STRENGTHS AND WEAKNESSES TO FACE THE DYING AND DEATH PROCESS: STUDENTS' REFLECTIONS

PONTOS FORTES E FRAQUEZAS PARA ENFRENTAR O PROCESSO DE MORRER E A MORTE: REFLEXÕES DOS ALUNOS

ABSTRACT

Objective:

to identify the strengths and weaknesses recognized by the students to face the dying process and death in the hospital setting.

Method:

a qualitative and descriptive approach. The sample was made up of 19 students of the fifth-year of the Nursing course, complying with the in-hospital professional practice, and the study was carried out at a university in the Magallanes and Chilean Antarctic Region, Chile, between September and October 2018. The collected data were submitted to the precepts of Content Analysis.

Results:

among the identified strengths, the following are to be mentioned: previous experience with death, the support provided by the guiding nurse during hospital stay, the student's mental maturity, soft skills, and sensitivity. In its turn, the limitations identified include lack of experience, psychological immaturity, the few tools they possess, factors associated with the patient such as age, and the affective bonds created with the patient that may end up causing suffering to the student.

Conclusion:

both the strengths and weaknesses recognized by the students must be worked on in the academy throughout the training, in such a way that the students may acquire the necessary tools to face the process of death and dying. Death must be discussed as an integral phenomenon in order to achieve a better understanding of this topic by the students, so that they can act in the best possible way in front of terminal patients, providing quality and humanized care for the patients and/or families.

DESCRIPTORS:
Death; Nursing education; Hospital care; Bioethics; Attitude facing death

RESUMO

Objetivo:

identificar os pontos fortes e fracos reconhecidos pelos alunos para enfrentar o processo de morrer e a morte hospitalar.

Método:

pesquisa qualitativa descritiva. A amostra foi composta por 19 estudantes do quinto ano do curso de enfermagem, conforme a prática profissional hospitalar, realizada em uma universidade da região de Magallanes e Antártica Chilena, entre os meses de setembro e outubro do ano de 2018. Os dados coletados foram submetidos aos preceitos da Análise de Conteúdo.

Resultados:

entre os pontos fortes identificados estão a experiência anterior diante da morte, o apoio prestado pelo enfermeiro durante a internação hospitalar, a maturidade mental do aluno, suas habilidades sociais e sensibilidade. Por sua vez, as limitações identificadas incluem a falta de experiência, a imaturidade psicológica, as poucas ferramentas que possuem, os fatores associados ao paciente, como idade e vínculos afetivos criados com o paciente que podem acabar causando sofrimento ao aluno.

Conclusão:

os pontos fortes e fracos reconhecidos pelos alunos devem ser trabalhados no curso durante todo o treinamento, a fim de que os alunos adquiram as ferramentas necessárias para enfrentar o processo de morte e morrer. A morte deve ser discutida como fenômeno integral, para que o aluno compreenda melhor esse tópico e possa agir da melhor maneira possível diante do paciente terminal, proporcionando atendimento humanizado e de qualidade ao paciente e /ou sua família.

DESCRITORES:
Morte; Educação em enfermagem; Cuidados hospitalares; Bioética; Atitude em relação à morte

RESUMEN

Objetivo:

identificar las fortalezas y debilidades reconocidas por los estudiantes para afrontar el proceso de morir y la muerte hospitalaria.

Método:

abordaje cualitativo, de carácter descriptivo. La muestra estuvo compuesta por 19 estudiantes de la carrera de enfermería de quinto año, cumpliendo con la práctica profesional intra hospitalaria, realizada en una universidad de la Región de Magallanes y Antártica Chilena, Chile, entre los meses de septiembre y octubre del año 2018. Los datos recolectados fueron sometidos a los preceptos del Análisis de Contenido.

Resultados:

entre las fortalezas identificadas se encuentran la experiencia previa frente a la muerte, el apoyo que entrega la enfermera guía durante la estadía hospitalaria, la madurez mental del estudiante, las habilidades blandas y la sensibilidad. A su vez, entre las limitaciones identificadas se encuentran la falta de experiencia, la inmadurez psicológica, las escasas herramientas que poseen, factores asociados al paciente como la edad, los vínculos afectivos creados con el paciente que pueden llegar a provocar sufrimiento al estudiante.

Conclusión:

tanto fortalezas y debilidades reconocidas por los estudiantes deben ser trabajadas en la academia durante toda la formación, de tal manera que los estudiantes adquieran las herramientas necesarias para hacer frente al proceso de la muerte y el morir. La muerte debe ser discutida como un fenómeno integral para lograr una mejor comprensión acerca de esta temática por parte del estudiante, y así este pueda actuar de la mejor forma posible frente al paciente terminal, entregando cuidados de calidad y humanizados para el paciente y/o familia.

