Nursing Students’ Experiences With Death and Terminal Patients During Clinical Education

Abstract

The aim of this study is to explore nursing students’ experiences with death and terminal patients during clinical education. A secondary analysis of qualitative data that were collected through 11 focus group interviews with nursing students was performed. Data obtained from the interviews were analyzed using thematic analysis. There were a total of 9 themes across 3 contexts. Data were grouped under the following themes: feelings experienced when encountering death for the first time, reactions to the first encounter with death, factors affecting the reactions to death, involvement in terminal patient care, being informed about the physical process that terminal patients are going through, students’ approach toward terminal patients and their relatives, health professionals’ approach toward terminal/dying patients/their relatives, changes in the ideas about death, and changes in the ideas about terminal/dying patients. The study shows a lack of guidance on the part of teachers who also avoid patients and families who are considered terminally ill.

Keywords

death experience nursing education nursing students qualitative study

Death is ultimately experienced by all living beings and has a different definition and meaning for each individual. An individual’s perception of death is shaped by cultural characteristics and beliefs as well as values (Jong et al., 2013; Qiu et al., 2015). Hence, each individual’s perception of and attitude toward death are unique (Jafari et al., 2015). Studies on this subject have determined that religious beliefs and having faith are important factors that affect attitudes toward death and toward terminal patients (Iranmanesh et al., 2008; Khader et al., 2010) in Turkey (Cevik & Kav, 2013). In addition, a belief in God and in the afterlife is associated with a more positive attitude toward death and dying among nurses, physicians, and the general population (Braun et al., 2010; Cevik & Kav, 2013; Fehring et al., 1997).

With advances in medical knowledge and technology, hospitals are preferred over the home for end-of-life care (Jack et al., 2016). In Australia, studies describe patients often dying in acute settings with escalating technology, invasive treatments, and limited access to their families (Australian Institute of Health and Welfare, 2019; McGrath, 2002; McGrath & Holewa, 2006). Although most people in the United States state that they want to spend their late life at home or in hospice (Cross & Warraich, 2019; Warraich, 2017), many deaths still occur in hospitals, especially palliative care units (Johnstone et al., 2016; Smith, 2017). Similarly, despite the vast majority of people in European countries wanting to die at a hospital or in hospice (Ali et al., 2019; Gomes et al., 2012; Hunt et al., 2014), approximately half of deaths occur in hospitals due to health problems and lack of a caregiver at home (Public Health England, 2018). Similarly, 90% of people in Africa prefer to die in their homes (Blanchard, 2019). Given the lack of hospice institutions in Turkey, especially with the opening palliative care units after 2010, most deaths take place in hospitals (Kart et al 2011; Kömürcü, 2011; Turkish Statistical Institute, 2019). Studies in Turkey indicate that individuals prefer to die at home when they are terminally ill, as in other countries (Ramazan et al., 2018).

Nurses frequently encounter dying patients and their relatives during their clinical practices, especially in intensive care units, palliative care units, emercency services, and during home visits (Poultney et al., 2014; Rosdahl & Kowalski, 2008). The role of nurses in this process is to meet the physical and emotional needs of the patient, who has spetnt the last time of her life, and to support the patient and her family in psychosocial aspects. In certain studies, it has been reported that caring for dying patients and their relatives elicits negative feelings in nurses such as despair, fear, pain, and concern that may adversely affect the quality of care, and that nurses tend to prefer working in environments that do not have terminal patients as they fear that they will be inadequate and unsuccessful (Gama et al., 2012; Gillan et al., 2014; İnci & Öz, 2012; Sharour et al., 2017; Shimoinaba et al., 2014).

For nurses to be able to manage the dying process effectively, it is essential that death and approaches toward dying patients be incorporated in nursing education, and that nursing students be prepared to cope with the thought of death (Beckstrand & Kirchhoff, 2005; Dimoula et al., 2019; Poultney et al., 2014). It is purported that student nurses’ experiences of first encounter with death have significant effects on their approaches toward patients, attitudes to death, and the nursing care they provide to the patients (Khader et al., 2010; Menekli & Fadıloğlu, 2014). Not being able to provide sufficient emotional and psychological support to dying patients and their relatives may cause nursing students to feel inadequate, leading them to avoid giving care to such patients (Anderson et al., 2015; Ranse et al., 2018; Terry & Carroll, 2008). Kent et al. (2012) conducted a study to investigate the first experiences of graduate nursing students in terms of the death of a patient. They found that the students had their first experience with death during undergraduate education, and had minimal or no involvement in the patient’s care. In another study, students reported that they were ill-prepared and experienced anxiety when they encountered the death of a patient (Parry, 2011).

