Death education for nursing professors and students: a document review of the scientific literature

Abstracts

Nas culturas Ocidentais, a Morte não se apresenta como tema preferido. Contudo, como os profissionais que convivem e enfrentam a Morte cotidianamente devem proceder? Qual o significado que esta assume? Este estudo se constitui de um levantamento da literatura científica sobre o tema na formação acadêmica de Enfermagem. A metodologia é qualitativa, através de um estudo exploratório documental, caracterizado pela pesquisa bibliográfica, num recorte temporal de cinco anos. As palavras-chave são: Docente e Discente de Enfermagem, Morte e Morrer. Foram localizados 12 artigos em periódicos, que compuseram três categorias: Os discentes de enfermagem e o convívio com a morte; O docente em enfermagem convivendo com a morte e as habilidades para ensinar; A formação acadêmica dando suporte para visão crítico-reflexiva sobre a temática morte-morrer. Concluiu-se que não há preparo dos discentes de enfermagem sobre o tema. Somente maiores investimentos e estudos trarão mudanças para a realidade atual.

Morte; Educação em enfermagem; Estudantes de enfermagem; Docentes de enfermagem; Atitude frente a morte

CRITICAL REVIEW

Death education for nursing professors and students: a document review of the scientific literature^*

Educação para a morte a docentes e discentes de enfermagem: revisão documental da literatura científica

Janaina Luiza dos Santos^I; Sonia Maria Villela Bueno^II

^IRN. Master's student, Graduate Program, University of São Paulo at Ribeirão Preto College of Nursing. Active member of the Palliative Care Group, University of São Paulo at Ribeirão Preto Medical School Hospital das Clínicas. Active member of the Research Group CAESOS. [e-mail]

^IIPsycho-pedagogue. Associate Professor, Psychiatrics and Human Sciences Department, University of São Paulo at Ribeirão Preto College of Nursing. Chairwoman of the Research Group CAESOS-DPCH-EERP/USP. Ribeirão Preto, SP, Brazil. [e-mail]

ABSTRACT

In Western cultures, Death is not among the favorite topics. Nevertheless, how should professionals who deal with Death on a daily basis behave? What meaning does Death have to them? This study consists of a survey on scientific literature about the referred subject in nursing education. Using a qualitative method, a documentary exploratory study was performed, characterized by a survey over a five-year period. The following keywords were used: Nursing Professor and Student, Death and Dying. Twelve articles were located and comprised three categories: Nursing students and dealing with death every day; The nursing professor dealing with death every day and the teaching skills; Academic education providing support for a critical-reflexive view about death-dying. In conclusion, there is o preparation for nursing students on the referred theme. Changing the current situation is only possible with greater investments and if further studies are performed.

Key words: Death. Education, nursing. Students, nursing. Faculty, nursing. Attitude to death.

RESUMEN

La muerte, en las culturas occidentales no se presenta como tema de preferencia. Así y todo, ¿cómo deben proceder los profesionales que conviven y se enfrentan con la muerte cotidianamente? ¿Cuál es el significado que ella asume? Este estudio parte de una investigación de la literatura científica sobre este tema en la formación académica de Enfermería. La metodología fue cuantitativa, a través de un estudio exploratorio documental, caracterizado por la pesquisa bibliográfica en un lapso temporal de cinco años. Las palabras llave fueron: Docente y alumno de enfermería, Muerte y Agonía. Fueron localizados 12 artículos en periódicos, los cuales compusieron tres categorías: Los alumnos de enfermería y la convivencia con la muerte; El docente en enfermería conviviendo con la muerte y las habilidades para enseñar; La formación académica brindando soporte para una visión crítico-reflexiva sobre la temática muerte-agonía. Se concluyó en que no hay preparación de los alumnos de enfermería sobre el tema. Solamente mayores inversiones y estudios provocarán cambios en la actual realidad.

Descriptores: Muerte. Educación en enfermería. Estudiantes de enfermería. Docentes de enfermería. Actitud frente a la muerte.

INTRODUCTION

Especially in the West, death has not been a theme that is easy to address, as the meaning constructed for the outcome of what we usually call life almost always remits to fear, anguish or rejection. Thus, Death is frequently linked with the supernatural, terror, punishment, pain, among so many other meanings Western nations consider 'negative'.

So, how do people live with and face the issue of Death day by day for professional reasons? And what meaning does it assume for these professionals? In this sense, for professionals like nursing workers, death is present almost ostensibly in their work routine, obliging them to live with it in a not always 'pacific' way. According to some studies^(1-2), Death has aroused feelings of frustration, fear and insecurity in these professionals. At least theoretically, these should not be part of their professional life.

Historically, at the start of the Middle Ages, Death was no more than a natural event. The patient followed a kind of ritual; he asked pardon for his sins, bequeathed his property and, then, waited for death to take him. There was no drama or excessive gestures.

