Challenges of nursing teaching-learning to care for human dying - professors' perceptions Desafíos de enseñanza-aprendizaje de la Enfermería para el cuidado frente al morir humano - percepciones docentes

The objective of this study was to investigate professors' perceptions about their experiences in the teaching-learning process of nursing care in relation to dying. This is a descriptive-exploratory, qualitative research, delimited by data saturation, was carried out with 11 nursing professors from three higher education institutions. Data collection involved the drawing-text theme technique and a semi-structured interview. Analysis used the technique of collective subject discourse. The results identified three categories: How I would like to take care in the context of finitude my challenge; Challenging fragilities in the teaching of nurses in the context of care concerned with death and dying; Strategies to compensate or promote more substantial nurse training related to care in finitude. We conclude that the graduation of the nurses studied did not satisfactorily develop the necessary skills and abilities to deal with human death and dying. This study infers the need of permanent education to support transformations in this area.


INTRODUCTION
The process of death and dying has undergone transformations throughout history and it is understood in different ways depending on the context into which it is inserted. 1Questions of death and dying are considered events that are uncomfortable in contemporary society, since historically this process has been distanced from the day-to-day life of society; for man the death of others brings to mind his own end. 2 In this regard, the end of life is still synonymous with failure, sadness, anguish, and in particular fear, 3,4 and is associated with injustice, since it interrupts the life trajectory, thus arousing feelings of indignation and frustration in caregivers. 5owever, the understanding of death as part of the life cycle, especially from the point of view of health professionals, demands the capacity to be distinctive care professionals during the process of dying, in order to provide dignity and respect to the individual who is going through this change. 6Thus, it is essential to welcome the experience related to death of nursing students in order to minimize the resistance of future professionals to end-of-life care.Proper training would help ensure that these professionals develop skills to provide quality care to patients and families, minimizing the impact of death and preventing emotional exhaustion. 7owever, the training of health professionals has superficially dealt with the issue of death, giving more emphasis on discussions of curative approaches, which diminishes the training opportunities of the graduating nurse, hindering the practice of care related to human death and dying. 8his fact is highlighted by the few subjects taught in the undergraduate curricula of health courses that deal with this theme that are insufficient for a sensitive approach to care in face of the human needs during this phase. 9In nursing especially, the approach to the issue of death and palliative care during graduation is superficial, pointing to a vocational training lacking strategies to develop skills in this area, which are possible according to findings from other studies. 10n this context, the challenge of the undergraduate nursing professor is to develop a better approach to education in respect to death that allows closer care of the patient and his/her relatives when faced with the end of life.In order to do this, professors should develop abilities to work with this theme, so courses should provide strategies that promote awareness and improve skills to deal with this theme. 11herefore, the relevance of this study is shown by the need to discuss and increase knowledge that contributes to scientific evidence on discussions about care for death and dying within the nursing curricula.The observation that few studies were found on this subject in biomedical databases reinforces and further justifies the importance of this research in investigating the guiding question: how do nursing professors perceive the teaching-learning process of the nursing curriculum in respect to care when faced with death?
Based on this guiding question, this study aimed to investigate professors' perceptions about their experience in the teaching-learning process of nurses in respect to human death.

