ARTÍCULO ORIGINAL / ORIGINAL ARTICLE / ARTIGO ORIGINAL

Experience of Nursing Students upon Their First Care Encounter with Terminally ill Patients

Experiencia de estudiantes de enfermería ante su primer encuentro de cuidado con enfermos terminales

Experiência de estudantes de enfermagem ante seu primeiro encontro de cuidado com doentes terminais

Irene Pamela Muñoz-Pino¹

¹RN, M.Sc Candidate. Professor, Universidad Católica de Chile. email: ipmunoz @uc.cl.

Receipt date: Feb 4, 2013. Approval date: Aug 20, 2013.

Subventions: none.

Conflicts of interest: none.

ABSTRACT

Objective. This work seeks to describe the experiences endured by third- and fourth-year nursing students upon their first care encounter with a terminally ill patient. Methodology. This was a descriptive qualitative study with methodology of analysis of contents of written testimonies at the end of the care experience. The study had the participation of 65 students from a private university in Santiago, Chile. Results. Emerging themes were classified into seven categories: life learning is accomplished, feelings regarding the encounter, loving care, interdisciplinary work with comprehensive care, sense to nursing, incorporation of the family in caring, and development of communication skills. Conclusion. The experiences of the nursing students show they have difficulties in facing the care of an individual in process of death. Educational strategies should be posed to improve undergraduate formation on end-of-life care.

Key words: students, nursing; terminally ill; education, nursing.

RESUMEN

Objetivo. Describir la experiencia vivida por estudiantes de enfermería de 3° y 4° año, ante su primer encuentro de cuidado con un enfermo terminal. Metodología. Estudio cualitativo descriptivo con metodología de análisis de contenido de testimonios escritos al final de la experiencia de cuidado. Participaron 65 alumnos de una universidad privada de Santiago, Chile. Resultados. Los temas emergentes se clasificaron en siete categorías: se logra un aprendizaje de vida, sentimientos antes del encuentro, cuidado amoroso, trabajo interdisciplinario con atención integral, sentido a la enfermería, incorporación de la familia en el cuidado, y desarrollo de habilidades comunicativas. Conclusión. Las experiencias de los estudiantes de enfermería muestran que estos tienen dificultades para enfrentar el cuidado de una persona en proceso de muerte. Se deben plantear estrategias educativas que mejoren la formación en pregrado del futuro profesional sobre el cuidado del enfermo terminal.

Palabras claves: estudiantes de enfermería; enfermo terminal; educación en enfermería.

RESUMO

Objetivo. Descrever a experiência vivida por estudantes de enfermagem de 3° e 4° ano, ante seu primeiro encontro de cuidado com um doente terminal. Metodologia. Estudo qualitativo descritivo com metodologia de análise de conteúdo de depoimentos escritos ao final da experiência de cuidado. Participaram 65 alunos de uma universidade privada em Santiago, Chile. Resultados. Os temas emergentes se classificaram em sete categorias: consegue-se uma aprendizagem de vida, sentimentos antes do encontro, cuidado amoroso, trabalho interdisciplinares com atendimento integral, sentido à enfermagem, incorporação da família no cuidado, e desenvolvimento de habilidades comunicativas. Conclusão. As experiências dos estudantes de enfermagem mostram que têm dificuldades para enfrentar o cuidado de uma pessoa em processo de morte. Devem-se propor estratégias educativas que melhorem a formação da graduação sobre o cuidado do fim da vida.

Palabras chaves: estudantes de enfermagem; doente terminal; educação em enfermagem.

INTRODUCTION

Nursing students, during their training process, tend to come into contact with death experiences of patients under their care, which can generate in them emotional conflict in terms of how to address or face the patients' sudden or expected death. Evidence exists confirming the negative perception of death, prior to relating to this process,¹ which changes as they become involved in the healthcare environment, with effective guidance and support measures provided by teaching and clinical staff.² The palliative care is the total and active attention to a patient in terminal phase, who is suffering a progressive disease without expectations of recovery, with death foreseen soon, and within a situation in which it is not possible to conduct active treatment to stop said process.³

One of the clinical experiences during the undergraduate training of third- and fourth-year nursing students at Pontificia Universidad Católica de Chile (PUC) takes place in a healthcare institution with terminally ill patients receiving palliative care. The students participate during a morning in care giving and attention activities carried out by an interdisciplinary healthcare staff. None of the students has had prior experience with terminally ill patients, but they have received theoretical instructions in the classroom on palliative care and the care model employed in the healthcare institution, which emphasizes on caring for the spiritual dimension.