Today, death is related as a taboo and, over the centuries, it has been moved from home to the hospital. Thus, it is no longer a natural phenomenon, but has turned into a cold, hidden and deeply unwanted death⁽³⁾. And this difficulty to deal with Death has caused a range of problems that directly affect the country's public health system, especially due to its professionals' illness experiences⁽⁴⁾. These experiences, deriving from emotional exhaustion, which favors the development of the Burnout syndrome, described as the individual's final reaction to stressful experiences accumulated over time during a certain job activity, leading to the modification of care, generating cold and indifferent nurses in health⁽⁵⁾.

Death, treated with indifference, derives from nurses' defense mechanism to stay mentally sane as, besides the lack of preparation to deal with Death, many of these professional still face long work journeys, overloaded and scrapped nursing wards, aggravating the stress they are submitted to even further.

This demonstrates the need for effective education to deal with Death as, with respect to the issue of Death, despite the countless factors responsible for nurses' illnesses, how should these professionals be prepared? What do these professionals know about this process? What are the conditions to face it? What are the most common difficulties reported? What contributions has literature in this area offered? Can the produced research support these nurses' practice and/or education with regard to Death? What pedagogical paradigm has been used for professional education?

Hence, a progressive educative approach is needed? The goal of this research is based on the survey of scientific literature produced in the last five years about Death in academic Nursing education.

METHOD

The most adequate method for this research is the Qualitative⁽⁷⁾, based on the universe of meanings, beliefs, aspirations, values and attitudes. An exploratory documentary study was proposed and the indirect documentation technique was used.

The research was based on journals classified as Qualis A₁, A₂ and B₁, B₂, as these represent the best assessed journals. Thus, contents from the following databases were accessed: MEDLINE, LILACS, BIREME, SCIELO, BDENF, respecting the production period of the last five years (2005 - 2009). The following combined keywords were used to search these databases: Death, faculty, student, Nursing.

The searches were done between July and October 2009, respecting the above defined selection criteria, which resulted in 12 articles. Next, data analysis was accomplished⁽⁸⁾,

[...] the word category, in general, refers to a concept that covers elements or aspects with common or mutually related characteristics. This word is connected with the idea of class or series. Categories are used to establish classifications. In this sense, working with them means grouping elements, idea or expressions around a concept that is capable of covering all that. This type of procedure, in general, can be used in any type of qualitative research analysis [...].

Thus, in view of convergences and divergences, three categories were constructed in the approach and identification of the Death theme, in which the definition of the category concept refers to the range of elements or aspects with common or mutually related characteristics: 1-Nursing students and contact with Death; 2-Nursing faculty living with Death and teaching skills; 3-Academic education providing support for a critical-reflexive view on the theme Death-dying.

RESULTS AND DISCUSSION

After the selection, identification, ranking, synthesis of the papers and interpretative Reading, the findings were analyzed, resulting in the establishment of three categories.

The first category: Nursing students and contact with death:

The contents of the articles referred to research like: a study involving first-year undergraduate Nursing students, who had not gone through training and/or patient contact yet, but had "prejudices" towards Death, based on sociocultural and family contact. These new students saw Death as an enemy, believed that they should 'fight it', so as to preserve life. The belief was verified that progressing in the Nursing course would make these students gain knowledge and that, once they had graduated, they would be capable of helping to cure patients. According to these students, Death is a synonym of failure⁽⁹⁾.

In the papers^(10-12), practically the same results are described regarding the students' perception of feelings towards Death. These students described feelings of anguish, fear, sadness, anxiety, frustration, guilt, and some also shared the family's mourning. The authors also defend stimulating the skills of students responsible for care delivery to terminal patients, as well as the creation of spaces for reflection, as there is an important pre-existing sociocultural factor that influences them.

Although they express the desire to deliver humanized care to terminal patients and their relatives, most students mention difficulties to deal with this situation, not knowing how to deal with the relatives, nor with their own feelings⁽¹³⁾.

Another paper⁽¹⁴⁾ describes a study involving students from the final training period in an undergraduate Nursing program. It was also verified that, among these students, Death is still an event that shocks and causes great suffering. It is important to highlight that these answers were obtained from future Nursing professionals, who will soon be performing their functions in the job market.

In another article, which involved first to fourth-year undergraduate Nursing students, a lot of difficulties were reported in care delivery to terminal patients. The students demonstrated feelings of anxiety, stress and insecurity. And one truly concerning fact are reports about distancing between these future professionals and terminal patients⁽¹⁵⁾.

One article⁽¹⁶⁾ describes a study involving students enrolled in the subject Nurse/Patient Relationship, which addresses the understanding of how students perceived themselves in care delivery to terminal patients. These students mentioned a painful experience, justifying that their difficulties may have resulted from their own inability to accept Death and the lack of emotional preparation and inexperience, highlighting the lack of support from the professionals with whom they share care.