METHOD
This is a descriptive-exploratory study with a qualitative approach carried out in three higher education institutions in the southwestern region of the State of Bahia.The institutions were two public universities, one federal (Campus Anísio Teixeira, Federal University of Bahia -UFBA) and one state (State University of the Southwest of Bahia -UESB) and one private university (Independent Faculty of the Northeast -FAINOR).The participants, 11 nurses, were included as they fulfilled the following criteria: to be professors of the undergraduate Nursing courses, to have acted in this type of setting for at least two years, and to have had at least one year of experience in care practice.Selection followed the non-probabilistic technique for convenience, according to accessibility.The number of participants was delimited by saturation of data and all signed informed consent forms.The research was approved by the Research Ethics Committee of the Federal University of Bahia (Campus Anísio Teixeira) -protocol number: 1.651.116-CAAE: 55796516.0.0000.5556, in compliance with the Declaration of Helsinki and Resolution 466/12 of the Brazilian Ministry of Health.Data collection took place in the period from July to September 2016 and used multiple techniques: drawing-text theme, a semi-structured interview and documentary analysis.The design was chosen in order to access the subjective expression of the professors.Crayons, a pencil, rubber and a white sheet of A4 paper were available for the drawing.The stimulus for drawing was: What is the meaning of caring in the context of death?After completing the drawing, the participant was asked to explain the drawing and to assign a title, with this information being recorded and later transcribed.The text and title were used to anchor the image, adding resources to its analysis and interpretation from the dialogue. 12he semi-structured interview comprised five questions on the subject.The interviews were recorded on an MP4 recording device allowing a complete transcription of the responses.As additional sources of data, a documentary analysis was made of the curricular components cited in the interviews of the institutions involved (Graph 1).These totaled seven curricular components: three syllabuses on Basic and Fundamental Nursing, two on Ethics and Bioethics and two on Elderly Health.The analytical process was based on the collective subject discourse technique (CSD) that uses statements in the first person singular representing the collectivity of the study

Death and care, perceptions of nursing professors
Nunes ECDA, Santos AA participants.CSD consists of key expressions, central ideas and methodological anchoring in which the key expressions consist of passages, transcripts of the discourse that are highlighted by the researcher because they reveal the essence of the testimony, or the content of the discourse.This is a kind of empirical proof of discourse, which becomes the raw material of the discourse of the collective subject.The central ideas are linguistic expressions that reliably describe the sense of the person's dialog; this is not an interpretation, but a description of the meaning of the statement or set of statements. 13

RESULTS
The participants of this study were 11 female nursing professors aged between 29 and 58 years of age; their time of training was between nine and 33 years and their teaching career had lasted between two and 24 years.The analysis pointed to three categories of discussion.

Subcategory IA: The end-of-life individual
My understanding is that the nurse must take care of the individual throughout his life cycle, including at the time of death.In the same way that I am happy to take care of a child being born, I must also be pleased to be present at this other extreme.The whole care process for this patient who is leaving must maintain the zeal, respect and ethics.It must be developed in a spiritual, loving way, with compassion, gentleness and cordiality because I understand that the person needs to have a dignified, comfortable, pain-free death with little suffering.So we must take into account that this is the last care that we will give and it should be thought through with respect, because even though the patient is unknown to us, he is important to someone.Someone will miss him and will cry.We cannot lose the essence of the care of this moment.(CSD IA)

Subcategory IB: The family facing death and dying
Care should not only be offered to the patient in this process, but also to his family.You must also take care of this family, they will miss him, they will cry and they need to be protected.It is us [nurses] who often give the first support until other family members arrive, so we must take care to make ourselves present at this difficult time.(CSD IB)

Subcategory IIA: Being human and being a nursing student -an encounter with the suffering and insecurity of caring for the end of the other
When the student is there working and there is a situation that the patient may die, she does not feel prepared because she does not have the maturity to act in that case.It is a time when they do not feel well, they are overwhelmed easily.When we are going to perform body preparation in the field, some do not want to participate.

Subcategory IIC: Evidence of an insufficient curricular approach to care in human finitude
The university has to prepare students and society because death is a certainty, but the approach to death and dying is inadequate.We work in a very fragmented way within the disciplines, without contextualizing, generally, we center this approach only in a class that talks about death and body preparation, but the focus is procedural ability, not attitudinal or relational ability; we do not speak of the other aspects of death.The syllabus itself, does not allow Death and care, perceptions of nursing professors Nunes ECDA, Santos AA me to do this and I think it should be a cross-sectional theme not in the sense of quoting, but in the sense of working in a cultural, sociological way.It is necessary to work more on the subject of death, to include more and to rethink it because there is a gap in the teaching.It requires a change in the entire nursing curriculum so that it is integrated, in which we do not work with isolated disciplines.Thus, everyone would work on all the subjects, since when you work with active methodologies you stimulate the student to reflect, to think and to analyze critically every situation, this facilitates the growth and autonomy of that student.(CSD IIC) Such evidence is reinforced by the analysis of the syllabuses of the disciplines mentioned in the interviews as shown in the following Graphic 1.