DESCRIPTORES:
Muerte; Educación en enfermería; Atención hospitalaria; Bioética; Actitud frente a la muerte

INTRODUCTION

Nursing professionals are constantly facing the death of people under their care, showing difficulties in integrating it as part of life, perceiving it as a result of therapeutic failure and of the effort to cure diseases. These characteristics are associated with professional training that aims to achieve healing, not failing, and saving lives.1 Therefore, due to the characteristics attributed to death during the training process, many professionals end up feeding the feeling of the experience that they now acquire.2

In long-term contact with the context where death is imminent, reports of difficulties were found regarding how to deal with this situation; a characteristic lies in the distancing of the team that is not seen as a support to face certain situations.2 The nurses in the intensive care unit point out that, although death is a recurring problem, this is not a topic of regular discussion and that it is somewhat neglected.3 Therefore, it is understood that the processes of denial experienced by the professionals can be related to the constant approach to death associated with the feeling of sadness that some professionals end up feeding.2

Preparing to live their own death and that of the others is a challenge for health professionals, due to the beliefs associated with the theme. Therefore, the reflections associated with this theme generate fear and anguish due to the approach to the end of life.4 This professional preparation was pointed out in a studio as a space for the transformation of professionals, where they take care of themselves and of the others. This transformation, caused by the training of professionals, helped them to reflect on their beliefs, values, and personal reasons that may compromise the care provided, which further qualifies the care practice.5

It is important that the professionals themselves seek to resolve the limitations they identify in end-of-life care practices, since many of the difficulties that result in feelings of failure are associated with failures in the professional education process itself, which did not provide teaching coping strategies, a fact that could psychologically harm the professional.⁴ How these professionals deal with the death of the other can be associated with the losses already experienced by the professional.6

Death itself makes up the process of human development and has been present in the daily life of the nursing professionals since graduation.7 Even with the advances in the curricula, in the sense of a more holistic view, it remains a challenge to articulate the knowledge for the integral care of the patient and a greater reflection on the confrontations of the finitude of the human being. The training of health professionals is still oriented towards the promotion, recovery and preservation of life, reinforcing a permanent fight against death, based on the understanding that it is not part of life.8^-10 Issues related to death need to be addressed from the first semester through different pedagogical approaches, providing a space to listen and receive the suffering of the university students.¹⁰

For some nursing students, death is not considered natural, which ends up being perceived as negative, since it is associated with a feeling of failure, and the search for rescue measures can even be observed for patients with irreversible clinical situations.6

Nursing students do not feel prepared to deal with the death and dying process, as nursing schools are not adequately training students for end-of-life care, leading to inadequate care once they are employed.11 The findings highlighted the lack of content in textbooks and the lack of content on end-of-life care in the undergraduate college curriculum. The students are prepared to face life, but not for the finitude of the patients.12

Training the nurses for the professional practice must go beyond techniques and theories, they must also be trained to face situations that involve their feelings, such as the dying process and the death of patients with terminal diseases.12 The authors of a research paper13 propose that, during the nurse training process, the Peaceful End of Life Theory (PELT) be used as a necessary part of the theoretical support, since it provides a guide to the actions and skills that the nurse facing the patients and their relatives should develop, mainly in situations of ethical conflicts; in addition, it can be applied in all contexts concerning hospital health care. The students are not excluded from these situations since, when they start their professional practices, they often witness this type of conflicts that develop during the dying process.

One of the assumptions proposed by the PELT is that end-of-life care is not intended to optimize care in the sense that it must be the best treatment and resort to the use of the best technology, or excessive treatment, with the risk of falling in therapeutic obstinacy, but rather, in that the objective is to maximize treatment, providing the best possible care through the judicious use of technology and well-being measures, promoting quality of life and a peaceful death, thus contributing to the experience of dignity and respect for the patient.14

Understanding as strengths the advantages that allow taking an opportunity or facing a threat; and, as weaknesses, facing the same theme,15 this study aimed to identify the strengths and weaknesses recognized by the students to face the dying process and death in the hospital setting.

METHOD

A qualitative and descriptive research study, carried out in the city of Punta Arenas, XII Region of Magallanes, Chile, at the University of Magallanes, Health Sciences School, Department of Nursing.

The working universe were 61 students of the Nursing Course attending the ninth and tenth semesters of the 2018 academic year, and in the first and second period of the Professional Internship in the Clinical Hospital of Punta Arenas; therefore, the number of case studies was finally reduced to 36; the sample was determined by data saturation, resulting in 19 study subjects. A student was excluded who, for the third time, did not respond to the summons to the interview.

For data collection, a number of stages were carried out, namely: first, the Nursing Course students who met the inclusion criteria of the sample were selected, contact was made personally in their places of Professional Internship and others through telephone communication where, in addition, the date and time of the interview were arranged, carried out in university rooms previously requested for this purpose. Payment for transportation was offered in order to avoid monetary travel expenses falling on the student. The students who signed the informed consent approving to participate in the study were informed of the objectives to be achieved, doubts and questions they expressed were clarified, and they were informed of the commitment to confidentiality of the research.