To finish this category, the report of one Nursing specialty related to the Death theme is highlighted, which is organ donation. This study was accomplished during an event for Nursing students from several colleges and Brazilian states. The application of a questionnaire revealed that 92% of the interviewees did not known about the existence of the Organ Procurement Organ - the OPO. Other questions in the same study reveal professionals' lack of preparation to understand brain death, and of preparation for organ donation by approaching family members⁽¹⁷⁾.

Thus, it was verified that, nowadays, undergraduate Nursing programs have prepared their students very little for the Death process, perhaps for a theme as specific as organ donation⁽¹⁷⁾.

The second category: Nursing faculty living with Death and teaching skills:

Some papers fit into both categories, i.e. in the second as well as the first^(9,13).

In this second category, all papers restrictively asserted that teachers are impelled to develop a technical-scientific pedagogical approach, ruled by standards, rules and routines in an attitude without reflection, i.e. mechanic. Thus, these educators focus on charging attitude, which keeps them distant from the students, especially regarding the feelings deriving from terminal patients' experience^(9,13,18-20).

The faculty members justify themselves by asserting that subjects are short for such a complex theme which, according to them, involves various dimensions, including: existential, cultural and religious, whose perception varies for each human being⁽²⁰⁾.

Despite the difficulties, these educators try to demonstrate balance in the experience of Death, during student training, but often feel unprepared, feeling anguished and fearful like their students, as they had not been prepared either to accept or experience what is so present in their professional daily reality, i.e. Death⁽¹⁸⁾.

Finally in this category, one article⁽¹⁹⁾ presents the construction of 34 nursing teachers' profile, mostly women, between 40 and 50 years of age. Unfortunately, these experienced professionals demonstrated the same feelings as any and all Nursing professionals, independently of their work time. And, with a view to 'justifying' themselves, they defended that the approach of this theme demands profound internal mobilization, availability to recover feelings and mainly, getting rid of in-rooted prejudices originating in society.

The third and final category: Academic education providing support for a critical-reflexive view on the theme Death-dying:

The papers unanimously indicated that colleges have not been capable of introducing Thanatology in their curriculum in a critical-reflexive way. This Science studies Death in its broadest sense.

Although some colleges offered subjects about Death, all studies demonstrated that students lack reflection and discussion, so as to get rid of Western sociocultural prejudices they have experienced this childhood.

Thus, according to the analyzed studies, these subjects merely reproduce the experiences lived in society and their family ad aeternum, and are unable to see, listen or talk about Death as yet another, although often painful step in the trajectory of any living being, including humans^(9-20).

CONCLUSION

This study proposed a survey and analysis of scientific literature about Death, dying and the identification of this approach in academic Nursing education.

Respecting the five-year time period, twelve publications on the theme were located in different journals. In academic Nursing education, the approach of Death can be considered inferior, with scarce investments.

Further research and publications on the theme of Death are also needed. A critical-reflexive view on the death and dying process urgently needs to be introduced in academic education, so that these professionals are capable of accepting Death, when inevitable, in a more natural ways, thus detaching it from personal failure and frustration.

It was also verified that the faculty members experience feelings of helplessness, fear and insecurity as to how they will express the feeling of Death to the students and the patients' relatives. As mentioned above, students' education was also deficient in this respect. How can one teach what was never learned then?

Especially by putting in practice project on death/dying/mourning, mainly at colleges, by through the promotion of encounters, lectures, experiences, discussion groups and/or other alternative means to join forces, thus encouraging the dissemination of studies. It can also involve the socialization of the knowledge produced about Death in spaces outside the professional/academic context, as this theme is not only related with health researchers and professionals, but also with society as a whole, enhancing possible and desired changes in beliefs, attitudes and behaviors.

It is also important to highlight the need for further research involving Health and Education faculty, with a view to defining gaps and the best training methods for these professionals, which could include the incorporation of each faculty member's personal perception, in order to compose the most comprehensive 'panorama' possible on this theme, which is unanimously described as very complex.

Furthermore, a specific education program on Death and dying needs to be constructed, in view of action-reflection-action, within the critical-social approach, so as to achieve the affective transformation of current reality. This program would be applied to faculty in general, thus permitting the construction of educative plans directed not only at the cure process, but also at the Death and dying process, in a dignified way.