This article presents a qualitative research, which reveals the experience endured by nursing students upon their first care encounter with a terminally ill patient, receiving in-hospital palliative care, by an interdisciplinary healthcare staff. The purpose of this research is to guide faculty staff and nurses from clinical fields to optimize educational support and guidance strategies upon the process of death in nursing care.

METHODOLOGY

This was a qualitative study conducted with a group of third- and fourth-year nursing students from Pontificia Universidad Católica de Chile (PUC), which used content analysis as methodology. To gather the data, a survey was used to get to know the educational needs of the nursing students after their first care encounter with terminally ill patients, which included the question: what did this experience mean to you?

The sampling was intentional and opinion-based⁴ in which the selection manner was through manifest voluntariness of including their written surveys for this analysis. Between May 2011 and July 2012, 150 students participated in filling out the survey, and thereafter, 65 accepted to participate in the study by signing a consent form. The criterion to finalize the analysis of the surveys was the thematic saturation, reached with 31 surveys.

The professor who accompanied the student during the experience read and coded the response in relevant themes, which were distributed into categories of analysis. The methodological rigor was assured by applying the criteria of Qualitative Content Analysis.⁴ This study was approved by the ethics committee in the School of Nursing at PUC.

RESULTS

From the data obtained from the surveys seven categories were identified directly related to the care experience endured by the students with terminally ill patients.

Enriching experience, life learning is accomplished personally and professionally

The students referred to caring for a terminally ill patient as an enriching, significant, heartwarming experience that, although aimed at their professional formation as general nurses, touched them more in their personal setting, meaning growth as individuals. They mention this experience as necessary to understand aspects of life and death, which – indirectly – helps them in their professional formation. Coming into contact with the patient's pain and the family, brought them close to the topic of death, which caught their attention in that it is seen as something natural; as part of life: It meant confronting a different world, where death is not something terrible, but the next step (Int 12).

This contact also stimulated reflection on themselves, mentioning that knowledge is important to know how to face these crisis situations, to discover what happens to each one of them when confronting a patient who will die, and – at the same time – how to confront that patient to help: I believe I have to learn to act in the face of these situations of suffering... first, reinforce my personal aspects in terms of the emotional or personal'' (Int 20). The students stated having understood the importance of their own wellbeing, in all its dimensions, to be able to offer effective help to those suffering, working on their own spiritual, social, and emotional dimensions: I started discovering and constructing my own spiritual dimension (Int 14); ... I saw the importance of my emotional and affective management to be a support and conduct comprehensive care (Int 16).

Some students even managed a higher level of analysis of their own lives, mentioning the teaching stimulated by the story of life, illness, and near death of those they accompanied. Among these lessons, they mention being able to recognize their ''own pending issues'' to work on; being aware if they have or have not given closure to former episodes in their lives; understanding that silence is sometimes necessary during the process of helping; being aware of and appreciating their strengths, recognizing their skills and, at the same time, their limitations to improve them. One student, quite happily, identified that an aspect she believed was a weak point could be used as a strong point: My ''sensitivity'', which I thought was a difficulty, can be used as something positive more than negative (Int 30). The students highlight as a life lesson the appreciation of their own family: It touched in the personal aspect, my vision of my own family... I saw the importance of one creating one's own social network in life (Int 16).

Feelings and emotions upon the first encounter

Although almost all the students referred to the first encounter as ''heartwarming'', most expressed their misgivings, fear, and anxiety felt before said encounter, and that these emotions were rapidly alleviated as they started talking with and caring for the patients: I was afraid they would be suffering ... I lost the fear of approaching them and talking to them (Int 2). Some expressed not only relief, but pride and satisfaction for having been able to overcome their prior misgivings: I arrived with lots of fear, but I overcame it (Int 4). Clearly, positive and negative emotions are noted upon the first encounter. They state great sadness because of the situation of death and suffering of the individuals and their family members, so much so that at some moments they could not be of help and had to contain themselves, even removing themselves from the situation: It was difficult; I had to contain myself ... it was distressing not being able to help (Int 17).

