SOCIAL REPRESENTATION OF DEATH FOR NURSING STUDENTS

ABSTRACT

Objective:

to identify the structure of the social representations of death for Nursing students.

Method:

descriptive research, based on the Central Nucleus Theory. Free Word Association was used with 91 Nursing students from the last year of the undergraduation course, between April and June 2019, at a public university in the state of Rio de Janeiro. The data was processed by the EVOC software, which generated a chart with four quadrants, where the probable central nucleus and peripheral system can be located.

Results:

the central nucleus was integrated by the elements end, sad and pain; in the first periphery, longing; and, in the second, rest, loss, suffering, eternity, life, anguish and crying. The contrast zone was constituted by fear and cycle.

Conclusion:

this representation reinforces the need to insert the theme in the health courses and to create spaces that propitiate reflection and listening, helping the students to better elaborate the losses.

DESCRIPTORS:
Death; Nursing Students; Education; Nursing; Attitude towards Death

RESUMO

Objetivo:

identificara estrutura das representações sociaisda morte para estudantes de enfermagem.

Método:

pesquisa descritiva, fundamentada pela Teoria do Núcleo Central. Utilizou-se a Associação Livre de Palavras com 91 estudantes de enfermagem do último ano de graduação, entre abril e junho de 2019, em uma universidade pública do estado do Rio de Janeiro. Os dados foram processados pelo software EVOC, que gerou um quadro com quatro quadrantes, onde se pode localizar o provável núcleo central e sistema periférico.

Resultados:

o núcleo central foi integrado pelos elementos fim, triste e dor, na primeira periferia saudade e na segunda descanso, perda, sofrer, eternidade, vida, angústia e choro. A zona de contraste foi constituída por medo e ciclo.

Conclusão:

esta representação reforça a necessidade da inserção da temática nos cursos de saúde e da criação de espaços que propiciem a reflexão e escuta, ajudando os alunos a melhor elaborar as perdas.

DESCRITORES:
Morte; Estudantes de Enfermagem; Educação; Enfermagem; Atitude Frente a Morte

RESUMEN:

Objetivo:

identificar la estructura de las representaciones sociales de la muerte para estudiantes de Enfermería.

Método:

investigación descriptiva, fundamentada en la Teoría del Núcleo Central. Se utilizó la Asociación Libre de Palabras con 91 estudiantes del último año de la carrera de grado de Enfermería, entre abril y junio de 2019, en una universidad pública del estado de Rio de Janeiro. Los datos se procesaron en el software EVOC, que generó un cuadro con cuatro cuadrantes, donde se pueden localizar el probable núcleo central y el sistema periférico.

Resultados:

el núcleo central quedó integrado por los elementos fin, triste y dolor; en la primera periferia, nostalgia; y en la segunda, descanso, pérdida, sufrir, eternidad, vida, angustia y llanto. La zona de contraste quedó constituida por miedo y ciclo.

Conclusión:

esta representación refuerza la necesidad de incorporar la temática a las carreras universitarias de salud y de crear espacios que propicien la reflexión y y la escucha, ayudando así a que los alumnos elaboren mejor las pérdidas.

DESCRIPTORES:
Muerte; Estudiantes de Enfermería; Educación; Enfermería; Actitud Frente a la Muerte

INTRODUCTION

The word "death" comes from the Latin mors, mortis, which means the end of life. Traditionally, its definition referred to the cessation of heartbeats and, currently, it is considered as a progressive and natural phenomenon, which is part of a cycle, the consequence of a process or product (result) of life⁽¹⁾. This understanding has directed the scientific community to project more comprehensive attention on life and death, considering them from procedural, biological and cultural perspectives⁽²⁾.

In Brazil, it is verified that the health care model taught in the graduation of health professions is based on prevention, diagnosis, effective treatment and cure of diseases(³, ⁴). The increasing incorporation of technologies and the scientific advancement in the health area allowed for the increase of survival and stabilization of the population's health conditions, mainly in the case of chronic diseases and, in this direction, health professionals have learned since their training that their mission is to fight against death⁽⁴⁾.