Subcategory IIIB: Beyond the university -the permanent psychosocial and spiritual teaching of the being who will be a nurse
I do not think that the university or academic teaching is responsible for this alone.It has a share of responsibility, but people and families need to address this in their relational cycle, they need to discuss.We often see that parents do not take their children to a wake, so how does this child grow up valuing and respecting this moment?This needs to be worked out culturally.I think it is a discussion beyond the academic walls and it should start there in early childhood, in parenting meetings, in religious groups, in relational media so it is not seen as something so distant as it is so close and real.So it is necessary to have more preparation because death is still something that distances a lot of people, it is a taboo, so maybe my greatest difficulty is a cultural issue, not knowing how to approach this in a more profound way, after all we end up bringing much of what we learn culturally to our pedagogical practice.(CSD IIIB)

Category I: How I would like to take care in the context of finitude -my challenge
The first category presented the figure 1 and the discourses that refer to the care considered by professors as ideal in the process of finitude, both for the individual who experiences dying and for the family that accompanies this process.

Subcategory IIIA: Beyond my training -to be human-professor sensitive to the pedagogical challenge of caring for human finitude
The nurse needs to transcend this, she needs to have the will to transpose the values in which she was molded and to develop other knowledge and principles that will send her to an existential concreteness so that she can then work this moment, live this moment and care for the people who face this moment.It takes sensitivity to take care of the other, to have empathy to care for people and this will start from the person herself, from wanting to be, from overcoming some paradigms that they were taught and from allowing herself to continue constructing other views about care, especially at this moment of human death and dying.(CSD IIIA)