There is limited literature on nursing students’ experiences with terminal patients during clinical education (Adesina et al., 2014; Anderson et al., 2015; Parry, 2011; Ranse et al., 2018). Based on these studies and arguments, this study aims at thoroughly investigating nursing students’ experiences with terminal patients and their relatives during clinical education. It is believed that the results of this study may contribute to the literature, assist in enhancing the quality of care given to terminal and dying patients, facilitate the development of a curriculum that meets the needs of nurses and nursing students, and assist in the generation of a more efficient end-of-life care with provision of institutional support.

Method

Study Aim

This study aims to provide an in-depth investigation of nursing students’ experiences with death and terminal patients during clinical education.

Design

This was a secondary analysis of qualitative data collected from a study aiming to reveal the effect of professional education on medical and nursing students’ attitudes toward death. The parent study was comparing the main themes and language used by medical and nursing students, highlighting the similarities and differences. Consistent with guidelines for conducting secondary qualitative data analysis (Hinds et al., 1997; Long-Sutehall et al., 2011), this study was carried out to highlight the experiences of nursing students who had an encounter with terminal patients during clinical education.

Sample and Setting

Data of the parent study titled, “The effect of professional education on medical and nursing students’ attitude to death” were collected through 23 focus group interviews conducted between September 2017-May 2018 with fifth and sixth-year medical students and third and fourth-year nursing students from state and private universities located in Ankara, the capital city of Turkey. A total of 167 students volunteered to participate in the focus group interviews, including 105 nursing and 92 medical students.

In this study, as the second part of the project, the data obtained from 11 focus group interviews with 105 nursing students, which revealed their experiences, were analyzed.

Data Collection

Research data were collected through semi-structured interview questions. Interviews were conducted by a moderator and an assistant moderator who were in the research team. Focus group interviews lasted 45-90 minutes on average, and were tape recorded after receiving written consent from the students.

Data Analysis

Each student was assigned a protocol number indicating the type of university the student attends (private or state), the department he/she is in, and their year of education. These protocol numbers were used in archiving, analysis, and reporting processes. For example, a third year nursing student at a state university was coded as “SU.NURS.3.1.”

Collected data were evaluated using thematic analysis (Braun & Clarke, 2006), which is generally employed for qualitative studies. Each researcher read the data in hand and attempted to comprehend the content in all respects. Independent contexts, themes, and sub-themes were created by the researchers conducting the analysis. The sub-themes were grouped under the relevant themes, and the themes were sorted under the relevant contexts (Table 1). In the subsequent step, researchers revised the contexts, themes, and sub-themes together, and reached a joint decision by discussing the common and varied points. During the thematic analysis process, frequently repeated and distinctive phrases were gathered, and the statements that would best reflect the themes and sub-themes of the article were quoted.

Table 1.

Contexts, Themes, and Sub-themes of the Students’ Clinical Experiences Regarding Death and Terminal Patients.

Context	Theme	Sub-theme
First encounter with death	Feelings experienced	Fear
		Sadness
		Despair
	Reactions to the first encounter with death	Finding it normal
		Failure to recognize that the patient has died
		Experiencing confusion
		Refraining from touching the dead body
		Crying
	Factors affecting the reactions	Personal factors
	Factors affecting the reactions	Sociocultural factors
Clinical experiences of terminal patient care	Involvement in terminal patient care	Not being involved in patient care
	Involvement in terminal patient care	Not wanting to be involved in patient care
	Being informed about the physical process	Not being informed about the terminal patient
	Being informed about the physical process	Not being informed about the dying patient
	Approach toward terminal patients and their relatives	Adopting a more attentive approach toward the patient
		Avoiding the patient
		Avoiding patients’ relatives
	Health professionals’ approach toward terminal patients and their relatives	Professional approach
		Adopting an inattentive approach toward the patient
		Leaving the terminal patient to die
		Refraining from conveying the bad news
		Being calm when conveying the bad news
		Failure to give adequate support to the families experiencing the loss of a member
		Indifference to the dead body
		Trivialization of death
Changes after clinical experiences	Changes in the ideas about death	Thinking more about death
		Normalization of death
		Fear of becoming indifferent toward death
	Changes in the ideas about terminal patients	Not wanting to drag out the dying process
		Vacillating between preferring to die in the hospital or at home
		Abstaining from instrumentalizing the dead body

Ethical Consideration

Written permission for the research was provided by the institutions, and ethical approval was obtained from Gazi University Ethical Committee (Number: 77082166-604.01.02; Date: 25.01.2017). The aim and method of research were explained to the participants, and the volunteers were also included in the study. Informed consent with regards to the research was also obtained from the participants.

