curso de enfermería. Del análisis fenomenológico emergieron las siguientes temáticas existenciales: "Entendiendo la muerte como un proceso difícil de ser comprendido"; "Comprendiendo la muerte como un proceso natural"; "Percibiendo la muerte como un pasaje a otra vida". A través de este estudio comprendemos que el saber y la muerte están enmarañados en la temporalidad y la historicidad de cada ser, lo que requiere una comprensión científica, ética y filosófica del fenómeno muerte / morir para que el estudiante pueda prepararse para la atención humanizada al paciente y a su familia.

Descriptores: Muerte. Enseñanza. Estudiantes de enfermería.

INTRODUCTION

Death constitutes one of the most confusing, feared and ignored subjects by society. This natural process, which complements life but is still believed to be the opposite by many people, is one of the few concrete realities for all human beings^(1-2).

The idea cultivated by human beings regarding death follows them throughout their entire existence. Moreover, efforts to face it naturally contribute to developing beliefs that will only deny an undeniable fact, leading them to transpose the chronological time, that is, the time that determines the end of life ⁽³⁾, and to envision other possibilities for its continuity, often led by spirituality.

Death is more constantly present among health professionals than among other people, but they are not prepared to face it either. It is necessary to learn to understand it, accept it and dissociate from the perspective of failure that this phenomenon may generate. In this context, nurses are more exposed, as they deal more directly and spend more time with patients, but that does not mean they are prepared^(1,4).

Nursing undergraduate students also experience death, as they deal with disease, pain and death on a daily basis. These daily experiences may trigger hidden feelings of impotence in face of the unsolvable⁽⁵⁾. In the light of this, studying death since college is something that may help students work with its constant presence, so as to reduce the stress and anxiety of discussing this subjects and dealing with suffering on a daily basis⁽⁶⁾.

Some authors state that the discussion regarding the feeling of fear and insecurity, in some occasions, represents a gap in undergraduate education, which may harm professional education in terms of their preparation for the rough work routine in hospitals, where they constantly deal with the suffering of others. In these situations, the inappropriately prepared nurse does not assume a therapeutic attitude, and it is hard to find professionals who are able to talk to the family and the dying patient in the hospitals, assisting them in their psychological needs in the moments that precede death^(7-8).

Other authors express it is vital to introduce, during academic education, a critical-reflexive view towards the death/dying process, so that these future professionals are able to accept death naturally, with less suffering or the sensation of personal and professional failure⁽²⁾.

Thus, this content must be inserted in the beginning of the undergraduate program, either in the form of theoretical contents or extension projects, since students must be prepared to assist patients and families who experience the end of life. In this context, this study aimed to reveal the meaning of the death/dying process for freshmen nursing students.

METHODOLOGY

This qualitative study is philosophically grounded on the Heideggerian existential phenomenology. In Heidegger's reflections, to comprehend man in his facticity means to decipher the way he reveals facts in his speech, thus unfolding a phenomenon that irradiates from his own self. For the German philosopher, the core of the phenomenological thought is to understand human beings in their existentiality, or in other words, in their facticity⁽⁹⁾.

The participants in the research were all first-year nursing students (freshmen) from a public university in the State of Paraná, Brazil, in 2010, amounting 33 students. Freshmen were chosen so that their personal conceptions, even prior to experiencing death situations in their academic and/or professional trajectories, could be acknowledged.

Regarding the amount of words established by the journal, this present article brings statements uttered by 16 participants out of the 33 interviewees. The choice of the descriptions was a random process, as the objective of the research was not to unveil definitions only, but also the meaning of an existential essence of each academic student's experience.

Interviews were individually performed in a private office at the institution, counting on the use of a digital recorder, from August to October 2010. Interviewees were asked the following question: "What does the death/dying process mean to you?" In order to ensure anonymity, students were identified by the letter S followed by the number of the order in which they were interviewed.

Aiming to capture a comprehensive conception of the participants' statements and their languages, their selection took into account the individual analysis of each participant's respective speeches. Therefore, each statement was carefully skimmed in first place and excerpts or meaning units were highlighted as fundamental structures of existence. Next, the meaning units of each statement were assessed, and a phenomenological selection of the language of each participant was developed, as a meaning unit is generally composed of feelings revealed by interviewees, leading to ontological questioning processes⁽¹⁰⁾.