The data collection technique was performed through semi-structured interviews, which were recorded with the authorization of the participant, with a mean duration of approximately eighteen minutes, and was carried out between September and October 2018. After recording the interviews, they were transcribed into Word and saved on an external hard drive, to ease data treatment and analysis. After the transcription, the interviews were organized according to each objective of the study, that is, grouped by similarities into thematic sets.

The data obtained were treated with the precepts of Content Analysis, that is, the interpretation of the data collected during the entire investigation and which have been recorded to facilitate their study.16

RESULTS

According to demographic data obtained: 16 female students, three male, ages fluctuating between 22 to 38 years old. All of them had completed the Professional Internship in different hospitalization services.

From the analysis of the narratives of the interviewees, the following detailed categories emerged and were analyzed in the light of other studies related to the theme: Strengths and weaknesses related to the students' own characteristics; Strengths and weaknesses related to the routine of hospital work; The support of the guiding nurse and health team in the hospital as a strength against the dying process; Strengths and weaknesses associated with the patient and the family; and The theme of death in the academy.

In the Strengths and weaknesses related to the students' own characteristics category, it is shown that the previous experience of having been in contact with death is recognized by most of the students as a great strength when facing the process of dying and death, since it allows them greater capacity and professional resolution, emotional containment, and acquisition of tools, among others, that strengthen the student to face this fact: This year I've have had a lot of contact with death, yes, a relative died first (E3). For me, experience influences, yes, totally because for a person who has experience in death with people and patients, they will obviously have a much better capacity or resolution than someone who does not have experience from any point of view, from what as a professional they offer the patient in their last minute or hours of life (E4). I think that the main factor is that the experience for having lived various experiences that have to do with death, because all deaths are different, it depends on the patient's diagnosis, all the learning, the different experiences of death as you perceive them (E7). Well, I believe that more than anything else, the experience, if the person has already lived some experience of death in life, I think it helps a lot to know how to face it in the professional field (E9).

Therefore, lack of experience can be considered as a weakness to face this process, thus the students report: There are people who have never faced the death of a close relative or have never faced a death case nearby. So they can never put themselves in the other person's place or know what to do or know how suddenly it can happen because obviously they have never experienced it so it is something completely new (E17).

In parallel to the importance of previous experience, the students recognize some psychological characteristics inherent to them and necessary to face the death of the patients. Thus, as a weakness to face the environment of death, they identify the lack of psychological tools: I feel that I lack many tools to know how to cope, but it doesn't look like the psychological or emotional tools. (E9). We prepare ourselves for many things during the course, but the emotional side always requires much more work (E11). For me, feeling that a person suffers so much before dying is very shocking (E10).

The students mention that it takes great emotional strength to face the death process, as well as the training delivered at home, the acquired values and sensitivity to human pain: So it's necessary to have a lot of strength emotionally to be able to help the family too. (E11) I think it has a lot to do with the values that you have, and the sensitivity existing you have towards the human being (E12). I also think that there is the personal factor, the one that comes from home, in the education given since childhood actually (E13).

In relation to the maturity of the students according to age, it was considered that, at a younger age, there is less maturity to face death situations: “Either they are not mature enough to provide support, perhaps someone is not going to know what to say, or they are going to have many words or they are going to be offering the support that this family deserves, suddenly they embrace you and you are out of place (E1). We are talking about the average kids, they are graduating here, how old are they? [18, 19, 20, 22, 23 years old], and that they are faced with a patient who dies, they are still strong and for me they are children, so they are still strong the first time they are faced with that (E2).

Among the associated strengths and weaknesses, the personal characteristics of the students also influence care towards death: my mom says that I'm not very sensitive, but it's not that, I'm like more practical, actually, like when faced to that I say: If it's not useful for me, if it doesn't contribute to me in life I pass on (E1). There are people who are more serious than others, colder, so all those things influence how a person who is in front of you responds to that (E14). But you don't take the emotional burden home, because I still knew how to separate things, just like my personality is like super cold, so that it just helped me a lot (E18).

Linked to the experience of the professional duties, Strengths and weaknesses of the routine of hospital work, from the perspective of the students towards the nurses who have worked for years, is considered as a strength but, in turn, they criticize that the routine returns to the coldest and most insensitive nurse in the face of this fact. They also mention that the lack of routine would be detrimental to face situations to which they are not accustomed: I find that the routine influences, what do I mean by this? that you realize that over time people usually face death as they are obviously much more prepared, but also in a very cold way (E11). Sometimes people become very cold over the years, because I have had colleagues who from previous years had to live through death processes and who remained bad for a long time, who did not know how to react and who more than one had to face the family, anger, rage, screams, name calling… (E14). But us who have been a month and a half maybe we do not yet have that routine of years, then there is an issue of us not protecting the patient, but also due to ignorance about how to face new situations (E17).