Death and care, perceptions of nursing professors
Nunes ECDA, Santos AA

Category II: Challenging fragilities in the teaching of nurses in the context of care concerned with death and dying
Category II highlights the main limitations and shortcomings of approaching the issue of death in the teaching process of nurses.It is divided into three subcategories: Being human and being a nursing student -an encounter with the suffering and insecurity of caring for the end of the other, the teaching dilemma in nursing education and evidence of an insufficient curricular approach to care in human finitude.This category is well represented by Figure 2: Care-relational universe in the context of death, allusive to the social and contextual universe of the nurse.The CSD of this category points out that the main difficulties encountered by nurses to deal with death and dying are related to the teaching process they had.
To this result, care must be present in the face of the finitude of life, since death is a part of existence, and it is therefore necessary to maintain the dignity of each individual during the process of dying and death constantly. 6Despite this, research generally points to gaps in end-of-life care, such as a study that reported that nurses most focused on the symptoms of the terminally ill rather than assessing additional factors such as their spiritual beliefs, family ties, and social connections.These are aspects relevant to the preparation for the end of life and a better family response to the patient's suffering. 14n this sense, the caring practice in which the behavior of love manifests, intensifies the relationship between patient, professional and family, generating tranquility, trust and harmony between the individuals to contribute to the reconstitution (healing) of the individual who experiences the possibility of death.Thus, it is necessary for nurses to surpass the paradigms of medical and biological science and to transform the science of its profession into its art. 15rom this perspective, within the scope of public health, the family is gradually assuming an important role in the context of care, a fact evidenced by the transformations that arose with the proposals of changes in the care model.Thus, through the Family Health Strategy (FHS), promotion, prevention and recovery practices are focused on the family system, seeking to consolidate the principle of integrality proposed by the Brazilian National Health System (SUS). 16n other countries, there is also a lack of proximity between professionals and families in the home setting.In this sense, data from a study reports a lack of interest in palliative home care among Quebec family physicians, while pointing out the integration of nurses who practice palliative care in home care teams as important to stop the current trend of patients dying in hospitals at a great cost to the system. 17nother international study reinforces the importance of family participation in the end-of-life care of their loved one, even when the patient is hospitalized and in intensive care.The results reported good communications, expressions of empathy, explanations about the processes of therapeutic limitations and support for shared decision making as predictors of family satisfaction.These attitudes therefore emerge as important positive impact factors in the context of hospital palliative care. 18n this context, regardless of the setting, home or hospital, it is essential that the nurse is available to offer support and be truly present, thus assuming a welcoming position that facilitates improved aptitudes.It is important to be able to communicate to provide a vehicle to create security and trust in each other, encouraging communication, compassion and hope as a determining element for the satisfaction of the care provided.Thus, the process of death and dying is a challenge for the student due to the lack of preparation that the professionals of the area demonstrate in coping with death, a behavior responsible for enhancing the feelings of impotence and aversion generated during graduation. 20hese feelings converge in insecurity and self-perception of unpreparedness to exercise care after a diagnosis of impossibility of a cure.Such unpreparedness was attributed by participants in another study to personal difficulties and lack of contact with the subject during graduation.In view of this, strategies were chosen to read more on palliative care, to use group dynamics, to use art therapy especially with children, and to use critical-reflexive pedagogy, allowing the group to overcome the condition of object and become the subject of the knowledge produced. 10eath and care, perceptions of nursing professors Nunes ECDA, Santos AA The need for studies that more frequently address curricular proposals for undergraduate nursing courses is therefore stressed. 27n this perspective, it is necessary to promote changes to the curricula of health courses in order to include topics that more deeply address the issue of death, as existing syllabuses present professional training focused on the biomedical and curative model. 28hus, in view of the fragmented curriculum model used in the context of contemporary education, it is necessary to promote even deeper changes capable of taking apart the traditional syllabuses in order to construct an integrated curriculum that provides problem-based learning in that there is the active involvement of the student and the participation of the professor as a guide.There is also evidence of the need to incorporate interdisciplinarity into teaching practices in order to achieve more integrated training. 29n this context, based on observations of the courses of the institutions in this study and on the syllabuses of the subjects cited during the interviews, it was possible to verify how little this theme was approached in the researched setting as observed in graphic 1.The basic or foundation disciplines of the Nursing courses (UFBA, UESB, FAINOR) focus more on aspects of postmortem body care, with only the psychosocial and spiritual aspects of the patient and the family being treated in one of the syllabuses.The curricular component, Ethics and Bioethics (UFBA, FAINOR) deals only with questions of ethical conduct regarding the death process with issues such as euthanasia, dysthanasia, orthothanasia, and anticipatory guidelines.Finally, the discipline, Health of the Elderly (UESB, FAINOR) does not explicitly present the theme of death in its programmed content.It should be emphasized that only the syllabuses of the subjects mentioned by the participants during the interviews were analyzed.
Therefore, it is necessary to reflect on nursing training and practice, which points to the need for thanatology studies during graduation in order for students to learn to act in the face of the possibility of death.For this, it is initially necessary to improve the professors so that they can more safely address discussions on the theme. 11hus, to teach nursing it is necessary to transpose the knowledge transmission process to comprehend the relationship that exists between caring, teaching and learning.

Category III: Strategies to compensate or promote more substantial nurse training of care in finitude
The third category includes suggestions brought by the subjects and includes the spheres: teaching, methodology and society contributing to the objective of this study proposes.It has the representative figure 3 of the transcendence that the professional nurse needs to develop in this universe of care in the face of human finitude.
Another critical point stressed by the students in this process are the professors because they give greater importance to the technical activities developed within the course, than the humanistic ones, besides presenting difficulties in addressing the theme of the dying process. 11n this sense, one of the determinants of professors' inability to deal with this issue is their own professional training, since during graduation they also did not have qualified approaches or had only few opportunities to reflect on the loss, thus reproducing this absence as professors. 11hus, professor training should receive greater influence from the knowledge of the areas of education, pedagogical, didactic and experiential knowledge. 21It is understood that a science professor is not molded from a sum of knowledge, but is constructed through the confluence of knowledge integrated to teaching practices experienced throughout their daily life. 22hus, teaching nursing is built between the absence of pedagogical training and the persistence of conflicts and difficulties of being a professor and being a nurse in the universe of the praxis. 23In order to teach, the teaching nurse bases her teachings on her own experiences and the knowledge she seeks in the course of her experiences. 24It is necessary to rethink the formation of both the student and the educator in such a way as to include the theme of death and mourning in the teaching of both. 25rom this point of view, it is evident that the discussions about this topic when they arise are presented in a fragmented, punctual and superficial way, which makes it difficult to expand understanding about death and dying, 26 pointing to an insufficient academic formation to collaborate with the development of care capacities at the end of the person's life.
According to the National Curricular Guidelines of the Undergraduate Nursing Course (NCGs), the profile of the graduated professional should be based on generalist, humanistic, critical and reflexive training capable of knowing and intervening on the problems of health-disease situations.The professional needs to identify the biopsychosocial dimensions and their determinants, denoting a sense of social responsibility and commitment to citizenship as a promoter of the integrative health of the human being in their praxis, including physical and mental self-care, the search for the well-being of the population, 26 and the care needs of the entire human life cycle.This includes death and dying (emphasis added).
Therefore, the nurse needs to develop skills that guarantee full assistance to the patient for his/her different needs as an individual within a family, 26 which is understood as part of the moment of terminality and death that families face in their daily lives.
However, studies claim that NCGs approach some aspects quite subjectively, which may lead to different interpretations.Thus, it is understood that the teaching process should not be based only on the aspects of the NCGs alone, since they do not consolidate the necessary conditions for quality training.

