Death education: sensibility for caregiving

Objective: to report the application of a participatory teaching-learning method on the themes death, dying, and associate care to highlight its applicability to the students. Method: report of application of participatory method in 22 students from the 6th period of the undergraduate program in Nursing and Obstetrics of a public university. The fi rst stage focused on personal experiences of the students and the second on professional prospects. As resources for data collection we used music, drawing, drama, and photography. Results: after applying the method, the students assigned meanings to death and nursing care, refl ected, criticized, and resignifi ed experiences on the theme. Conclusion: the method was considered applicable and effective to achieve the objective, that is, it enables learners to act as protagonists of the teaching-learning process, building together a new perspective of end-of-life care. Descriptors: Death; Nursing Students; Education in Nursing; Nursing Care; Attitude Before Death. RESUMO Objetivo: relatar a aplicação de um método participativo de ensino-aprendizagem sobre o tema da morte, morrer e cuidados associados, a fi m de evidenciar sua aplicabilidade junto a estudantes. Método: relato de aplicação de método participativo com grupo de 22 estudantes do 6o período do curso de Enfermagem e Obstetrícia de uma Universidade Pública Federal. A primeira etapa focou experiências pessoais dos estudantes e a segunda, as perspectivas profi ssionais. Foram utilizados como recursos para coleta de dados: música, desenho, dramatização e fotografi a. Resultados: após a aplicação do método, os estudantes atribuíram sentidos à morte e aos cuidados de enfermagem, refl etiram, criticaram e ressignifi caram experiências e vivências sobre o tema. Conclusão: o método mostrou-se aplicável e efi caz para o alcance do objetivo, ou seja, possibilita que os educandos atuem como protagonistas do ensinoaprendizagem, construindo, juntos, uma nova perspectiva do cuidado com a morte e o processo de morrer. Descritores: Morte; Estudantes de Enfermagem; Educação em Enfermagem; Cuidados de Enfermagem; Atitude Frente à Morte. RESUMEN Objetivo: relatar la aplicación de un método participativo de enseñanza-aprendizaje sobre el tema de la muerte, morir y los cuidados asociados, con el objetivo de evidenciar su aplicabilidad junto a estudiantes. Método: relato de aplicación de método participativo con grupo de 22 estudiantes del 6o período del curso de Enfermería y Obstetricia de una Universidad Pública Federal. La primera etapa enfocó las experiencias personales de los estudiantes y la segunda, las perspectivas profesionales. Fueron utilizados como recursos para la recogida de datos: la música, el dibujo, la dramatización y la fotografía. Resultados: Después de la aplicación del método, los estudiantes atribuyeron sentidos a la muerte y a los cuidados de enfermería, refl ejaron, criticaron y resignifi caron las experiencias y las vivencias sobre el tema. Conclusión: el método se mostró aplicable y efi caz para el alcance del objetivo, o sea, posibilita que los educandos accionen como protagonistas de la enseñanza-aprendizaje, construyendo, juntos, una nueva perspectiva del cuidado con la muerte y el proceso de morir. Descriptores: Muerte; Estudiantes de Enfermería; Educación en Enfermería; Cuidados de Enfermería; Actitud Delante la Muerte. Márcia de Assunção Ferreira E-mail: marcia.eean@gmail.com CORRESPONDING AUTHOR