The research was approved by the Research Ethics Committee of the State University of Maringá under protocol number 497/2010. Data collection did not take place until the student fully agreed to participate in the research and signed the two copies of the Free and Informed Consent Form, in compliance with the ethical principles established by Resolution 196/96 of the National Health Council.

RESULTS AND DISCUSSION

In search for the objectives proposed by this present research, the meaning units of the statements revealed the framework of the questioned phenomenon. Achieved results were grouped in three emerging themes, which were interpreted at the light of some of Heidegger's concepts, as well as other authors who elaborate on the death/dying process.

Understanding death as a difficult process to be understood

As the Being-there finds himself cast out in the world and starts experiencing unplanned, yet concrete situations, he opens up to the world and expresses himself through affection, disposition, comprehension and language. In the Heideggerian analytics, man's ways of unveiling himself to the world are called existential structures. The disposition, understood as the mood or the affective tone, does not represent a mere psychological phenomenon that provides things and people with colors, but a constitutive definition of our being. "The mood reveals 'how one is and what he becomes'. And it is in this 'how one is' that the tuning of the mood leads the being to its 'pre'."⁽⁹⁾. In this thought, the Being-toward-the-end is not primarily originated in an event that sometimes takes place in man's life; it essentially stems from the factus that he has been cast out, an incident shown in the mood framework in several different ways.

Bearing that in mind, statements displayed a difficulty to grasp and accept the suffering caused by the obscure sense brought by death to each individual. This sense is quite a painful process. Each student describes his perception about death by showing diverse ways of understanding and coping with it. S6 reveals that death can only be comprehended by those who experience it. This may be the reason for human beings to struggle with finitude, which points out the enormous subjectivity in the real meaning of death in their lives.

I believe that speaking of death is as complex as thinking about it; the meaning of such process is so much dependent on each person's culture and that will influence their creeds. Questionings are related to what happens after death; that's where we have to stop mulling over it and refuse to accept that life ends right there. Then, we come up with several attempts to unveil such inner conflict: where do we go to after death? However, it is quite interesting that this question and others related to our existence will never be fully answered. So, we will have to wait until we ourselves experience what death is. (A6)

Death is quite a complicated reality to deal with. Although we are born under the certainty that we will surely die one day, we choose not to think about this reality and that's why we are so impacted by the loss of our dear ones. I think that we should not suffer so much, as it is just one more fulfilled phase, [...]; when it is time for us to die, even when everything that could be done was done, it will worth nothing [...]. (A28)

The human existence can become a matter of questioning, especially when the Being-there experiences facticities in his daily life that he is not able to immediately cope with, thus generating feelings of fear and suffering. In this moment, the human being seals himself in, unable to comprehend his own existential condition and denying himself the unveiled truth surrounding him, that is, the fact that he is a finite being.

A study carried out with Nursing students pointed out the need of promoting a reflection about the presence of negative feelings, as their recognition becomes an indispensable process toward rendering quality services. This is the moment when the student starts establishing the first connections with situations of loss. It is a compulsory need, therefore, to cope with their emotional aspects in this process, so that they find out strategies to deal with their own pain and the affliction of their patients⁽¹¹⁾.

The conception of being finite awakens in the student a feeling of injustice concerning those who fight for a lifetime and receive death as a reward, thus provoking anguish and indignation. Such perception is manifested by a type of existential emptiness, bringing an end to the sense of continuity and generating frustration.

I think it is the end for those who fought for a lifetime or for those who saw life passing by a window. (A3)

People focus their attention only in the facticities of death and the transience of life. They forget to enjoy the events of their past, their achieved projects, joys, their creative acts, as well as all the sufferings they bravely coped with⁽¹²⁾.

Although the vast majority of people admit that death is part of the human existence, some statements express a feeling of denial. It can be realized that those feelings of fear expressed by the students unveil their concern at assimilating death. People fear and fight against this natural event named death by valuing youth, health and immortality, sometimes hiding and some other times denying such inescapable reality⁽¹³⁾. Another study also pointed out a reaction of denial on the part of nurses, which may interfere in the way they care of dying patients and their families⁽⁷⁾.

Death is a natural process which all of us are subject to, there is no way one can change that. Yet, although everyone knows about it, no one thinks about death in a daily basis. People always fear this process and it is hard to believe that one does not fear death. (A18)

In his initial everydayness, the Being-there often veils to himself his condition of Being-toward-death, thus fleeing the only absolute certainty about his existence. However, it is by existing that the Being-in-the-world actually dies, although most of the times he does this in a decadent way. "This decadent Being-together-with announces the attempt to escape strangeness; in other words, a more appropriate Being-toward-death"⁽¹⁰⁾. This thought enlivens a reflection about A18's words, who said that whenever one finds out his finite being he/she will dive into a state of decadence, experiencing an immersion in daily trivialities and neglecting his/her true existential condition, that is, that of being a Being-toward-death.

