Temporality: existing and the perspective of finiteness for nursing students when experiencing death¹

Temporalidad: la existencia y la perspectiva de la finitud para el estudiante de enfermería experiencia de muerte

Abstracts

Phenomenological qualitative research that used Heidegger's hermeneutics, with the aim to understand the meaning of finiteness for nursing students when experiencing death. Data were collected between March and May of 2011, by means of interviews with eight nursing students from the Federal University of Santa Catarina. The audio of the phenomenological interviews was recorded and later transcribed. Data were analyzed as per the stages of pre-understanding, understanding, and interpretation of what the participants said, and the following units of meaning emerged: Temporality and existence as a prerogative of the academic being, The experience of death: when a loved one passes away, and Disease as a possibility of being-toward-death. Nursing students view themselves to be temporarily inserted in the world and are aware that they are a being-toward-death when reflecting on death, and their constant return to fundamental questions of their being, configuring themselves as the basis of their entire interpretation about life and living.

Nursing students; Family relations; Death; Nursing philosophy

Estudio cualitativo que utilizó la hermenéutica fenomenológica heideggeriana con el objetivo de comprender el significado de la finitud para el estudiante de enfermería y la experiencia de la muerte. Los datos fueron recolectados entre marzo y mayo de 2011, se entrevistaron a ocho estudiantes de enfermería de la Universidad Federal de Santa Catarina. La entrevista fenomenológica fue audiogravada y transcritas posteriormente. El análisis de los datos fue por pre-comprensión, comprensión e interpretación del discurso de los participantes. Surgieron las siguientes unidades: la temporalidad y la existencia como la prerrogativa del ser académica, la experiencia de la muerte: cuando un ser querido se ha ido, y la enfermedad como una posibilidad del ser para la muerte. El estudiante de enfermería es comprendido como un ser que entró temporalmente en el mundo y como un ser para la muerte en consonancia con la muerte, y su retorno constante a las preguntas fundamentales de su ser, lo configuran como la base de la interpretación de la vida y del vivir.

Estudiantes de enfermería; Relaciones familiares; Muerte; Filosofía en enfermería

Pesquisa qualitativa fenomenológica que utilizou a Hermenêutica heideggeriana, que tem como objetivo compreender o significado da finitude para o ser-acadêmico-de-enfermagem ao experienciar a morte. Os dados foram coletados nos meses de março a maio de 2011, sendo entrevistados oito acadêmicos de enfermagem da Universidade Federal de Santa Catarina. A entrevista fenomenológica foi audiogravada e posteriormente transcrita. A análise dos dados deu-se pela pré-compreensão, compreensão e interpretação das falas dos sujeitos. Emergiram as seguintes unidades de significado: Temporalidade e existência como prerrogativa do ser-acadêmico; A experiência da morte: quando um ente querido se vai; e A doença enquanto possibilidade de ser-para-a-morte. O ser-acadêmico-de-enfermagem compreende-se como ser temporalmente inserido no mundo e tem consciência de que é um ser-para-a-morte quando reflete sobre a morte, e seu retorno constante às questões fundamentais de seu ser, configurando-se como a base de toda a sua interpretação sobre a vida e o viver.

Estudantes de enfermagem; Relações familiares; Morte; Filosofia em enfermagem

INTRODUCTION

Contemporary reflections about the human being pass through intrinsic phenomena sometimes linked to temporality and experiences, or observed within the scope of death linked to finiteness.

Philosophically, death has been discussed since the beginning of times as a human condition to exist temporally. In his work, Heidegger seeks to reveal the phenomenon of being and time in their nuances, and in paragraphs § 68 and § 69 of Being and Time he addresses temporality and everydayness as possibilities of opening to presence.¹

Existence, as temporality, is linked to the nexus of presence, in its happening, which when released in its existential and temporal conditions, leads to an ontological understanding of historicity.¹

When thinking of being, Heidegger raises the question of its origin, which assumes man as having a beginning and an end based on a temporal happening. Heidegger's origin is linked to the being of presence, which represents the phenomenon that leads man to think, not strongly on birth itself, but from a perspective centered on death. The same author says that Heidegger does not refer in particular to the ontic and ontological problem of birth and neither to his experience.²

In this interim life and death are at stake as possible phenomena to being where "the sense in which life takes on a function: the context, the fundamental reality, the circum-inclusive unit within which all phenomena are erected".^1:30 Here, life and death are given to the being-in-the-world in his temporality and treated not as parts of an existence, but as an intrinsic condition of being.