INTRODUCTION
Daily life care imposes situations of duality as health and disease, birth and death, which require professional preparation to deal with limiting situations.In Western society, death is still considered taboo and, therefore, needs to be addressed with honesty and integrity in the various situations of care.
When health professionals face suffering, disease, death, and dying, it is hard for them to deal and communicate to the patients about their illness and eventual death, so that often they feel limited to act in this scenario of suffering and distress (1) .It is an approach that needs to be trained from vocational training, since it requires technical expertise, knowledge, reasoning, perception, and sensitivity.
Although death is part of the cycle of life and present in the daily life of health professionals, pedagogical investments are still required to help dealing with this phenomenon, particularly for the nursing staff (2)(3) .A study reports a lack in the training of nurses to face the death of critically ill patients as a factor that interferes in the quality of the assistance provided.However, it does not indicate paths to minimize this lack (4) .
This deficiency is also reflected in the education area, evidenced by the presence of professionals insecure to address the theme, treating it with impersonality and discouraging reflection on it on the part of students (5) .In teaching, the fragmentation of content, the lack of coordination between disciplines, and the maintenance of conventional educational models do not contemplate the complexity of the human being (6) .
If the care of the body after death requires technical expertise, understanding the process of death and dying requires knowledge about human existence, its psychic, spiritual, and social demands.Thus, integrating content and applying innovative methodologies that address this issue with students enhances and enables the teaching-learning process to be closer to people's reality.
Working on communication skills and dialogue in such a singular and complicated situation, leading students to understand death in the experience of another (5) , and introducing a critical-reflexive view about the process of death and dying in the academic education are urgent measures, since providing quality end-of-life care is possible, especially when one is educationally prepared for that purpose (7) .That was the aim of a group of professors who resorted to an active, participative-oriented methodology to work the theme "death, dying, and end-of-life care to patients and their families" in a discipline of Nursing.
In the participatory methodologies applied in the researches, the subjects are co-producers of knowledge (8) ; Likewise, in the educational process, students are shifted from the role of passive receivers of the knowledge transmitted by professors in the classroom to become protagonists, to enhance their knowledge and experiences on the subject (9) .To apply active and participatory methods in the process of training is important because it allows better understanding of the issues, from both theoretical and practical points of view, and encourages a critical reflection of the students by placing them in the role of protagonists of their own learning and training (10)(11) .
Because this study involves pictures and written documentation on the discussions carried out during the activities that compose the teaching-learning method, students expressed agreement so that all content discussed at these moments integrates the discipline reports.Thus, this report was composed of material extracted from reports written by the professors who proposed and developed this method.
This article aims to report the application of a participatory teaching-learning method on the themes death, dying, and associate care to highlight its applicability to students.

OBJECTIVE
To approach students to the theme of death and dying through activities that promote self-knowledge and reflective discussions, awakened by the dimension of affection on the role of nurses in the end-of-life care to patients and their families in situation of loss and grief.

METHOD
The method was applied to students of Nursing and Obstetrics of the UFRJ-Macaé Campus.This Campus reflects the initiative of internalization of the State University of Northern Rio de Janeiro, being an integrated and non-departmental structure, organized by undergraduate and graduate students with their respective committees.The undergraduate program in nursing began in 2009, with integrated syllabus and interdisciplinary disciplines, articulated to other undergraduate programs in health offered on the Campus.
The method was developed during the discipline "Care I: Adult, Senior, and Family" in the sixth period, because the theme "death and dying" integrates the discipline abovementioned, although it may be addressed in others, upon demand.The steps described below are sequential and aim to approach students to the theme, from the perspective of personal experiences, feelings, and expectations related to it.To develop it through the method applied, we predicted a time of 4 hours of the course load, which is 195 hours.
The participatory teaching-learning method on death and dying aims originally at nursing education, but it may be applied in the training of other health professionals.It is supported by two stages developed through activities, whose purpose, related to general content learning on the theme, is to raise awareness of the students to the end-of-life care.It is based on the idea that students need to be better prepared to deal with death and offer end-of-life care, since formal education falls short in providing subsidies, in sufficient number and quality, to meet the needs regarding this theme (5) .
The central concepts applied are based on awareness and dialogue, understanding that consciousness is not separated from the context in which the human being lives (12) .Such concepts are usually adopted aiming to develop critical-reflexive capacity to work the production of knowledge in different groups, in participatory methodologies, and to create new possibilities for the construction of knowledge (6) .In this sense, the dialogue with the other is a powerful mediator for the formation of critical consciousness, since it enables the expansion of human consciousness (12)(13) .
1 st Step: it focuses the theme from a personal perspective.In this step, paper and crayons of different colors are distributed Death education: sensibility for caregiving Lima R, Bergold LB, Souza JDF, Barbosa GS, Ferreira MA.
to students, who must express the theme by drawing after listening to a song.The song is not always the same, but can be chosen for each experience of application of the method.In the case reported, we chose "Pavane pour une infante defunte," by Maurice Ravel, which, through a slow and melancholic melody, promotes an atmosphere favorable to reflect the theme.Since it is a classical song little known of the public, it reduces the influence of previous memories related to certain widely known musical stimuli.The duration of the musical moment was six minutes, and the activity was assessed as adequate and sufficient to induce a state of relaxation and reflection, without becoming tiresome.
The professors suggested the question "How I experience death" for debate and requested students to listen to the song under that perspective and, then, to start drawing and conclude it in 15 to 20 minutes.At the end, each one explained what they drew and, afterwards, there was a group discussion aiming to highlight similarities, specificities, and singularities of each drawing and, thus, to raise awareness about the influence of personal emotions and culture on the conception of death.
The development of this step emphasizes the group reflection on the subject proposed, with a view to the dialogue of the group, which, in its turn, gives rise to the expression of other topics related to the culture of that group.This expression is then encoded by the artistic productions the participants regarding the theme, which will be decoded during the group dialogue to promote the achievement of the ultimate objective: the awareness about everyday situations through critical and reflective discussion.
2 nd Step: it focuses the theme from a professional perspective.It consists in the presentation of the question "How I deal with care in death situations."In this moment, students are divided into groups and must create a scene related to this question, as well as a scenario, in a time that may be adjusted according to the needs of the group.They stage the situation, take pictures, and explain it to other participants.Thereafter, they are asked to analyze and evaluate the pictures, reporting if they wish to redo the scene for a new record.That way, they can rethink their actions and express what they consider important and essential concerning end-of-life care.After the presentation of all groups, another group discussion is carried out, followed by a final evaluation of the entire process.
This step is intended to shift the students from the personal discussion on experiences with death and bring them to the professional care, to facilitate the perception of the influence of culture and personal feelings on the act of care in this context and discuss assistance experiences in situations of death (1) .It is a move that comes from feeling and perceiving to acting and creating.This change of perception, based on questioning a reality and its contradictions, implies an appropriation of the context and, therefore, provides a more critical and deep view of the situation.Acting, thinking, creating, and transforming are stimulated, in the perspective of a problematic, critical, and dialectic education (6) .
To maintain uniformity in the development of the method, all the steps were performed by the same professors, which were distributed in the functions of coordination and observation of the students, through written records, to stimulate group discussion and, at the same time, document the experience with content for later evaluation.
This case report presents the results obtained with four classes, totaling 22 students and five professors, in the academic years of 2012 and 2013.There was a predominance of female students (20) and only two men; the age ranged from 21 to 25 years old (21 students), and only one was 30 years old.The five professors had teaching experience in undergraduate courses with application of active teaching-learning method, but had no specific training in thanatology, except the proponent of the method, who presented previous experiences in end-of-life care of people with cancer.
For greater reliability in the evaluation of this teachinglearning method, the contents generated by the students and registered by the faculty during the steps that produce senses and meanings about death and dying, through drawings and scenes, were submitted to lexical analysis with software for textual data analysis (Alceste 2012).
The contents from the professors' observations will be presented in narrative analysis.