The feeling of anguish is frequently mentioned. Sadness also emerged upon becoming aware of the great need for care terminally ill patients have and that, in our social reality, these patients do not receive the sufficient care and attention to die with dignity: I got sad when I realized the deficiencies of care these patients have... palliative care should work even better (Int 29); ...intense, full of good and bad feelings. ...happiness because of the attempt to find sense to pain, illness, and death; sadness because of the proximity of death and the family's sadness (Int 19). They also manifested positive feelings and emotions. The students recognized suffering, but from another point of view, as an aspect that allows patients and family members accomplish something good. Most referred to the gratification they felt when they were able to significantly help the person suffering, more so, when the patient thanked them explicitly: I enjoyed and was filled with the words and smiles from the patients (Int 31). Several mentioned the ''emotional load'', but in a positive manner, which motivated them to continue caring: The cases touched me emotionally ... it meant a big emotional load and a big challenge (Int 22).

The participants also referred to the pleasantness of the closeness accomplished in the care giving relationship; in spite of the reduced time (one morning), they were surprised that people ''opened up'' and trusted them, a situation that is difficult to accomplish in other clinical contexts. It was favorable and gratifying, being able to accompany and being able to be there for them. Regarding feelings for the future, they mentioned the challenge of trying to control sorrow and anguish and the challenge of accompanying those who suffer: it became a challenge... I have always avoided accompanying people in pain and suffering (Int 14).

Loving care

In relation to the observed manner of providing nursing care, the students described the importance of love expressed in the care giving relationship and that this love is a therapeutical strategy nurse can offer. The expression of affection was integrated in care: I realized people always want affection and contact and that nurses can provide this (Int 8). They managed to note that kind, respectful, and cordial treatment affects positively the process experienced by patients. They indicated that a way to dignify care is through love, thus, dignity is granted to people for what they are. They recognize that the affectionate relationship provides the opportunity and space for expression for patients to see their suffering as something that will make them grow.

Most stated that this care encounter, which integrates affection, reinforced their ideal of delivering love in service: ... I understood that although the ''technique'' is important, sensitivity is essential to have contact with another and offer care with love (Int 14). Lastly, they reflected on the reality of healthcare from other clinical contexts, where care is distant, aimed at the technical aspects and regret that many patients miss out on this loving and professional nursing care.

Sense to nursing

In most of the surveys, the students refer to the nursing role observed, demonstrating a high degree of satisfaction upon experiencing comprehensive, personalized, and humane care close to God: It gave sense to nursing... I found what I was looking for (Int 28); I saw that contact with another human being makes nursing real (Int 11). They evaluate the role of this discipline in the area of palliative care, given the big and diverse needs for care the terminally ill patients and their families have. Also mentioned was the risk of frustration, given that ''comprehensive care'' demands a great deal of time and it could be difficult to delve into the dimensions of each patient: it allowed me to know the integral environment of nursing... although the system does not permit embracing all the dimensions, especially the spiritual (Int 8).

Proudly, they mention the value and meaning of direct care, referring to concrete, simples, and routine care activities, like feeding, helping to get out of bed, combing, helping with oral hygiene, changing, accompanying during outings: ...I helped them in small, but significant activities (Int 12); ...the best I can do was listen actively (Int 20). This direct care, with basic nursing actions, reaffirmed the motivation for caring, urging students to carry out holistic nursing, considering its real application: I noted the true vocation toward care; in spite of scarce resources, all that is needed is ingenuity and willingness (Int 12).