The nursing training process involves different contexts and actors where the academic being experiences moments of learning involving theoretical and practical knowledge. When in contact with the real environment of learning in the practical field, these academic beings encounter death, which makes their own finiteness evident and can greatly influence their way of caring. Therefore, knowing the feelings and experiences of nursing students in their learning process involving death can bring elements to minimize their distress and the suffering that this reality shows.

Nursing students experience death in their daily work in the first practical contacts in the field, and they are faced at that moment with sensations and feelings of loss, finiteness, and fragility of life. These feelings are then carried over to themselves, their family, and the people they love, creating tension and fear of loss.

These dimensions of being, life and death are present for nursing students in their daily lives, which raises the following research question: how do nursing students deal with and experience death? To think about these questions and temporally reveal the meaning of death to the academic being are the perspective of this study, which aims to understand the meaning of finiteness for nursing students when experiencing death.

METHODOLOGY

This is a phenomenological study using Heidegger's theoretical framework^{1 - 3} with the hermeneutic perspective on the movement of pre-understanding, understanding, and interpretation of the phenomenon not as something fragmented or sequential, but as something that unveils the phenomenon in movement where the "hermeneutics of presence also becomes a hermeneutic towards developing conditions of possibility of the entire ontological investigation."^1:69

The study participants included eight students enrolled in the third term of the undergraduate nursing course of the Federal University of Santa Catarina, in Brazil. The collection of testimonials occurred between March and May of 2011 through phenomenological interviews in a classroom at the Federal University of Santa Catarina. The audio of the interviews was recorded and later transcribed. After repeated readings, the testimonies pointed to the understanding and interpretation of the phenomenon.

The study complied with the requirements of resolution 196/96, which concerns studies involving human beings.⁴ The study was approved by the Research Ethics Committee of the university under protocol n. 1086/10. All participants signed an informed consent form, and they were given an alpha-numeric code to ensure their anonymity.

The data collected originated the following units of meaning for the analysis: Temporality and existence as a prerogative of the academic being; The experience of death: when a loved one passes away; and Disease as a possibility of being-toward-death.

DISCUSSION AND UNVEILING OF THE MEANINGS OF THE NURSING STUDENT PHENOMENON AND THE PERSPECTIVE OF FINITENESS

Pre-understanding emerges here based on the closeness to the phenomenon and its conception, which at this first moment we will call 'temporality and existence as a prerogative of the academic being'. The second hermeneutic movement, characterized as understanding, is related to the contact and experiences of the academic being with the perspective of finiteness through their memories since childhood to the present day, which we call 'the experience of death: when a loved one passes away', and finally 'disease as a possibility of being-toward-death', the understanding represented by experience. The third perspective is the interpretation of the phenomenon, which occurs simultaneously with the other two, such as come and go in Heidegger's movement of veiling and unveiling.

Temporality and existence as a prerogative of the academic being

Historically, death is treated by society as a condition of life. Therefore, "experiences, individual men, a population, a culture succumb to death"^1:36 and the analogy of men with death is different from the one they have with other transient phenomena. Death characterizes temporal beings, which we all are, and our existence as human beings is directly connected with this perspective. Nursing students perceive themselves as a finite and mortal being when inserted into the hospital field during their academic training process. When they experience the death of others, they reflect on their own death and that of their loved ones.