Meanings of death
The corpus generated by the testimonials of the students obtained 93% of utilization by the software, that is, only 7% of the content was not considered.There were a total of 65 elementary context units (ECU) forming fragments of speeches representing the lexicons, which give sense to the speeches.The students' speeches are named initial context unit (ICU) in the software.Thus, each ICU corresponds to a student who produces the speech.After running the software, the contents of all reports were organized into three lexical classes, described as follows: Class 1 brought together 17 ECUs, with 26% retention of the corpus, and 31 words analyzed.It refers to feelings about death, whose lexicons of larger statistical association were: heart (Phi 0.58); God, angst, hope, and uncertainty (Phi 0.53); cycle, uncertainty, and insecurity (Phi 48).The meanings of death and dying reported by the students were:

Funeral, cycle, religion, disappearing, uncertainty, nice place after death, comfortable death and beautiful place, hole, cycle, birth, growth, reproduction, and death, imagining that the ones who died are fine, learning, thinking about God, death itself, new Sun. (ECU n° 1, ICU 1)
Objective cycle, religiosity, tight heart, agony, suffering, lonely for those who died, questions about where we are going, comfort, loss, pain, green-hope, insecurity, powerlessness, God, God, God, is born, grows, reproduces, dies, the pain is greater, door closed, broken heart, God, God, God, longing, sadness, new time, new Sun, comfort.(ECU n° 3, ICU 3) Religion does not let us live the anguish of the disappearance, tight heart when thinking about death, agony, suffer alone, uncertainty about death, better place, fear, insecurity, to accept the God's will, to interrupt the cycle, it is a greater pain.(ECU n° 12, ICU 8) Death education: sensibility for caregiving Lima R, Bergold LB, Souza JDF, Barbosa GS, Ferreira MA.
Class 2 brought together 34 ECUs, with 53% of the corpus, and 17 words analyzed.In Class 3 there was the following distribution: 14 ECUs, with 21% of the corpus, and 20 words analyzed.Classes 2 and 3 added meanings on family and beliefs professed by the students, expressed in lexicons with the following statistical associations: father (Phi 0.29), family (Phi 0.21); people and lost (0.55), light and peace (0.41).
I couldn't prepare the body, you must look and see, I thought 'I have to do this process,' feeling of loss, grief, I couldn't talk about my loss, I'm getting used to the idea of losing, talking helps the other.(ECU n° 22, ICU 14)