Results

Of the 105 nursing students who participated in the study, 91 were female and 14 were male. Fifty-four of the participants were third-year students, and the remaining 51 were fourth-year students. There were a total of 9 themes across 3 contexts. The themes that were assessed under the context of “first encounter with death” were “feelings experienced,” “reactions to the first encounter with death,” and “factors affecting the reactions.” The themes that were assessed under the context of “clinical experiences of terminal patient care” were “involvement in terminal patient care,” “being informed about the physical process,” “approach toward terminal patients and their relatives,” and “health professionals’ approach toward terminal patients and their relatives.” The themes that were assessed under the context of “changes after clinical experiences” were “changes in the ideas about death” and “changes in the ideas about terminal patients” (Table 1).

Context 1: First Encounter With Death

The nursing students’ statements on their feelings and reactions when they first encountered the death of a patient in a clinic and the factors that affect those reactions were grouped under the context of “first encounter with death”.

Theme 1.1: Feelings Experienced

Common feelings that the nursing students experienced when they encountered death in a clinical environment for the first time were categorized under the sub-themes of “fear,” “sadness,” and “despair.”

One student said the following:

… I was in the second year and we had a cancer patient in the clinic. A friend of mine and I were there together when the patient died … it was a hard time for me. They took us out of the room, and I remember shivering and being scared. (SU2.NURS.4-8)

A statement illustrating the sadness and pain that students experience when they encounter death for the first time is as follows:

There is nothing that you can do. Even if you were a high-ranking person and had all the power in your hand to make use of, you could not interfere with that process. You could just watch the death in despair. (PU1.NURS.4-6)

Theme 1.2: Reactions to the First Encounter With Death

Nursing students’ statements on their reactions to the first encounter with death in a clinical environment highlight the sub-themes of “finding it normal,” “failure to recognize that the patient has died,” “experiencing confusion,” “refraining from touching the dead body,” and “crying.”

One student explained experiences that fall under the sub-theme of “finding it normal” as follows:

… when I first had an encounter with this I said, “so it is this simple.” About death, we read a lot, watch a lot, and so on. The person before us stops breathing in an instant while he was breathing just a second ago. It is such a short and simple moment. It just disappears at once. (SU3.NURS.4-1)

When the students’ statements belonging to the sub-theme of “failure to recognize that the patient has died” were evaluated, it was observed that the students basically expressed that they had difficulties in detecting the signs of death. An example statement for such a situation is:

… we tried to take the peripheral pulse of the patient and I could not. I said “Professor, I cannot feel it” and the family was there too. It is weird. I guess they knew too. I could not say anything else as the professor was also there, I just said “professor, I cannot feel the pulse” … At the time, I was not able to tell if the patient had died or not. (SU1.NURS.4-4)

Students expressed that they were confused, and even froze when they encountered death for the first time in a clinic. One of the students said:

We went up to the oncology department in the second year. Patients with serious conditions were coming. My first encounter happened there, and I froze. I just couldn’t move. (SU2.NURS.3-8)

Students pointed out that apart from being afraid, they also avoided touching the dead body. One of the participants said,

… when the patient died in intensive care, they told me to hold it. I said I could not. They said, “we think you can, you can be sure that it’s not going to do anything to you” and I touched the dead body … They wanted me to apply pressure as the bleeding wouldn’t stop. For a split second, while I was pressing down to stop the bleeding, for a second, I felt like it was looking at me. It was weird, and then we closed its eyes so that it would not look… (PU1.NURS.4-7)

Some students said that they and/or their friends cried when they first encountered death. They shared this experience as follows: “It was during my internship. The patient’s condition was bad. She died and it was the first time for the other interns that were there with me too, and we started crying. It was a hard time.” (PU2.NURS.3-3)

Theme 1.3: Factors Affecting the Reactions

An assessment of the factors that affected students’ reactions when they encountered death in a clinic revealed that “personal” and “socio-cultural” elements were prominent among all.