At the same time, the support by the guiding nurse and the health team in the hospital as strength against the dying process becomes a fundamental pillar when facing the first experiences of death of the patients. Likewise, the students identify as one of the strengths the opportunity provided by the guiding nurse to make them participate in this process: I believe anyway that the fact of having a containment, for example as an intern, that you have a professor who knows how to explain this process a little and who knows how to cope with it in the best way, who is concerned about how you feel, or who contains you at that time, I think it is very important (E9). You can face it in different ways, either because of the support you have received or the training you have had through the nurse teachers themselves... (E19). It was my turn at the internship with Mrs. S, then she like she also has good management in this sense with the patients (E5).

Additionally, the students consider communication with the health team as part of the process to face death situations: You can talk to the team and at some point still talk to the doctors regarding what you see as the patient is worsening (E2). Teamwork I believe, because it is important to work with the team you are in, the emotional part, because it is not funny so to speak, something very satisfactory that one of the patients, who is, in the shift with you, with your team dies, even if being a TEL patient (E11).

The students are aware that, when they decide or act, the decisions made are not their responsibility, which can cause discomfort to the students: at the end, the decisions are always made jointly by the nurses and the doctors who are there, suddenly you as an intern feel that you cannot intervene beyond what they want to (E13). I listened to his lung murmur, his heart, and I felt that it was slowing down, and I was calling and no one got me, then the feeling I had was like guilt too, because perhaps if I had insisted more, the patient would not have died (E15).

In the Strengths and weaknesses associated with the patient and the family category, it can be seen that, when facing the dying and death process, there are instances and factors that can hinder acceptance of such event, like the age of the patient, the time the patient is accompanied, the bonds created with him, and the way in which death occurs. On the other hand, the tools, mainly for communication, to face the family are also an important factor when dealing with them, in situations of finitude regarding the patient.

The students report, the age of the patient is equally very important, because obviously an older adult patient will not be the same as a child (E1). As for the children, no! it's terrible, I had deaths of children the same (E2). When the cycle ends up at an early age I already see it as something more shocking so to speak, something that should not be so like you are not used to it, I don't know why a child or an adult die at an age not like the end of their life cycle (E5).

The bond created with the patient due to the follow-up time can be interpreted as limiting, phrases such as becoming attached to the patient or creating emotional ties are identified by the students as significant factors that can even lead to suffering when a patient dies: I was with the same patient for three months and it was impossible not to get attached to them, so that's still like a matter of time, they were people you saw every day (E8). When I went to the 3 ^rd and 4 ^th year practices, it happened to me that in the end I became fond of the people, like I still went out with a little pain or suffering or something like that (E15). If you are a person who is perhaps too sensitive or I do not know, you create bonds with the patients and finally you will suffer every time a death occurs, perhaps of some of them, because you are not prepared (E16).

The participants state the great difficulty they have when facing the family, since they recognize not knowing what to say, or how to act, trying to remain calm so as not to distance from their professional role, this while continuing to recognize family members as an important and fundamental component in the care and accompaniment of the terminal patient: I don’t know what to say, what words to use with this relative, it has happened to me that I did not know what to say because I did not know what words to use well so as not to get out of the nursing role (E16) . That feeling of despair that is experienced by the family member, touched me much more and I said: Oh, my God! What do I do now? (E19). Family is an important factor in that sense, because in their despair just as if it is your first-time, they also despair to be able to explain things, so it was still like trying to stay calm, order the ideas, it is still quite difficult (E5).

In this study, the theme of death in the academia is presented with some ambiguity: on the one hand, it is considered as a strength, since the theme is discussed in some subjects like Mental Health, Ethics and Bioethics but, in turn, the students identify that there are still shortcomings when presenting the topics. They consider that it must be deepened even more in order to acquire the necessary tools to act against the death process and the death of the patients who are under their care: and in bioethics, we also saw it, the death process, the ethical considerations of death, all of this for non-CPR patients, TEL patients, there we saw the theme of death, ethical considerations (E1). There is the issue of ethics, where they explain to us what dignified death is, how to work with the patient, for example, if the patient needs something, give it to them, make it easier for them. But if, in bioethics, it seems to me, that of the dignified death, that there we actually even saw a film and we commented on it, and we did surveys, that is, questions (E6). Not cases, but if in the Ethics and Bioethics subjects if they are presented, for example, classes are held focused on the process of death and how you have to face it, they give some theoretical tools to do it (E7). In Mental Health, in general, the process of mourning more than anything, that is, the process of how to give to the patients, for example... if they have a terminal illness, or from the other perspective, how to approach the family after a relative dies (E14).