To work the conception, to see death as best as possible, I don't know how, I think I'm going to find out when my parents die, I have no sentimental bond to the rest of the family, they already died, as well as the patients, I faced it well, I'm just not going to face my parents' death well. (ECU n° 39, ICU 20)
A sad day, but of peace, images that I've lived, I lost friends and relatives, burial and cemetery, I'm evangelical and that influences 100% on my view of death, I believe in heaven, we suffer for the absence, longing, I lost an uncle.(ECU 40, ICU 21) Anguish, uncertainty, impotence, and insecurity were the most common feelings among students, denoting the need to work with them the sense of finitude, losses and grieves, and their emotions to subsequently prepare them to take care of people/families and prepare the dead body.The difficulty of dealing with the theme and the desire to take care in a closer way and with less fear of death were highlighted in the speeches.
About the scenes and pictures produced, they generally portrayed the pain of loss, with the characters crying and seeking the comfort of others.Spirituality, faith, and support between pairs were also evidenced in the scenes organized by the students.
The class of 2012 is an example, whose organized scene was composed of a dead person, lying, and another one standing with one hand resting on the hand of the dead person and the other on the forehead.According to the students, the scene aimed to express the importance of the aesthetic care of the body as a form of comfort for the family.Another scene was organized with three people standing in circle position, showing support between them through the touch of hands on shoulders and head.This scene, according to the participants, expresses concern regarding the pain of others and approach by touch.It also highlights the need for psychological and emotional support to the family after confirmation of death.As for the class of 2013, the scenario was initially formed by two people hugging each other, which denotes support and reception in a situation of distress.However, when the students saw the photo and discussed whether it was consistent with what they wanted to convey, they decided to change the scene for two people sitting, sad, hugging, and with clasped hands, both consoled by a third person standing, bent over.In a second scene, there is a person lying dead, observed by two others in an embrace.The meaning produced in this case was the care for the body and the family embracement.
In summary, the drawings and speeches show how religion greatly influences the way students experience the situation of death.The representation that, despite the pain of loss the deceased person could be at peace, was comforting to students.To report experiences of care with family members of people in terminal stage and the anguish experienced collaborated for the group to resignify human needs for a more sensitive care, which transcends the technique.
It was observed, in one of the groups, a contribution beyond the theme: the students, who initially appeared to have few affinities among themselves, with personal differences and expression of extreme rationality during classes, shared diverse experiences, including excited reports on the theme, during the activity of sensitiveness.This allowed the observation that the method not only generated learning about death and dying, but also favored the self-knowledge and the group knowledge, leading the students to reflect upon death, now better understood, through stories of life, perceptions, and feelings.

On the participation of the groups
The first group (class 2012-2) proved to be eager to deal with the unknown, because it was an unprecedented lesson.In the second group (2013-1 class) there was less apprehension, since students were told by the others that it would be a different and "deep" class.There was anxiety, but this time it was for participating in this experience.
Every start of semester, students were waiting for the release of the class date, reiterating the difference of the work performed, which, according to them, involves a subject still little discussed in nursing.During the activity, beyond the theme, the procedures applied were highlighted, and an effective immersion of students in the process was promoted, which gave a distinguished status in learning and motivated participation.
Indeed, the participatory method produces this result -it mobilizes the engagement when puts the learner at the center of the process, emphasizing the development of critical-reflective, evaluative, and interactive process in the groups (11) , as showed in the results.It is noteworthy that, by discussing the theme through an immersion in the own experiences and productions of senses and meanings about it, the students perceived themselves as able to develop awareness about how they are products and producers of senses and of a culture of practice on how to deal with death and the dying process, which is also the legacy of the participatory method (12) .
Living experiences through the method reported here strengthens the group because the members are more familiar with each other, their pains, difficulties, and thus, they respect each other more, a benefit highlighted by the students at the end of the activity.Being alongside classmates does not always mean being together, but when there is opportunity to experience moments in which the difficulties and anxieties are raised and discussed together, the frailties of human beings emerge, and they are joined by possibilities of sharing strategies for their resilience, which contributes so that humanization of care can express itself through communication (14) .In this sense, the communication -base for human interaction -enables the exchange of information and extends the possibilities for mutual understanding (15) ; thus, the exercise of dialogue with colleagues in class on a mobilizing topic, which involves the