Understanding death as a natural process

The explanation of the Being-toward-death in the human being's everydayness is seen in the world's publicity. It is in the public arena of life that the Being-toward-death envisions death as an announced, yet distant fact, always as a natural process. Death meets men as a daily occurrence known within the world⁽¹⁰⁾.

Literature highlights that as students and Nursing professionals live death situations, they experience feelings of inefficacy and impotence^{(1,2,4,12,14)}. However, the present study reveals that some students face the phenomenon as being a proper or natural fact of human beings.

To me it means the aging process, a natural process, or the development of a disease. (A1)

Death may take place either by the natural aging process of the living beings or by a sudden event, such as an accident, a disease, among other factors. (A17)

The statements show that some students understand death as a concrete incident, taking into account the aging process, a disease or an accident as possibilities in man's daily life. Such vision may be related to the fact that death and the feelings stirred by it are so far away from their realities that the students are led to face them objectively. Nevertheless, such thought may favor them in better coping with finitude whenever they are challenged by the most diverse death situations inherent to their future professional activity.

Another aspect in this context is that the meaning of death may be related to a natural process, hence being comprehended as a consequence of life whenever the care involves aged patients or patients presenting chronic diseases, to whom the professionals do not yet have an affective bond. On the other hand, when it comes to dear ones, the idea of finitude as a natural process gives place to a painful loss. Thus, to cope with the human being's finitude dos not only entangle the technical aspects of death, but also affective/emotional ones⁽¹⁴⁾.

It means that a cycle is over, either provoked or caused by natural events. This process will be experienced by everyone. And although it is very sad to lose someone we love, death will eventually take place, regardless of our will. (A15)

This is a process all of us will face one day. For those who lose a relative, a close friend, it is quite a tough process to readapt to life without that person. Many people do not accept it and suffer very much. This is quite a delicate and complicated process. (A20)

It can be observed that although death is understood as an acceptable event, something that will happen to everyone and that should be assimilated, students recognize the suffering caused by the loss of a dear one, showing that death is not easily absorbed, as reason and emotion confront each other in the search for an understanding of the meaning of death. "Death is revealed as a loss, a loss felt by those who stay; yet, only the physical loss is felt, as the existential loss can only be experienced by the dying one"⁽⁹⁾.

Notwithstanding, some students understand death as inescapability to the being, something that will be experienced by all of us, with no exception. One has to let go of the prejudices surrounding this existential structure in order to get rid of the fears and sufferings unleashed by death.

It means that all of us will undergo such process. Death is unavoidable; all of us are going to die one day. We do not need to get scared; this is a natural step in anyone's life. (A25)

I think that we should not suffer that much, as this is just another stage [...] When it is time for us to die, even when everything that could be done was done, it won't change anything [...]. (A28)

Death can be characterized as the end of the human condition and the interruption of vital, social and psychic functions of the being, an essential datum in the human existence. Death is exactly this end without another beginning, this definite closure. It is the human possibility that ceases all others⁽¹⁵⁾.

Death is the absence of vital signs, when the person ends a life stage. Many religions believe that life goes on after death. For me, it is the end of a phase of living, dreaming and achieving anything. (A11)

The end of social relationships, as well as biological and psychological functions. (A7)

The statements presented here show that the being tends to rationally deal with the terminality of life, an attempt to live with this certainty in a harmonious way. Hence, to conceive death as a natural and inevitable event means to admit that life has a beginning, middle and end.

The end of life brings the termination of a universe of possibilities, desires and dreams, resembling the individual's body that no longer exists, in such a way that no experience whatsoever will be added anymore besides death itself.

In a final analysis, among all things that are given to us, the most real and absolute is death. Such reality consolidates the appropriation of our own existence, causing us to take up our singularity and finally understand that, in the end, we are all Beings-toward-death and that no experience, except our finitude⁽¹⁵⁾, exists at all, no matter how intrinsic or constitutive they might be.