In other nuances of death experienced by men in history, there is the one in which this relationship corresponds to the death of the other, not upon death itself, as the philosophers mention, but the perspective of it happening to a loved one, a friend, a family member, leads to a dimension of suffering and pain with the loss. In the mid-nineteenth century, men began to occupy themselves less with their own death and more with the death of others. This attitude remains to this day, as there is a concern about ourselves, but also with the possibility of losing someone we love. Beginning in the 20th century, death, which had been treated as a phenomenon of nature that would take place at home with our loved ones, was dominated by technology and linked to the hospital, to treatment, to the healthcare team, and no longer to the family as before.⁵

The temporal aspects related to death and dying bring the perspective of life, of living as a condition of existence. Life is a creative release, becoming exposed, where the being-there, as termed by Heidegger as presence or being-in-the-world, is in this life experimenting and learning what is experienced in a condition called subject-object split, which cannot be separated.¹

In the pre-understanding movement, to transit among the concepts and definitions about the phenomenon that is being unveiled is essential so that the movements of the academic being and the possibility of being-toward-death can be understood.

The interviews showed that nursing students recognize their temporal dimension, and the perspective of death as part of their life experience. In moments they describe, conditions of health and disease are at stake, situations in their own childhood that bring back memories of the hospital, of medical procedures, loss of family members to death, and the existential conditions that finiteness presents to them each day.

These situations lived out are part of the fundamental experience of being, called preconceptions, understood as a guideline that sustains all else, the basis of everything that we call life. Thus, "the nexus of life consists of a sequence of experiences in time. In this sequence of experiences, the only thing that is real is the experience simply given in each moment. Past and future experiences are no longer or not yet real".^1:464

From another perspective, the above author states that, if the basis of the characterization of life is the period between birth and death, viewed as simply temporal, this is not sufficient to explain the phenomenon. There is something more in this nexus than just time, the events that happen themselves, and the being has the possibility to experience them in different ways. Thus, when understood existentially, birth is not and can never be the past in the sense that it is no longer simply given. Likewise, death does not have the underlying nature of something that simply did not happen any more, that is pending and in advent. "In fact, presence only exists as a wellspring and it is a wellspring that already dies in the sense of being-toward-death."^{1:465- 66}

This soil of life delimits the existence as the characterization of something, its determination of being oneself in a keen sense of self, however, this formal definition of existence occurs based on an interpretation of oneself and of life itself conceived by the sense of being where oneself is linked to the world, shared and surrounding, giving meaning to one's experience, characterizing historicity.¹

Nursing students experience this historical conception where they transit, as it is observed in the following testimony:

[...] if today I have compassion, if today I can practice nursing, it is because I think that nursing is not for everyone. You deal with people, you deal with a critical period. So for you to be a good nurse, for you to take care of a person, you have to have an image of life, you have to have a life history that makes you humble enough to be able to care for a person. It is a construction of what I am today. I think that today I can do this. I hope that as a nurse I'll be able to look at people with a different look and be able to give a little bit of myself in the profession (A10).

When she mentions that she expects something from her life, the future is manifested. The things to come are a condition of being, and are not necessarily tied to a future perspective, but a happening of experience. Another account that links looking ahead as a temporal possibility has to do with how the nursing student wants to view her daily tasks in a different way than what has been observed, which shows that she has a position about her life.

I hope to be like this and not lose it over time. I am a caring person and not like we see today. Many people don't care about their work and do it any way. I don't want to become like that (A3).

At the movement of recovery, described by Heidegger as a remembrance, nursing students recall their childhood and how it may have influenced their being-toward-death when they mention the care of their mother and the significance of this gesture as a mode of temporal being.

[...] I remember from my childhood. I have a neighbor that since she was a child, when she got sick, her mother did not take care of her so she would come to my house and my mother would take care of her (A4).

The experience of death: when a loved one passes away

Experiencing death is configured as a way of being for nursing students, who reveal their confrontation when questioned. Each being has within them a conception about this experience and thinks, however, that this will be sufficient to minimize the suffering and pain that loss brings.