The absence of the end of life theme in the nursing curricula, as well as the distance between practice and theory, is identified as a gap in the learning process: here for example, in the university, they pass on to us the theory of the process, of the stages it has, you learn how to act more human, not to be so mechanized: it is not that I have to do this and this, but rather how to try to better accompany the patient and the family, who bear the emotional burden of the process (E8). I believe that the theoretical part will always be very far from the practice because although they give you a presentation of what to do in cases of crisis or contention, it is very different to apply it (E12). At the university they always teach you everything as the ideal, but they do not teach you what the reality is that you are going to get to see in your clinical internship, the real situations that you are going to face (E13).

Thus, in relation to identifying the lack of tools provided in the academy, the students suggest delving further into the theme of the death and dying process in order to face this fact: “I believe that, at least it should be like this for a semester and since they teach us, as well as all post-mortem care, from everything in itself (E6). Because not in all topics, for example, they teach us everything that humanized care is and all that, I would perhaps like it to always be dealt with in all the topics but it is not so, suddenly there are topics that focus a lot on the pathophysiology or anatomical part (E13). The university lacks a little of this, like let's say the part of mental health and death is missing a little, if the only thing missing is that they give us like the tools to be able to be, how to act in front of death, how we have to order ourselves emotionally and how to treat to the family, it is like the most important thing, because, even if you don't want to everything the family does or says affects us anyway (E5).

DISCUSSION

Fear and anxiety, feelings manifested in the early professional experiences, have been shown to decrease with advancing age as there is greater experience of loss and of unpleasant circumstances.17

The students perceive that they are not capable of mastering this process and, therefore, they recognize themselves as individuals with limitations. In this way, knowing how to deal with the feelings caused by death is considered as the starting point for preparation because, while the theme is denied from the real dimensions and meanings, it will be considered as something distant until the moment of confrontation with self-finitude or to the finitude loved ones. It is believed that nurses, when aware of their emotions, recognizing limits and potentialities, have better preparation to deal with the suffering of the other, showing sensitivity, support and identity of the role, without developing mental suffering for such a behavior.18

When an authentic way of being is acquired, the students begin to glimpse the valuation of the request in the entire context of the academic practice in Nursing, always trying to act to relief the suffering of the others.19

Additionally, recognizing an emotionally distant and insensitive personality as defense mechanisms makes them distance themselves from death, probably as a form of denial; one student even stated that he chose his Professional Internship in a unit where “there was not so much death”. When the student faces the patient's terminal illness condition, there is the inability to cope and express his own feelings. The fear of expressing feelings is the result of the construction of the myth that the nurse must be indifferent to the death situation.12

In other words, human beings use defense mechanisms to try to flee from the apparent emotional disorder caused by the death and dying process. The students need to be sensitized when offering care to those who experience and/or accompany this process. The lack of discussions on this theme in the classroom contributes to the formation of this protective mechanism, hindering the expanded Nursing care, which proposes the understanding of the death phenomenon as an integral event of the life cycle.7 It is believed that the moments of theory and practice associated with this theme should provide situations that allow the students to create coping strategies in relation to death, strengthening the training of a professional who will be qualified to adapt to these situations.2

In a study on the reflections of nursing students about death, it is observed that constant contact with the end of life can harden the nurses' work process. There is an ambiguity of feelings; on the one hand, participation and sensitivity and, on the other, distance and coldness that awaken an emotional burden that the nurse needs to learn to face,6 probably as a psychological protection to avoid suffering or other feelings derived from grief, such as guilt, depression, and anxiety, as well as the onset of somatic symptoms.2

It can be seen that death becomes much more complicated and disconsolate when faced without the support of other professionals, especially in the first experiences of the students. The opportunities offered at this stage to care for patients who are in their final phase are rare and, when the students do not feel properly guided and supported, the difficulty of working with these patients is not reduced, there being a need for a psychological approach.12

Thus, the interviewed students report that the death of a young person or child is little accepted compared to an aged person since, in our society, the death of an older adult is more expected and considered as an foreseeable end, not so with a child or young person, since it is considered that they still have a whole life ahead of them to fulfill as a person. The sudden or early death of a child is one of the most challenging and unique experiences that child caregivers will encounter in the practice. There is evidence suggesting that the effect that this can have on a student can affect quality of care. Although education for the nurses on how to deal with death has been studied, there is no literature on the education of people working with dying children, and how effective their training to face the situation. This deficit in Nursing training with children is an important challenge and an opportunity to be innovative.20

An integrative review shows that, depending on the relationships developed by the nursing professionals, closely linked to the emotional ties, the connection established during the service and the care provided to the patients in their terminal stages, they provoke feelings of sadness, anxiety and difficulty to accept death. Additionally, the students tend to develop intense ties with the patient, generating great affective implication, which leads them to project the death of their own relatives, hindering acceptance.12