When analyzing the aspects of suffering and in view of the complexity of human nature, which transcends biological aspects, the nurse must integrate all dimensions of the human being, from the physical and biopsychic to the spiritual and social. In the last decades, human care was recognized as the essence of Nursing. The focus on care has been evidenced and highlighted in its professional ethics and philosophical perspective, as well as in Nursing theories, in curricula and in the daily practice, with a view to the humanization of its actions and its interpersonal interactions, in the reciprocity between the Nursing team and the person cared for(³, ⁵).

Adequate understanding of the care provided to the dying patient is a key point for the treatment that is implemented, so that, regardless of life expectancy, the best care is offered, even when life is over. However, when faced with death, health professionals are often not prepared to deal with this phenomenon, which leads them to think about their own finitude.

Nursing works with human beings and accompanies them from birth to the final moments of life, being responsible for the promotion of holistic care that contemplates the care process in the biological, psychological, social and spiritual dimensions(², ⁴). In this sense, it is necessary for the Nursing students to receive the training and acquire the skills and competences necessary to care for the patients and their families, helping them to understand and develop coping strategies in the face of the evolutionary process they are going through.

It is therefore understood that they make the choice to care for and help other human beings to be born and live in a healthy way, to overcome health problems, live with limitations and find meaning in this experience and die with dignity. In the process in which they are prepared to carry out these various actions competently and face situations of suffering and death, Nursing students can be influenced both for the humanization of this work and for its trivialization(², ⁴).

The relevance of this study refers to the possibility of recognizing the influence of representation and its repercussions on care, valuing the subjective aspects that involve it and its effects on the quality of life of the assisted patient. Consequently, the aim is to analyze the structure of the social representation of death for Nursing students.

METHOD

This is a descriptive study with a qualitative approach, developed with the support of the Theory of Social Representations through its structural approach, that is, the Central Nucleus Theory.

This theory is characterized by proposing that a representation has a particular structure organized around some central elements that give it its meaning, justification and temporal continuity. As a consequence, it is highlighted that the central nucleus has the functions of generating meaning and organizing its elements, creating and/or transforming the meaning of the constituent elements of the representation, assigning them meaning and value. The central nucleus is determined by the nature of the represented object and by the relationship that the subject maintains with that object. At the same time, the representations have peripheral elements that present the most practical and everyday aspects, floating in time and connected to the most immediate context. They establish the interface between the central nucleus and the concrete reality, in which the representation works and is elaborated⁽⁶⁾.

The data were collected directly and exclusively by the researcher, from April to June 2019, at a public university located in the state of Rio de Janeiro. 91 undergraduate students who met the inclusion criteria were included: aged over 18 years old and in the last year of the Nursing course. For the survey of sociodemographic data, a structured questionnaire prepared by the researchers was applied, containing questions related to gender, age, marital status and religion. The participants' approach took place in the classroom, in the final moments of certain academic activities.

As data collection, the Free Word Association Technique was used, which is characterized by the immediate response of words from one or more inductive stimuli⁽⁷⁾. Thus, each participant was asked to write up to five words that immediately came to their mind when they heard the inductive term "death". The importance of each word was given according to the order of evocation, considering the most readily evoked words to be more significant.

The set of data collected, the characterization and the evocations were transcribed in an Excel® file, generating a master spreadsheet. The evoked words underwent a process of stemming, so tnat gender, plural/singular and synonyms were standardized, such as rest and break, for example. The data obtained in the sociodemographic survey were analyzed based on simple statistics.

Forthe analysis of the evocations, the Ensemble de Programm Espermettant I'Analyse dès Evocations - EVOC 2005® software was used, which organizes the elements in a four-house chart structured in two axes: the frequency (horizontal, the lower ones with less frequency) and the order of appearance of the words, that is, the rang (vertical, those on the left with the lowest number, which means that they were more readily evoked). As a consequence, a four-house chart is formed, where the data are allocated in four spaces: upper left, which presents the words with high frequency of evocation and lower rang value (most readily cited), is the likely central nucleus.