An example of statements indicating the impact of personal factors is:

… Life experiences. As it has such a huge effect, especially if you have experienced the sudden loss of a loved one before, this enables you to approach other people in a nicer manner. (SU2.NURS.4-4)

An example showing that the socio-cultural factors were also effective is as follows:

In my hometown, people say “don’t look” when somebody dies. “Go to the other room or it may haunt you in your dreams and you’ll get scared.” I mean they make it look bad and dire. It does not matter if we were 10 or 20, it was always mentioned in a scary way. (PU2.NURS.3-4).

Context 2: Clinical Experiences of Terminal Patient Care

The themes of the context that involves the students’ clinical experiences of terminal patient’ care are involvement in terminal patient’ care, being informed about the physical process, approach toward terminal patients and their relatives, and health professionals’ approach toward terminal patients and their relatives.

Theme 2.1: Involvement in Terminal Patient Care

Some of the students in the study stated that they either were not involved in the nursing care of the terminal patient in the clinic or did not want to be involved in the process themselves.

One participant said;

… they do not want us near terminal patients, it is not something you talk about a lot … I feel like we are being driven away from the clinic, and educators are doing this too. (PU1.NURS.3-7)

The students who did not want to be involved in terminal patient care expressed their worry about the abundance of the diagnoses that needed to be established for the nursing care plan and they said they were concerned that they could not provide the required quality care to the patient. A statement reflecting these concerns is as follows:

… we are running away from the terminal patients as, like our professors say, health professionals are there to heal. We think we have nothing to do for a patient we cannot heal, what can we do … I can only provide palliative care in the terminal period and professors demand a much more thorough care from us, they demand highly comprehensive nursing diagnoses. We just pull away with the fear of not being able to meet the demands of the professor. (SU1.NURS.4-7)

Theme 2.2: Being Informed About the Physical Process

Part of the students reported that they were made to visit terminal or dead patients without knowing about their general situation. The following statement illustrates such experiences:

… it was our first day in internship, we really didn’t know the clinic … The nurse told me “Remove the IV cannula of that patient.” I went to the patient and removed the cannula. The patient felt cold at the beginning, there was no response, the family was there, and they had an air of sorrow and grief, I felt that. I asked the nurse what was wrong with the patient and she said “dead.” I was really surprised; the patient was dead, and I had no information about that. (SU1.NURS.4-7)

Theme 2.3: Approach Toward Terminal Patients and Their Relatives

An assessment of the students’ accounts revealed two prominent contrasting patterns in their communication with terminal patients and their relatives. While some students adopted an attentive approach toward them, others resorted to avoid those patients and their relatives. A statement exemplifying students’ adoption of “a more attentive approach” toward terminal patients and their relatives is as follows:

…a shade of more affection and compassion … maybe you spare a little more time for them, and you feel the need to chat with that patient and spare some time for him/her. (PU2.NURS.4-7)

The students who resorted to the act of “avoiding the patient,” on the other hand, expressed that they displayed avoidance behavior because they did not know what to do or they were afraid of death. One student commented,

We just keep away from terminal patients and their relatives. We do so maybe because we do not know what to do or because we think we cannot lend any help. We experience great difficulties especially in, for example, deciding on what to say, what to do, how to give support or what we need to do etc. (SU1.NURS.4-4)

The common focus in the students’ statements regarding “avoiding patient’s relatives” is on the idea that families may be more upset and sensitive than the patients, and thus, their reactions can be unpredictable. One of the participates said that:

I can talk to the patient more. As I said, I know the physiological process of death. I know what to talk about with the patient, but a patient’s relatives can be more sorrowful than the patient. I still walk away from their relatives after a patient has died. (SU2.NURS.3-4)

Theme 2.4: Health Professionals’ Approach Toward Terminal Patients and Their Relatives

While sharing their clinical experiences, students also commentated on the behaviors of health professionals within the context of death. Students’ opinions in this regard are focused on the sub-themes of “professional approach,” “adopting an inattentive approach toward the patient,” “leaving the terminal patient to die,” “refraining from conveying the bad news,” “being calm when conveying the bad news,” “failure to give adequate support to the families experiencing the loss of a member,” “indifference to the dead body,” and “trivialization of death.”