The study7 reports the difficulty on the part of the nursing students in comforting the family and in welcoming them for the loss of a loved one, that is, they assert that they do not know how to deal with death and/or mourning due to lack of preparation in the academy. As well as other studies show that the students experienced difficulties during contact with the patient's family in the death process and at the time of comforting the family and carrying out the support for the loss of a loved one, the students say that they do not know how to act, contribute with some word or gesture of affection; on the contrary, they remain repressed.12^,19 On the other hand, the PELT has the concept of proximity associated with the feeling of physical or emotional connection, with everything that is assigned some meaning, and it is thus expressed through interpersonal relationships.14

A number of studies have shown that training in communication skills and palliative care can significantly reduce the levels of anxiety for death3 or modify the reactions to the emotional stimuli directly related with death.21 Leading the student to understand death in the experience of the other5 and introducing a critical-reflective view of the death and dying process in the academic education are considered as urgent measures, since it is possible to provide quality care at the end of life, especially when being educationally prepared for such purpose.22

The study6 shows the desire of the nursing students for getting adequate training, capable of providing the necessary tools so that they can cope in the practice with the adverse situations that may occur at the end of the patient's life. It also reinforces how fear and insecurity are factors that interfere with the quality of the professional practice, proposing the adoption and promotion of effective coping strategies in the training of future nurses.

The search for a professional focused on biopsychosocial care has been changing the profile of academic education, changing curricula to include end-of-life care, which tends to be minimized due to the biological approach found in health courses.2

Several studies conclude on the need to delve more into the theme of death, since there is great lack of training among the professionals and students of the Nursing Course, where they are forced to provide care without having acquired adequate training, which ends up generating feelings of suffering associated with the understanding of a low-quality practice offered to both the patient and the family member.2^,7^,12^,19^,23

It is necessary, therefore, that the death and dying process is discussed as integral phenomena of the life cycle and not as an end in itself. Therefore, this theme must be discussed and developed throughout the training process of the Nursing course, so that the future professionals feel at least the necessary support to deal with this problem in their daily life.7

In this sense, the PELT is necessary as a theoretical support in academic health institutions, since it provides a guide of actions and skills that the nurse must use when facing the patient and their family members, mainly in situations of ethical conflicts, and in all contexts of hospital health care.13 The unique feature of this theory is that it was developed from a standard of care, created by expert nurses to treat the complex care of terminally ill patients in a university hospital; therefore, it can be considered as an interim step that effectively links the clinical practice with the theory.14

Finally, it is important to consider that education involves training and preparation. Training to address technical knowledge and skills and preparation that will include the tools necessary for end-of-life care. Therefore, it is a quality training process that will provide professionals with comprehensive care.23

The data that were self-reported by the participants can be pointed out as limitations of the study, since they may contain potential sources of bias because they were not independently verified.

CONCLUSION

From this study, it can be seen that the nursing students are able to identify strengths to face the theme of death, such as previous experience with death, the support provided by the guiding nurse during the hospital stay, mental maturity of the student, soft skills, and sensitivity, among others. In turn, they identify the limitations they have, such as lack of experience, immaturity, the few tools they have when facing the family of the patient who is undergoing the death process, factors associated with the patient such as age, and the affective bonds created with the patient that can end up causing suffering to the student.

Regarding the tools provided by the academy, an ambiguity occurs when it is recognized as a strength, since the theme is discussed in some subjects but, in turn, it is considered a weakness, when it is discussed superficially and fragmented during training. From this, the students offer suggestions to delve deeper into the theme and that, in turn, the theme is continuous and integrated into practical discussions.

Three proposals emerge from this study: firstly, to develop the PELT in the theoretical classes, as an innovative method when dealing with the theme of the end of life, in addition to being considered an easily understood theory for its study. Secondly, since death is a complex theme, the theoretical content of the classroom could be linked to the clinical environment through clinical simulation, a method that allows the student to practice skills and techniques discussed in nursing education, allowing this to happen in a safe and controlled place before reaching professional practices. And finally, to continue carrying out studies to analyze the problems presented by the students around death, where the qualitative research plays a fundamental role as a useful tool for detecting students' concerns, worries, and needs.