In Heidegger's philosophy, "to the extent that life is a fluent and infinite whole, but the concepts are ways that stabilize life, making it impossible to truly grasp life."^1:51 Therefore, the meanings about death assume in each person a possibility of meaning that we recall in difficult situations, and to live with the certainty of finiteness feeds many uncertainties in this universe of possibilities that life offers.

The prospect of death causes in beings many sensations such as that of feeling fear, anxiety, grief, and sadness, but there is one in particular that causes beings to reflect on their convictions: the feeling that they did not live intensely, that they could have done more, other things, that they should have had other experiences. This perception of life, when faced with the possibility of death, brings out feelings of guilt and stress.⁵

From this temporal point of view, beings face the loss of loved ones, which is configured as "one of the most intensely painful experiences a human being can suffer".^6:389

Death is usually conceived in our imagination as a temporal succession where first of all the being is born, grows, has experiences, ages, and only then is death present in the imagination, like an afterthought. This biologic view of death does not always happen in the everyday life of beings, and haunts them through disease, an accident, a sudden illness, or another possibility not thought of rationally.

To think of death as a loss, especially when it comes to loved ones, raises suffering and pain because of the impossibility of making any intervention. The absence of the "familiar can take the family to an existential loneliness in which all aid and protections are ineffective in quenching it, so the family feels completely lost and helpless"^7:215 as we can see in the testimony: [...] my grandfather passed away. It was very sad. My grandmother was heartbroken. At first she didn't have any energy for anything. She didn't eat right, and that was another obstacle. It took a long time for my grandmother to understand what had happened, for her to get through that and have courage to continue and see that life goes on. Today she is fine (A1).

From this angle of the nursing student, her grandfather's death had consequences for her companion of many years, destabilizing her life as well because of the long time of living together that created mutual affinity and attachment, and the loss of a loved one generated profound changes in those who stayed behind. It is important to note how difficult it is for family members to accept this process of death/dying, considering that the death of a family member causes an intense reaction to the bereaved individual and the family system.⁷

The being-there manifests itself in everyday life, and the experiences of this being are brought out from the perspective on the situations that are part of their world. Being our loved one presupposes that in the absence from death, the pain is ours because of the loss of our loved one, and at this moment of suffering, despite having knowledge of the disease and the fragility of our family member, death is not understood as part of human life.

[...] I lost my grandfather...I was very sad. He was always sick, as he was a diabetic. He had only one lung and was very weak. Sometimes he had to be on oxygen at home. I felt sorry for him with that tube of oxygen he had to have. There was a time when he lived more at the hospital than at home (A3).

The impact that death causes on family life, and in this case to a nursing student, is felt for life. When a loved one is lost, beings keep in their memories this image and recall it whenever faced with a similar situation to that of their loss. The nursing students in this study revealed death as present in their life, and presented in different ways. Generally, at first with grandparents, but also with cousins, uncles, and other loved ones. This loss is remembered as a fatality, injustice, as something that should not have happened at that time, even without referring to when would be the best time for this event, when it would be less painful.

[...] I have a grandfather who I never met. He died before I was born. And I have a grandfather who died when I was in sixth grade. He had lung cancer. I was very attached to him (A4).

[...] I barely knew my grandparents. They died very early. On my father's side, when I was born. A year later, my grandmother died. And on my mother's side, her parents had already passed away, so I didn't have the opportunity to get to know them (A5).

The being free to death place existence in its finiteness, and this finiteness removes from the presence the eternal condition of well-being that temporally offers itself as a possibility and places it "in the simplicity of their fate".^1:476

The testimonies from the nursing students reveal that the experiences of loss, when recalled, are capable of making them get a glimpse of their own finiteness as a possibility of a being-toward-death, that time numbs but their historicity unveils. Thus, the same anticipatory disposition to which the being-there is immersed leads to understanding their finiteness in trying to understand the death of other ones.⁷

Disease as a possibility of being-toward-death

Our daily lives reveal to us a contradictory perception of death: in one respect, it draws our attention to every headline related to death or the process of dying brought at any moment by the news media; in another aspect, when we think or experience something that brings us closer to or reminds us of our death or that of a loved one, we try to change the subject or sublimate the thought to something spiritual.