Addressing death as a passage to another life

Religiosity is considered by several authors as a relevant ally in the process of accepting and coping with death, as it comforts us, gives us hope and helps us overcome such hard moment. Religion not only offers comfort in times of suffering, but, at least in some creeds, it offers a promise of life after death and of meeting the lost family⁽¹⁶⁾.

When questioned about the meaning of death, some students said that death is a phase of life that leads to "another level", that is, a moment of a passage to something better, from a finite to an eternal life. It can be observed that this vision, based on religious beliefs, influences the way these subjects accept death:

To die is to pass from this earthly life to a spiritual life. It means to interrupt the relationship with earthly people and to start ruling with Christ in a much better place than this one we live here. (A2)

Death is deemed to be the end of life. But, for those who believe in God and in the eternal life, it is just the beginning. (A5)

Religious and spiritual beliefs offer possibilities of meaning and answer to the existential questions triggered by the dying possibility⁽¹⁶⁾. It can be noticed that for the students who believe in the conception of the beginning of a new existence, death sounds like a positive fact. In this way, it can be observed that the fact of believing that such phenomenon is not an end causes human beings to keep the flame of hope that one day they will meet their loved ones again, something that gives them strength to bear the hardships caused by death and supply their emotional needs of having an expectation toward the future, as posed by A27:

When the person is known and loved it hurts a lot to know that the connection in this life is over. I believe in salvation and eternal life, and this makes the loss less painful, as I know that I will possibly see that person again. (A27)

This approach of death as a passage to another life has been corroborated by the results achieved by a study carried out with Nursing professionals, which pointed out that students tend to associate death to the meaning of transcendence, that is, they tend to see it as a passage and not an end⁽⁶⁾.

Another significant phenomenon observed in the statements refers to the fact that the students quoted death as a loss of bodily functions, but not a loss of the functions of the soul:

A process which all of us will undergo one day, when our body will lose its biological functions and our souls will head to another dimension. (A24)

Biologically speaking, it would be the loss of all functions, it would be the interruption of vital signs. Spiritually speaking, it would be the loss of the breath of life, which would return to God, and we would be no longer living souls, but a body that would return to the ground where it has come from. (A26)

It is clearly seen that, in the perception of the students, life is composed of an immortal soul that owns a mortal physical body. Such belief is reinforced by the vast majority of religions and spiritualist schools that believe in the concept of the immortality and indestructibility of the soul⁽¹⁷⁾.

Nonetheless, some authors believe that the romantism produced by the religions is nothing more than a desperate way of neglecting man's own finitude, due to the difficulty he has to cope with his own fears of death and actually working like defenses against pain. Man suffers because he starts to realize his finitude, in spite of knowing that death is an inherent part of the human condition. The existence of a whole social framework of denying death is quite a common practice⁽¹⁸⁾.

In the perspective of the subjectivity of the meaning of death, it is possible to comprehend it as a passage or beginning of a new life, which can be understood as a positive fact, as many individuals find in faith and religion subsidies to make death more acceptable and understandable. However, others comprehend death as a negative fact; specialized literature on this issue reveals that denying death is one of the ways men come up with in order not to contact painful experiences, thus leading him to a world of fantasy where the illusion of immortality lies⁽¹⁹⁾.

CONCLUSIONS

The conceptions of the students allow for a reflection on their immaturity at entering the nursing course concerning the way they cope with the death/dying process. Such revelation matches the findings of the studies presented in this article, which highlight how important it is to address this issue in the beginning of the undergraduate course, as students need to be prepared to experience the death/dying process of future clients.

For the students in this present study, although death is considered as a natural fact of life, it brings along the painful experience of separating people from their loved ones. That is why many of them refuse to accept it and approach it as being a mystery that can only be unveiled by death itself.

This present study also showed that knowledge and death are bound in the temporal world and in the historicity of each being, making the scientific, philosophical and ethical understanding an essential step toward comprehending the death/dying phenomenon and urging the student to get ready for the humanized care of the patient and his family. In this way, healthcare professionals are able to provide a whole and high quality care in finitude situations, having in mind the biopsychosocial and spiritual needs of those human beings and effectively acting in the care process.

It is the right moment to point to some limitations of the study, stemming from the fact of its contextualization in the time and space of the experiences of the participants, which may not leave any room to generalizations. However, it is believed that it can be used in similar environments and contribute toward the deepening of the knowledge and reflection regarding this issue.

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Publication Dates

• Publication in this collection
  03 Apr 2013
• Date of issue
  Mar 2013

History

• Received
  12 June 2012
• Accepted
  04 Feb 2013