Importance of the interdisciplinary healthcare staff and the comprehensive care model

The students surveyed mentioned the importance of seeing the work of an interdisciplinary team in which all the members work and help toward the same cause, which is to facilitate the illness and death process of the person and the family, optimizing their quality of life. It was noted that the work was performed as a team within a cozy, pleasant, and joyful environment, where the professionals display affection, with empathy and ability to manage the situations: ... I was impressed by how the staff treated the patients and family members... and how they treated each other (Int 31). Statements were made on the quality of the professionals, indicating that working in this area requires preparation and knowledge, which is compatible with the expression of values of love and dedication. They claim that the preparation of the staff is not only on empirical knowledge about palliative care, but also on their own growth: I was impressed by the strength and spiritual peace of the care givers (Int 6); ... each member knows how to act to be a facilitator of the process of illness' transcendence, even the technicians ... (Int 23).

In the clinical experience, the students had to identify the healthcare model in palliative care, which seeks to help the person in his/her spiritual, psycho-social dimensions, and not merely in the physical dimension. In terms of this, they managed to identify the model: ... it felt strange at first, but then, when becoming aware of the realities, said approach is justified (Int 22). They also managed to identify that the care actions are centered on the person, and that many of these needs can occur in the patient's distinct spiritual, psychosocial, or physical dimensions. They denote the concern of the healthcare staff for all of the individual's aspects, highlighting that all were willing to do everything: if the patient wanted to pray, the nurse would accompany the patient ... I don't know if I would dare ... just when kinesiology was being practiced, the patient urinated, the kinesiology therapist simply changed him and kidded with the patient!.., the TENS seemed proud to contribute during change of shift ... you don't see that everywhere (Int 5).

The students recognize the comprehensive care model in detecting the needs given by the patient and in the interdisciplinary approach. They repeatedly refer to the ''comprehensive nursing care observed'' and that the care needs are diverse and in the person's dimensions. It motivated reflection of the application of this model in other contexts: the model is experienced in the personal aspects ... it motivated my personal reflection on the model's application and comprehensive care in any context in or out of the hospital (Int 17). Lastly, they state that it is a place where they would like to work, with a cozy and affectionate staff that applies a healthcare model worth imitating.

Incorporation of the family in caring

It is recognized that palliative care must be practiced on the patient and on the family. Noting the inclusion of family members in care giving, motivated several students to replicate this modality in other clinical settings, where family support is not given the importance required. The experienced the comprehensive care model, understanding that the family is part of the patient's social dimension: I saw that working with the family is also helpful for the patient (Int 31); I understood the importance of the family network to accomplish the person's emotional, spiritual, and physical stability'' (Int 27). This category was the first reach thematic saturation, given that it was mentioned as relevant, within nursing care of terminally ill patients, in most of the surveys.

Need for communication skills

The students often mention the significance of verbal and non-verbal communication skills and of the skills to establish interpersonal relationships to detect and intervene in the person's needs: As nurses, we must develop interpersonal skills that allow us to provide care that spans physical, social, spiritual, and emotional aspects (Int 6). They appreciate the diverse forms of communicating: I was able to communicate in different forms (Int 12); I experienced the simplicity and majestuous nature of a gaze (Int 19). They state having lived that care experience as a pleasant way of putting into practice what they had learned during their training on skills of the helping relation: I was able to put into practice the skills of the helping relation... I was motivated to continue developing them (Int 23).

DISCUSSION

Analysis of these experiences reveals the different experiences of the students, most with great emotional and reflexive content regarding themes related to human beings: sense of death, importance of the family, human communication, physical contact, spirituality; aspects that are often displaced from what nursing care means. Jean Watson, author of the ''Theory of Humane Care'', holds that upon the risk of dehumanization in patient care, caused by the great administrative restructuring of the majority of healthcare systems in the world, it is necessary to rescue the human, spiritual, and transpersonal aspects in clinical, administrative, educational, and research practice by nursing professionals.⁵ The content of the experiences reflects the need for the students to rescue this human aspect in the clinical practice, described by the theorist, which seems to be a big teaching opportunity to humanize care from the undergraduate professional formation.