At the same time, at bottom left there are the words that have low frequency, but also low rang, located in the so-called contrast zone, where a representational sub-group can be observed when there is a contrast with the probable central nucleus. On the right side is the peripheral system, on top, the first periphery, with high frequency and also high rang, while below, the second periphery, with low frequency and high rang.

The evocations were also analyzed from the similitude analysis by co-occurrence through the construction of the maximum tree, showing the elements of the representation with the highest number of connections. It is noteworthy that this analysis took place only on the words that were present in the four-house chart and allowed retaining only the strongest relationships between the items(⁶, ⁷), being used to deepen the representational structure.

For the construction of the maximum similarity tree, a spreadsheet was built in the Excel® tool with all the words that were inserted in the four-house chart. Then, the number of times that the co-occurrence of the constitution of a binomial between these words, for example, end and sad, occurred among the participants was counted. Then, the cooccurrence of each binomial was divided by the number of participants who cited at least two words present in the chart, generating the similarity ¡ndex⁽⁸⁾.

The study was approved by the Research Ethics Committee under opinion No. 3,383,384.

RESULTS

It was observed that 80 participants (87.9%) were female; 76 (83.5%) aged between 20 and 25 years old; and 83 (91.2%) were single or dating. In relation to religion, there was an equal number of Catholics and Evangelicals: 27 (29.7%); and 24 (26.3%) did not profess any religion. When asked about the content of death/dying during undergraduation, 73 (80.2%) asserted that the theme was addressed; however, 78 (86.7%) thought that the deepening of the discussions was not enough.

The inductive term "death" originated a universe of 431 evocations that, after being treated and analyzed, constituted a total of 132 different terms. It is added thatthe following was defined as cutoff point: minimum frequency of 10, mean evocation order (M.E.O.) of 21, and rang of 2.70, as shown in Chart 1.

Chart 1
Four-House Chart for the inductive term "Death". Rio de Janeiro, RJ, Brazil, 2020

M.E.O.	<2.70			=2.70
Mean. Freq.	Evoked term	Freq.	M.E.O.	Evoked term	Freq.	M.E.O.
=21	End	45	2,378	Longing	26	3,462
	Sad	38	2,605
	Pain	25	2,56
<21	Fear	20	2,45	Rest	16	3,188
	Cycle	18	2,5	Loss	16	2,813
				Suffer	16	2,75
				Eternity	13	3,308
				Life	12	3,5
				Anguish	11	3,364
				Crying	11	3,273

• Note: N=91; Min. F.=10; Inter. F.=21; Range=2.70
• Source: The authors (2020)

In the Four-House Chart, it is observed that the central nucleus, located in the first quadrant, is formed from the high frequency of evocation and hierarchization, being integrated by the elements end, sad and pain. Regarding the peripheral system, constituted by the second and fourth quadrants, which maintain the central nucleus and integrate new information into it, the term longing is found in the first periphery; and, in the second, rest, loss, suffering, eternity, life, anguish and crying. As for the third quadrant, called the contrast zone, elements with low frequency are portrayed, but promptly evoked, consisting of fear and cycle.

These findings demonstrate the existence of difficulties in coping with the experience of the death and dying process in the everyday of their teaching and learning practices, showing the little preparation that students obtained during their academic training to act in situations of this nature as health professionals.

Considering the links between the terms, the subsets of the categories, their relations and the meaning assumed by each expression(⁷), the similarity analysis of the words demonstrated through the construction of the maximum tree was performed, shown in Figure 1.

Figure 1
Maximum Similarity Tree of the evocations of the inductive term "death". Rio de Janeiro, 2020

Figure 1 reveals the centrality of three blocks of words: end, sad and pain; all belonging to the first quadrant of the Four-House Chart, probable central nucleus of the representational structure, and each establishing five connections. The bonding strengths between the blocks are different, the greatest being evidenced in sad-end (0.19) followed by sad-pain (0.14). The words longing and fear are present in the three blocks; however, the greatest strength is in the sad-longing connection (0.16), with the same strength in end-fear and sad-fear (0.08).