Death and care, perceptions of nursing professors
Nunes ECDA, Santos AA

FINAL CONSIDERATIONS
This study responded to the objective by showing the understanding of nursing faculty about the meaning of caring in the context of end-of-life care.It pointed out that nursing care in the face of death and dying should be based on a care that permeates the spheres of the patient and family and verified that, in this setting, the theme is approached in a superficial and fragmented way during graduation.This identifies the insecurity and suffering of students to talk about death, the lack of training of nursing professors on this topic and the inadequate curricular approach to human death and dying as fragilities inherent in the discussions of this theme.
Thus, this research demonstrates the need to rethink the teaching-learning process in nursing related to care for the terminally ill so that the training of nurses is redirected to the development of nurses who work with terminality by providing greater skills that hitherto have been neglected in their significance and magnitude.From this, changes in the curriculum of nursing undergraduate courses that go beyond the inclusion of topics that discuss death and dying are suggested.It is necessary to think about and discuss a curricular model that involves interdisciplinarity and promotes cultural, philosophical, sociological and humanistic discussions about death in a context of active methodologies and investments in the permanent education of professors and nurses, increasing the possibilities of change in this context.
Thus, this research contributes to the promotion of transformations in the nursing training process in the context of the terminally ill.One limitation of this study is that the setting of the research in just one region of the state of Bahia, and therefore, its results cannot be generalized for all nursing courses.Thus, this certainly does not exhaust the theme, but encourages more investment in research, debates and educational proposals capable of mobilizing this important contemporary discussion.Thus, teaching is built on the mobilization of knowledge, values and perceptions, which contribute to the formation of the professor's identity. 23In this way, the professor's knowledge originates from experiences that begin within the family environment and pass through cultural experiences, and school and university education. 22t is understood from there that learning occurs through social interaction and involves previous knowledge of the individual and what the individual can still learn. 30Thus, family histories, beliefs and educational experiences before graduation exert a great influence on the performance of professors in their dealing with death, and it is therefore unwise to blame academic education alone. 11hus, a new paradigm is proposed, in which it is necessary to transcend the reductionist and simplifying action towards interactions, reflections and self-knowledge capable of leading nurses to provide extended care.For this, it is necessary to reformulate the thinking, from the simple to the complex, from the parts to the whole, in order to interconnect and integrate disciplinary knowledge and shared experiences so that the learning is an interrelated whole, respecting the singularities of professionals and patients as active participants in an expanded, safe and effective care process. 31here are, however, no recipes or methods to teach the ideal way to deal with death.Thus, the professor must become selfaware and sensitized in a way that develops a vision of death and grieving processes, since she will be the mediator in the course of the discussions on this approach. 23n this sense, the teaching-learning process involves the ability of the educator to work and develop psycho-cognitive abilities of the person involving thought, readiness, humor and their relationship to the world, connecting with other perceptions, feelings, concerns and knowledge for practical transpersonal care. 19

Figure 1 .Graphic 1 .
Figure 1.Support for the transition to death.Source: designed by the research subjects.

Figure 2 .
Figure 2. Care-relational universe in the context of death.Source: designed by the research subjects.

Figure 3 .
Figure 3. Life here and beyond.Source: designed by the research subjects.