REFERENCES

• 1. Kovács MJ. Educação para a morte: desafio na formação de profissionais de saúde e educação. São Paulo: Casa do Psicólogo; 2004.
• 2. Costa JC, Lima RAG. Luto da equipe: revelações dos profissionais de enfermagem sobre o cuidado à criança/adolescente no processo de morte e morrer. Rev Lat Am Enferm. 2005; 13(2):151-7.
• 3. Ariès P. História da morte no ocidente: da Idade Média aos nossos dias. Rio de Janeiro: Ediouro; 2003.
• 4. Popim RC, Boemer MR. O cuidar em oncologia. São Paulo: Ed. UNESP; 2006.
• 5. Palú LA, Labronici LM, Albini L. A morte no cotidiano dos profissionais de enfermagem de uma unidade de terapia intensiva. Cogitare Enferm. 2004;9(1):56-79.
• 6. Guedes GF, Ohara CVS, Silva GTR. Processo de ensinar e aprender em UTI: um estudo fenomenológico. Rev Bras Enferm [Internet]. 2008 [citado 2009 out. 14];61(6):828-34. Disponível em: http://www.scielo.br/pdf/reben/v61n6/a06v61n6.pdf
• 7. Minayo MCS. O desafio do conhecimento: pesquisa qualitativa em saúde. 7Ş ed. São Paulo: Hucitec; 2001.
• 8. Minayo MCS. Pesquisa social: teoria, método e criatividade. 19Ş ed. Petrópolis: Vozes; 1994.
• 9. Bretas JRS, Oliveira JR, Yamaguti L. Reflexões de estudantes de enfermagem sobre morte e o morrer. Rev Esc Enferm USP [Internet]. 2006 [citado 2009 out. 6];40(4):477-83. Disponível em: http://www.scielo.br/pdf/reeusp/v40n4/v40n4a04.pdf
• 10. Carvalho LS, Silva CA, Santos ACPO, Oliveira MA, Portela SC, Regebe CMC. Perception of the death and dying of the nursing students: a qualitative study. Online Braz J Nurs [Internet]. 2006 [cited 2009 Oct 6];5(3). Available from: http://www.objnursing.uff.br/index.php/nursing/article/view/507
• 11. Carvalho LS, Oliveira MAS, Portela SC, Silva CA, Oliveira ACP, Camargo CL. A morte e o morrer no cotidiano de estudantes de enfermagem. Rev Enferm UERJ. 2006;14(4):551-7.
• 12. Oliveira JR, Bretas JRS, Yamaguti L. A morte e o morrer segundo representações de estudantes de enfermagem. Rev Esc Enferm USP [Internet]. 2007 [citado 2009 out. 10];41(3):386-94. Disponível em: http://www.scielo.br/pdf/reeusp/v41n3/07.pdf
• 13. Bernieri J, Hirdes A. O preparo dos acadêmicos de enfermagem brasileiros para vivenciarem o processo morte-morrer. Texto Contexto Enferm [Internet]. 2007 [citado 2009 out. 10];16(1):89-96. Disponível em: http://www.scielo.br/pdf/tce/v16n1/a11v16n1.pdf
• 14. Oliveira WIA, Amorim RC. A morte e o morrer no processo de formação do enfermeiro. Rev Gaúcha Enferm. 2008;29(2): 191-8.
• 15. Takahashi CB, Contrin LM, Beccaria LM, Goudinho MV, et.al. Morte: percepção e sentimentos de acadêmicos de enfermagem. Arq Ciênc Saúde. 2008;15(3):132-8.
• 16. Sadala MLA, Silva FM. Cuidando de pacientes em fase terminal: a perspectiva de alunos de enfermagem. Rev Esc Enferm USP [Internet]. 2009 [citado 2009 out. 10];43(2):287-94. Disponível em: http://www.scielo.br/pdf/reeusp/v43n2/a05v43n2.pdf
• 17. Silva AM, Silva MJP. A preparação do graduando de enfermagem para abordar o tema morte e doação de órgãos.Rev Enferm UERJ. 2007;15(4):549-54.
• 18. Carvalho MDB, Valle ERM. Vivência da morte com o aluno na prática educativa. Ciênc Cuidado Saúde. 2006;5 Supl:26-32.
• 19. Bellato R, Araújo AP, Ferreira HF, Rodrigues PF. A abordagem do processo do morrer e da morte feita por docentes em um curso de graduação em enfermagem. Acta Paul Enferm. 2007;20(3):255-63.
• 20. Pinho LMO, Barbosa MA. A morte e o morrer no cotidiano de docentes de enfermagem. Rev Enferm UERJ. 2008;16(2):243-8.

Correspondência:

Janaína Luiz dos Santos

Av. Paris 707 - Bloco B 13 - Apto. 23 - Jd. Independência

CEP 14076-110 - Ribeirão Preto, SP, Brasil

*

Extraído da dissertação "Revisão documental da literatura científica sobre educação para a morte a docentes e discentes de Enfermagem", Escola de Enfermagem de Ribeirão Preto da Universidade de São Paulo, 2009.

Publication Dates

• Publication in this collection
  22 Mar 2011
• Date of issue
  Mar 2011

History

• Accepted
  27 May 2010
• Received
  18 Nov 2009