As shown in Figure 1, the element end constitutes the conceptual dimension of death for these subjects and seems to be the one that centers the greatest connecting strengths of the representation and, in the Four-House Chart, it is the most frequent element (f=45) and with the lowest mean order (MEO=2.378). The elements sad (f=38, MEO=2.605) and pain(f=25, MEO=2.560) are part of the affective dimension of the representation, together with longing, suffering, anguish and fear; the imagery dimension is represented by rest and the symbolic dimension by cycle.

DISCUSSION

The representation of death revealed in the study presents nuances constructed by the participants as undergraduate Nursing students. Through the results obtained, there is a need for reflection on the teaching and learning strategies related to death and dying used throughout undergraduation, with a view to the construction of pedagogical subsidies that contribute to the improvement of their practices in the health care context.

Understanding death from the perspective of the structural approach to social representations implies recognizing the diversity of factors that influence the shaping of the representations, considering the importance that the subjects involved attribute to the phenomenon as a process and its possible interferences on the health care that will be provided.

The final element, part of the central nucleus of the representation in the four-house chart, is linked to the certainty characterized by the end of a cycle and the sadness evidenced by the pain of longing. In view of the evocations, it becomes possible to observe that the representation of death is permeated by suffering generated in the face of longing for the loss of those who left.

In general, the structural analysis in conjunction with the word blocks constituted in the similarity analysis characterize the representation related to the understanding of death as a phenomenon marked by the end of a cycle or as an integral part of life, by the suffering caused by the separation and subsequently by the religious acceptance of rest and eternity. This representation seems to be closely related to the imaginary of a happy life after death, in which religious beliefs and religiosity include the notion that death can bring peace and harmony with God.

The absence of proposals related to the profession and social commitment allows us to understand that the anchoring of the representation is firmly linked to naive knowledge, different from the scientific knowledge acquired during undergraduation. This information corroborates with the data found on the content of death and dying having been insufficiently addressed during undergraduation. It is known that preparation for death in undergraduate Nursing courses is based on the performance of technical procedures, where reflection on the end of life is not developed as necessary and, in some contexts, not even encouraged.

The National Curriculum Guidelines for Undergraduate Nursing Courses are based on the recommendations of the National Education Council, and provide for the training of critical-reflective nurses, capable of acting and transforming the context in which they are inserted⁽⁹⁾, guiding their actions based on scientific principles that underlie them and need to be widely debated and learned.

However, some studies(², ⁴, ¹⁰, ¹¹, ¹²) bring to light the professionals' unpreparedness towards patients out of the possibility of cure, making care regretful, composed of feelings of suffering, anguish, failure and fear. Pain, impotence and frustration contribute to the denial of death and dying and, often, without knowing what to do or how to position themselves in the face of the suffering of the other and of their own. It is well known that the emphasis on education for death can minimize the impact on the care provided to the patients in the death process and ensure that future nurses are prepared to provide quality assistance⁽²⁾.

As this study was carried out with participants who were in the last period of undergraduation, it is verified that the training offered is not providing the necessary preparation so that they can deal with death. This situation must be related to the fact that undergraduate courses tend to privilege the objectivity of care, to value more technical and scientific training, impersona and mechanized, and to present greater emphasis on the disciplines that instrumentalize care for the preservation of health and cure of diseases, to the detriment of the subjective aspects implicit in the care that takes place in the experience of the death process(¹¹, ¹²).

The Nursing student needs to understand death and not just explain it and, for that, it is essential that education goes beyond biological concepts and that it allows the student to reflect and greater appropriation of the contents that cover and integrate other areas of knowledge which present interfaces with human care, such as sociology, anthropology, philosophy and psychology(¹³, ¹⁴). Therefore, it is necessary to instruct the student in the face of this complex phenomenon, which will be absorbed from the expanded understanding of life⁽¹⁵⁾.