REFERENCES

• 1. Perboni JS, Zilli F, Oliveira SG. Profissionais de saúde e o processo de morte e morrer dos pacientes: uma revisão integrativa. Pers Bioét. [Internet] 2018. [cited 2019 Jul 25];22(2):288-302. Available from: https://doi.org/10.5294/pebi.2018.22.2.7
  » https://doi.org/10.5294/pebi.2018.22.2.7
• 2. Freitas, TLL, Banazeski, AC, Eisele, A, Souza, EN, Bitencourt, JVOV, Souza, SS. The look of nursing on death and dying process of critically ill patients: an integrative review. Enferm Glob. [Internet] 2016 [cited 2019 Jul 25];15(41):348-60. Available from: http://scielo.isciii.es/pdf/eg/v15n41/en_revision2.pdf
  » http://scielo.isciii.es/pdf/eg/v15n41/en_revision2.pdf
• 3. Jang SK, Park WH, Kim H, Chang OS. Exploring nurses’ end-of-life care for dying patients in the ICU using focus group interviews. Intensive Critical Care Nursing. [Internet] 2018 [cited 2019 Jul 25];52:3-8. Available from: https://doi.org/10.1016/j.iccn.2018.09.007
  » https://doi.org/10.1016/j.iccn.2018.09.007
• 4. Mondragón-Sánchez EJ, Cordero, EAT, Espinoza, MLM, Landeros-Olvera, EA. A comparison of the level of fear of death among students and nursing professionals in Mexico. Rev. Latino-Am. Enfermagem. [Internet] 2015 [cited 2019 Jul 25];23(2):323-8. Available from: https://doi.org/10.1590/0104-1169.3550.2558
  » https://doi.org/10.1590/0104-1169.3550.2558
• 5. Huang CC, Chen JY, Chiang, HH. The transformation process in nurses caring for dying patients. J Nurs Res. [Internet] 2016 [cited 2019 Jul 25];24(2):109-17. Available from: https://doi.org/10.1097/jnr.0000000000000160
  » https://doi.org/10.1097/jnr.0000000000000160
• 6. Pogránylvá AH, López MVG, Serrano, MRC, Sánchez BLD, Martín JMB, Conty JLM. Nursing students reflections on the death process. Enferm Glob. [Internet] 2014 [cited 2019 Jul 25];33:145-56. Available from: http://scielo.isciii.es/pdf/eg/v13n33/en_docencia1.pdf
  » http://scielo.isciii.es/pdf/eg/v13n33/en_docencia1.pdf
• 7. Dias MV, Backes, DS, Barlem ELD, Backes MTS, Lunardi VL, Souza MHT. Nursing undergraduate education in relation to the death-dying process: perceptions in light of the complex thinking. Rev Gaúcha de Enferm. [Internet] 2014 [cited 2019 Jul 25];35(4):79-85. Available from: https://doi.doi.org/10.1590/1983-1447.2014.04.45177
  » https://doi.doi.org/10.1590/1983-1447.2014.04.45177
• 8. Luz KR, Vargas OAM, Barlem ELD, Schmitt PH, Ramos FRS, Meirelles BHS. Coping strategies for oncology nurses in high complexity. Rev Bras Enferm. [Internet] 2016 [cited 2019 Jul 25];69(1):59-63. Available from: https://doi.org/10.1590/0034-7167.2016690109i
  » https://doi.org/10.1590/0034-7167.2016690109i
• 9. Gulini JEHMB, Nascimento ERP, Moritz RD, Rosa LM, Silveira NR, Vargas MAO. Intensive care unit team perception of palliative care: the discourse of the collective subject. Rev Esc Enferm USP. [Internet] 2017 [cited 2019 Jul 25];51:1-6. Available from: https://doi.org/10.1590/S1980-220X2016041703221
  » https://doi.org/10.1590/S1980-220X2016041703221
• 10. Souza MCS, Sousa JM, Lago DMSK, Borges MS, Ribeiro LM, Guilhem DB. Evaluation of the death attitude profile-revised: a study with health science undergraduate students. Texto Contexto Enferm. [Internet] 2017 [cited 2019 jul 25];26(4):e03221. Available from: https://doi.org/10.1590/0104-07072017003640016
  » https://doi.org/10.1590/0104-07072017003640016
• 11. Gillan PC, Riet PJ, Jeong S. End of life care education, past and present: A review of the literature. Nurse Educ Today. [Internet] 2014, [cited 2019 Jul 25];34(3):331-42. Available from: https://doi.org/10.1016/j.nedt.2013.06.009
  » https://doi.org/10.1016/j.nedt.2013.06.009
• 12. Stochero HM, Nietsche EA, Salbego C, Pivetta A, Schwertner MVE, Fettermann FA, Lima MGR. Sentimentos e dificuldades no enfrentamento do processo de morrer e morte por graduandos de enfermagem. Aquichan. [Internet] 2016 [cited 2019 Jul 25];16(2):219-29. Available from: https://doi.org/10.5294/aqui.2016.16.2.9
  » https://doi.org/10.5294/aqui.2016.16.2.9
• 13. Fructuoso OV, Pablo BR, Plaza MF, Milà VF, Estalella GM. Perspective of intensive care nursing staffon the limitation of life support treatment. Enfermería Intensiva. [Internet] 2016 [cited 2019 Jul 25]; 27(4):138-45. Available from: https://doi.org/10.1016/j.enfi.2016.06.002