Disease is one of those aspects that keep us always connected to death and its nuances. Thinking about death is almost always inevitable when a phenomenon undermines health and beings begin to bring their life into balance based on what they have available emotionally and physically. Upon receiving a medical diagnosis detecting a change in health, no matter how small, this opens the doors of beings to a series of expectations about their existence as a being-in-the-world.

By remembering events that occurred in their life linked to some kind of fragility, this nursing student describes her mother's illness as an unpleasant experience when she experienced feelings of loss and pain when seeing death as a possibility:

[...] what I have marked in my teens of care was when I was about 15 or 16. My mother became ill. She had thrombosis and was a period when she had to be hospitalized I think for about four months. It was a period of shock for me. What passed through my mind at that moment was that I could lose my mother. It was very complicated (A5).

Another testimony on the experience with disease and the perspective of finiteness is described by a nursing student who experienced a situation of having to care for her mother. In this reference about the disease, she says that her mother had to make an important decision involving not only herself, but the other being, as noted: [...] there was a time when I took care of my mother. She had a fibroid. She had already has this fibroid actually when she was pregnant with me. The doctor had asked her, "Do you really want to carry the pregnancy farther? Because it could turn out that you will have to choose between the fibroid or the baby, or her as well", as her life would be at risk too. But my mother decided to carry the child to term. My mother was very afraid of doing a surgery. She was very reluctant and still is. My mother has a lot of fears about health and hospitals (A1).

Nurses work all the time with this reality in their daily tasks and since the process of career choice, they know that the presence of death is a prerogative of their work. In their professional training, nursing students undergo a context that is opposite to that of acceptance of natural death, but they gain knowledge and learn to deny death and preserve life. Our Western society negates death and professionally speaking death is regarded as a failure since nurses are instructed to impede it.⁸ In the case of professionals, the death of a being under their care generates doubts and questions about their competence.

The possibility of accepting natural death is currently not a part of the professional daily task for the nurse, as well as of the lives of beings, considering that the technology and resources developed so far make it possible for patients to have a longer life or the cure of their pathology. Between the 5th and 15th centuries, natural death was viewed as something that occurred in a family atmosphere, assisted by all, and was accepted as a certainty of life, experienced and shared among friends and family, giving the opportunity to the being to say goodbye, but this is no more experienced in the Western world today.⁵

However, faced with the prospect of death, nursing students see in themselves the unveiling of the being-toward-death where the finiteness is realized as inevitable. And when they choose their profession, their family tries to protect them from the suffering and pain, as described below: [...] 'think well. You are going to deal with sick people, you could catch a disease, you are going to cry, to suffer. You know how much you cry and are sentimental. You could suffer when someone dies, when someone you really wanted to get better gets worse' [father talking]. Then I got to thinking and said: what if I take care of someone who gets better, the person recovers and doesn't die, or even if the person dies, I'll take care of that person-that is what is important. This person needs someone to take care of them (A7).

On the other hand, there are different opinions about death and its way of being, as mentioned in another study related to nursing students highlighting that newcomers to the course view death as an enemy and believe that their goal is to fight it and preserve life.⁹

In general, nurses avoid talking about death in their everyday conversations, and when they talk about it, they replace the word death with another word, which sometimes does not mean the same thing, or they even refer to it evasively, implying about what they are talking about.⁵ This behavior can be seen in the account of this nursing student: [...] once I had a seizure. My mother says that it was a big shock because I had this seizure with a very high fever. They were taking me to the hospital and I had this seizure. I was hospitalized, was left unconscious because of the seizure, it was serious. For them it was a big scare. They even thought that something more serious could happen to me (A1).