It is known that the central objective of the shaping of representations is the transformation of the non-familiar into familiar, through cognitive mental processes, which allow the subject and social groups to incorporate the new and transform the already known. This incorporation process allows social representations to be generated by two processes: anchoring and objectification. By anchoring, there is the process that transforms a foreign object into something familiar, using a pre-existing thought. In turn, objectification is the process of materializing a concept and making concrete wnat is abstract⁽¹⁶⁾.

When the search for the preparation to deal with situations that involve death and dying are not effective in academic education, religion and faith in God are important tools that are mobilized to face these moments. Both professionals and students end up leaving the scientific and conceptual knowledge of the health professional and externalize their human side, bringing out their religious and cultural conceptions, expressing suffering and anguish for not knowing or having nothing to do in the face of death.

Suffering, anguish and fear of death reflect representational contents that express pre-existing or acquired thoughts and feelings about the researched phenomenon, so that distancing, as an attitude, whether through speech or contact, can be interpreted as a strategy found by many participants to reduce the fear and anxiety that afflict them(¹⁴, ¹⁵, ¹⁷).

The feeling of helplessness and guilt arise from the training itself, which prioritizes the maintenance and recovery of life. Increasingly, research has shown the need to prepare undergraduate students to deal with this phenomenon, since many professionals demonstrate their unpreparedness to experience the death and dying process(², ⁴, ¹⁰, ¹⁴, ¹⁷).

A number of studies reveal that nurses' attitudes towards death arouse emotions and feelings, which can negatively impact on their behavior and on the quality of care offered to terminal patients and their family members(¹⁴, ¹⁵, ¹⁷, ¹⁸). In this sense, it is understood that identifying the representation of death of the students and future Nursing professionals is important, as they are the ones who will live with this phenomenon on a daily basis, and this may influence the way they will care for patients at the end of life, as well as their family members.

On the other hand, some studies indicate that the inclusion of the theme of death and dying during undergraduation can influence the positive attitude towards human purpose(¹⁴, ¹⁵, ¹⁷, ¹⁸). From this point of view, depending on the professionals' representation in relation to the phenomenon studied, they may adopt a more or less positive attitude towards patient care at the end of life, impairing the quality of the professional-patient relationship.

Since there is support in the literature that health professionals need to develop skills and competences to face the emotional problems resulting from the experiences of the death process and consequently the loss of their patients⁽¹⁸⁾, the understanding of the representational structure of death for undergraduate students of health courses can lead to the consolidation of solid arguments for the dissolution of gaps evidenced during professional training. It can also contribute to the improvement of the relationships and the quality of care that are established between those who care and those who are cared for, in the most varied scenarios of action where death and dying are faced.

As a limitation, the study analyzed data from only one academic unit, and it is necessary to expand it to other universities.

CONCLUSION

The representation of death for Nursing students reinforces the need to include this theme in health courses. Although death is part of the human experience and its discussion has a transversal character, the death and dying process has been a cause for fear, anguish and suffering, since it shows the vulnerability and susceptibility of human finitude. The experience of the death of the other causes feelings and sensations to emerge related to the denial of their own death, causing ruptures in the relationship between those who die and those who continue to live, thus requiring adjustments in the way of understanding, perceiving and living in the world.

It was concluded that it is necessary to create spaces that provide reflection, listening and welcoming of the students' suffering, helping them to better elaborate the losses, using different pedagogical strategies. Although not yet the ¡deal therapeutic scenario, the approach to death in the classroom may mitigate the impact that the experience of finitude can have on the personal, social and academic lives of these young individuals, favoring a more comprehensive preparation for the care perspective, with a view to improving quality of care and interpersonal relationships.

The data found meet a gap in knowledge regarding the representation of students in relation to the death/dying process, considering the existence of few studies that explore the experience of professionals focused on this process.

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Publication Dates

• Publication in this collection
  29 Oct 2021
• Date of issue
  2021

History

• Received
  10 Feb 2020
• Accepted
  09 Sept 2020