  » https://doi.org/10.1016/j.enfi.2016.06.002
• 14. Zacara AAL, Costa SFG, Nóbrega MML, França JRFS, Morais GSN, Fernandes MA. Analysis and assessment of the peaceful end of life theory according to fawcett’s criteria. Texto Contexto Enferm. [Internet] 2017 [cited 2019 Jul 25];26(4):e2920017. Available from: https://doi.org/10.1590/0104-07072017002920017
  » https://doi.org/10.1590/0104-07072017002920017
• 15. Dios JG, Arroyo AA, Benavent RA, Guerrero SM. Análisis de debilidades, amenazas, fortalezas y oportunidades (DAFO) de la publicación pediátrica española a partir de un estudio cienciométrico. Anales de pediatría Asociación Española de Pediatría. [Internet] 2013 [cited 2019 Jul 25];78(6):351-422. Available from: https://dialnet.unirioja.es/servlet/articulo?codigo=4314393
  » https://dialnet.unirioja.es/servlet/articulo?codigo=4314393
• 16. Silva AH, Fossá MIT. Análise de conteúdo: exemplos de aplicação da técnica para análise de dados qualitativos. Qualitas Rev Eletr. [Internet] 2015 [cited 2019 Jul 25];17(1):1-14. Available from: http://revista.uepb.edu.br/index.php/qualitas/article/view/2113/1403
  » http://revista.uepb.edu.br/index.php/qualitas/article/view/2113/1403
• 17. García CM, Alcántara MF, Martín LR, Juárez RM, Montoro CH, Caro MPG. Facing death: Student’s thoughts towards the feeling of their own death. Anal psicol. [Internet] 2017 [cited 2019 Jul 25];33(3):630-40. Available from: https://doi.org/10.6018/analesps.33.3.248351
  » https://doi.org/10.6018/analesps.33.3.248351
• 18. Sampaio CL, Neri MFS, Araújo MAM, Caetano JA, Eloia SMC, Souza AMA. Problem-basead learning in teaching of thanatology in undergraduate nursing oragram. Esc Anna Nery. [Internet] 2018 [cited 2019 Jul 25];22(3):e20180068. Available from: https://doi.org/10.1590/2177-9465-EAN-2018-0068
  » https://doi.org/10.1590/2177-9465-EAN-2018-0068
• 19. Sampaio, AV, Comassetto I, Faro AC, Santos RM, Monteiro FS. The experience of nursing students facing death and dying. Invest Educ Enferm. [Internet] 2015 [cited 2019 Jul 25];33(2):305-14. Available from: https://doi.org/10.1590/S0120-53072015000200013
  » https://doi.org/10.1590/S0120-53072015000200013
• 20. Dexter, Y. Storyboarding as an aid to learning about death in children’s nursing. Art & Science. [Internet] 2016 [cited 2019 Jul 25];28(5):16-21. Available from: https://doi.org/10.7748/ncyp.28.5.16.s21
  » https://doi.org/10.7748/ncyp.28.5.16.s21
• 21. Garcia CM, Caro MPG, Riovalle JS, Alcántara MF, Juárez RM, Quintana FC. Formación en cuidados paliativos y efecto en la evaluación emocional de imágenes de muerte. Medicina Paliativa. [Internet] 2014 [cited 2019 Jul 25];23(2):72-8. Available from: https://doi.org/10.1016/j.medipa.2013.12.007
  » https://doi.org/10.1016/j.medipa.2013.12.007
• 22. Jafari M, Rafieli H, Nassehi A, Soleimani F, Arab M, Noormohammadi MR. Caring for dying patients: attitude of nursing students and effects of education. Indian J Palliat Care. [Internet] 2015 [cited 2019 Jul 25];21(2):192-7. Available from: https://www.ncbi. nlm.nih.gov/pubmed/26009673
  » https://www.ncbi. nlm.nih.gov/pubmed/26009673
• 23. Lopera MAB. The importance attributed by nurses to training in the care of terminal patients. Enfermería Universitaria. [Internet] 2015 [cited 2019 Jul 25];12(2):73-9. Available from: https://doi.org/10.1016/j.reu.2015.04.002
  » https://doi.org/10.1016/j.reu.2015.04.002

NOTES

• ORIGIN OF THE ARTICLE

  Extracted from the thesis - Perception of the death process: the perspective of the nursing students of the University of Magallanes, presented to the Post-Graduate Program in Nursing, Universidade Federal de Santa Catarina, in 2019.

• FUNDING INFORMATION

  This study was financed by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - Brazil (CAPES) - Finance Code 001

• APPROVAL OF ETHICS COMMITTEE IN RESEARCH

  Approved in the Ethics Committee in Research with Human Beings of the Universidad de Magallanes, opinion No. 047/CEC/2018.

Publication Dates

• Publication in this collection
  09 Oct 2020
• Date of issue
  2020

History

• Received
  23 Aug 2019
• Accepted
  19 Feb 2020