Regarding the life learning obtained by the students, accompanying during human pain and suffering generates reflections on their own life story. If students are properly guided during this process, they can achieve that personal growth mentioned, upon evaluating the positive aspect of suffering, leading to the transcendence of human beings, which will be reflected in their future professional management. Being willing to learn to become better individuals is reinforced by other Colombian nursing students, who published their care experience with patients with advanced cancer: We want, as nursing students, to appropriate of knowledge, gain more sensitivity each day, and not lose it over time, to care for others, to become not only better nurses, but also better individuals.⁶

Comprehensive training of future nurses constitutes a guarantee that permits having more competent personnel. Helping to die with dignity and accompanying during suffering requires training, knowledge, and maturity.⁷ On the contrary, it is also known that neither nursing students⁸, or nursing professionals who have spent some time in the practice know how to confront this situation;⁹ given that it seems that fear of their own death or that of a loved one can trigger such,¹⁰ which is why it can be said that accompanying death is an aspect that should be included in the undergraduate preparation.^7-11 During this preparation, it is necessary to guide students in the management and containment of emerging emotions and feelings, which in this study are known as anguish, sorrow, sadness, frustration, satisfaction, and happiness.

Caring for patients in terminal phase, their death, and suffering, and their family members have been some of the clinical activities that have cause the greatest stress in nursing students in Spain; these mainly generate sadness and anxiety, against which they have no resources available in a repertoire of behaviors to confront them.⁷ This can become a big opportunity for the teaching staff, which guides the learning process, through educational strategies like discussion, analytical writing, containment, and modeling of daily activities. In the same way that nursing professionals, through their relationship with the subjects cared for, explore their emotions, sensations, and accompany them in ways to assimilate their illness, the teaching staff can homologate this care relationship toward the students, through strategies that help them to confront their feelings and encourage skills of emotional selfcontrol,⁹ given that what really impacts on anxiety upon death is how each person perceives it and the coping resources available. Additionally, the younger students and those in the lower courses show greater fear and anxiety presentan,¹⁴ confirming the importance of early education on the process of death to reduce anxiety and improve attitudes toward terminally ill patients and encourage, in them, the desire to work in helping these patients.^8-11 Thus, not running the risk that future professionals experience the death of their patients with sorrow, regret, or in depersonalized manner, given the fear of experiencing grief that is not theirs.¹²

It is interesting to see the emerging categories of sense to nursing and loving care. Although agreeing in the affirmations of the students that the area of palliative care creates an environment where nursing can be deployed in all its sense,¹³ it is cause for concern when they state, with surprise that during the care relationship love is given and received as therapeutic strategy, given that it is a characteristic of nursing care. It is worth to, again, cite Watson, who has studied nursing care through philosophical-spiritual approaches, and sees care as a moral and ethical ideal of nursing; in other words, ''humane care as basic therapeutic relationship among human beings, which is relational, transpersonal, and intersubjective''.⁵ The analysis of the testimonies evidences the phenomenon of dehumanization and depersonalization undergone by healthcare, replacing the act or moment of genuine care⁵ by technicalities and procedures that must be complied. The fact students were motivated by this observation of loving care, that they had even mentioned that it reminded them of the sense of nursing, raises hope in the attempt to combine sincerity, honesty, and love with professionalism within the context of the act of caring. Professors must not forget that the nursing process is humanist because it is based on the idea that while we plan and offer care, we must consider the interests, ideals, and intimate desires of the person, the family, or the community.¹³ Human beings are fundamentally sacred. Dignity implies accepting the human obligation of serving with love, of existing for others.¹⁴ Thus, bringing this to the context of caring during death, it is worth mentioning that students grant greater importance to emotional aspects during the dying process, in relation to biomedical aspects, like pain control.¹⁰

Regarding the interdisciplinary healthcare staff and the comprehensive healthcare model, it is noted that it is a way of working and a healthcare model the student can easily acquire and execute. As concluded by Porto et al.,¹⁵ the integration of the interdisciplinary practice in palliative care is an innovative action, capable of improving the quality of care and of contributing to the satisfaction of the professionals who work with patients requiring this type of care.¹⁵

Analysis of these experiences can serve as a guide for undergraduate educational strategies on end-of-life care. Imparting, during the undergraduate, themes related to palliative care will generate changes regarding the perception and coping of the process of death and its care in future nursing professionals, optimizing the nursing discipline.

It is considered that a limitation of the study is that the analysis of the content was conducted by the professor who accompanied the student during the experience.

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