The difficulty in addressing this topic happens because the professionals in their training become linked to the preservation of life and healing, as these are the prerogatives that bring gratification for their work.¹⁰ When referring to death, the professionals experience feelings of sadness and helplessness because caring is always involved with the care in a close relationship, especially when there was a longer time in this interaction.¹¹

In this existential dynamics, academic beings encounter obstacles arising from their prior understanding of finiteness and at the same time are faced with other possibilities that they did not know about, and this context is presented in a personal and professional turning point because their occupation with care brings this permanent confrontation with the presence. In this sense, "to release the structure of what happens and its existential and temporal conditions of possibility means gaining an ontological understanding of historicity".^1:466 And as they recognize themselves as historical beings, academic beings reflect on their life story and understand their own temporality, as noted in these words: [...] first it was with my grandfather eight years ago. He developed stomach cancer and had to operate. He did fine until two years ago, but then it came back. Actually it didn't come back because it was another cancer, in the throat. It went getting worse, it hurt for a time, and we had to take care of several things. We took him, did therapy, chemotherapy, and everything, but in the end it went to the lung and then there was nothing else we could do. It was a difficult period for us, real drastic (A2).

This process of understanding is unveiled by academic beings when they recall their memories, "understanding is not a mere record of oneself that simply accompanies all behaviors of the presence. To understand means to project oneself at every chance of being-in-the-world, which means to exist with this possibility".^1:480

With respect to the process of understanding and interpreting the phenomenon, the being "upon understanding, the interpretation moves in becoming comprehensively toward a cyclical totality already understood".^1:211 The assimilation of what is understood, that remains veiled, unfolds in the unveiling conducted by the previous view, which is based on a previous position as a certain possibility of interpretation.¹

The reflections of academic beings about finiteness, death, and loss in their experiences make it possible to understand the being-toward-death that we all are, and from there their interpretation of existence as temporal prerogative was unveiled. By turning within, they recognize their life story while living and their experiences as a temporal experience depending on their interpretation: [...] things happen and time does not go back. I always say to my colleagues who say they want time to pass quickly. I'm different. I don't want time to pass by. I want to take advantage of every minute because I know that time passes quickly and I want to enjoy every minute. So I take advantage of these experiences also as a professional and try to make the most of them (A10).

By welcoming this interpretive possibility for existence we recognize the uniqueness and the specific nature of each being and each entity of this being is manifested in its simplicity, where each entity is not unveiled unless through the foundation of a prior conceptual understanding, though not aware of what this respective entity is and how it is. Every ontic interpretation moves over the ground of an ontology, and this ground is immediate and most of the times hidden.^1:72

Time begins to be understood as the beginning of all existence as we gain a sense of our finiteness, our physical death, and we organize our life from the moment we recognize ourselves as beings-in-the-world.

The existentialist perspective emerges as another possibility to understand life, considering man as the author of his story, as the main person responsible for his fate and, thus, keeping the space-temporal relationship in which he is inserted.

CONCLUSION

By examining the hermeneutic phenomenology to reveal the phenomenon of nursing students and their experience with finiteness and death, we realize that these beings view themselves as temporally inserted in the world and are aware that they are a being-toward-death.

These reflections bring up a universe of possibilities for interpreting this finiteness when reflecting on death, and their constant return to fundamental questions of their being, configuring themselves as the basis of their entire interpretation about life and living.

Nursing students as beings-toward-death define themselves as a temporal being and manifest themselves as being-with, which is a socially constituted being attentive to their loved ones close to their essence, concerned with others and with themselves. The understanding and interpretation of the experiences of nursing students about death may give rise to new perspectives to teaching nursing as a profession of care, where getting to know students and future professionals makes it possible to understand their behaviors in their future. Death, as a paradox of life, more than interpreted, should be assimilated as the only certainty in life and that it will never be unveiled in its entirety.

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• 1
  Excerpt of the thesis - The temporality of Being-academic-of-nursing in the care experience: an interpretation in Heidegger, presented to the Nursing Graduate Program of the Universidade Federal de Santa Catarina (UFSC) in 2012

Publication Dates

• Publication in this collection
  Jul-Sep 2014

History

• Received
  26 June 2013
• Accepted
  05 Dec 2013