The following statement exemplifies students’ ideas on the professional approach adopted by health professionals:

I went up to the oncology department. There were patients in bad condition but we were not assigned to them. However, I could see people caring for them. They were approaching the patients professionally and were making sure that they spent their days, even if it was the last day of their lives, in a peaceful and comforted way. (SU2.NURS.3-6)

Students who believed health professionals were being inattentive to terminal patients made their point in such statements as:

Patient care personnel are a bit harsher when bathing these patients. They move too swiftly, they do not pay attention to the water temperature, they just apply the moisturizer and that is it. There can be pressure sores or anything. (SU4.NURS.3-2)

Apart from health professionals’ inattentive approaches, students also dwelled on the fact that terminal patients were being left to die by health professionals, and this shook their confidence in those professionals. One student said,

When others were trying to figure out if and how they could save the patient, nurses had already accepted the death and only assumed the caregiving part. Nurses think patients should be at home with their families in the last days of their lives. During the internship, that calmness passes over to you too. I could not figure out when to leave patients to die or when to care for them … So, this shook my confidence in health professionals. (SU1.NURS.4-7)

In the clinic, students also had the chance to observe the way health professionals convey the bad news. Some students reported that health professionals were quite calm when conveying the bad news while others said they tended to refrain from conveying such news. The statements that fall under the sub-theme of “refraining from conveying the bad news” include:

I’ve seen this. “You don’t talk!” “I won’t talk” type of an avoidance. Doctor to the nurse, nurse to the resident, resident to the intern. The intern (sixth-year medical student) does not even know what to say in the first place. (SU1.NURS.4-7)

One student who reported having observed the health professionals’ calm attitude in conveying the bad news explained this:

Two hours after one of our patients died, the family came. They asked “Where is our patient?” I was really wondering what the physician would say. The physician said … “you already knew about his condition, we did our best but we could not save the patient.” The physician was really calm as he was experienced in that. (SU1.NURS.3-2)

In their statements, students also emphasized that health professionals failed to provide adequate support to the families that experienced the loss. One student said,

The approach to terminal patients, the approach to their relatives, thinking about the hospital environment, I can say these procedures are not followed in general. In the cases I have witnessed so far, nurses were not comforting the relatives. They were just sending them out of the room when patients got worse, then they took them back in; when the patient dies, they talk about the procedures like check-out at the secretariat or procedures in the cafeteria etc. (SU1.NURS.4-5)

While commenting on the behaviors of health professionals, students mentioned the presence of an indifference toward the dead body and pointed out that the respect felt for the body is lost with death and that they even witnessed it being utilized for educational purposes. The following statement illustrates these comments:

A patient in the intensive care unit died. It turns out it is the soul that gives people dignity (…) the patient was in intensive care; she was unconscious, and nothing was being done to or for her. Then the patient died, and it stopped being a human, students were allowed to do things on it like inserting a gastronomy tube etc. (SU1.NURS.3-8)

Students presume that health professionals are used to the idea of death, and thus, they tend to trivialize it. A student’s comment on this is as follows:

There should be feelings, even a little. Yes, feelings, as I felt that need when I first saw death at the hospital. The doctor came and made a few interventions and then he said “dead.” I said, “is that it?” and they said, “yeah that is it, what can we do?” They follow the procedures and then all is done. A patient dies but they do nothing else. He packed his things up and went away. He just said, “I’ll be in front of the morgue,” and that is it. It was that simple for him. (SU1.NURS.3-7)

Context 3: Changes After Clinical Experiences

While they were articulating their opinions/comments on their clinical experiences, nursing students also mentioned the changes they observed in themselves and their concerns in this regard. Students noticed that there were changes in their perception of death and in their ideas about terminal/dying patients. The sub-themes were, thus, constructed around these two themes.

Theme 3.1: Changes in the Ideas About Death

Students stated that they started to think about death more as they saw the pain patients go through and witnessed their death in the clinic. A participant explained their opinion on this as follows:

(…) We have already been aware of the existence of death but when we are doing clinic duties, we see the condition of the patients in terminal period and we see them suffering. This makes me think everyone is so close to death. I see a lot of people trying to fight against a number of diseases, I see them dreading death and striving not to die. I didn’t use to think that deeply on this before. I didn’t use to be reminded of death when I looked at the people I saw on the street. (PU2.NURS.3-1)

It is observed that, along with the increase in their clinical experience, death becomes something normal for students; their perception of death changes. A quote to illustrate this is as follows:

One day, I heard that the patient I was caring for in the oncology department had died and I could not say anything, I mean nothing positive or negative. Just nothing … I could not feel a thing. I could not make any meaning out of it. I felt like it was something normal. (SU2.NURS.4-3)

Apart from this normalization of death, students also mentioned that they felt the “fear of becoming indifferent toward death.” This concern reaching up to a point of fear can be exemplified with this statement:

I am afraid of becoming indifferent. At the beginning, while I was drawing blood from patients, I was worried about hurting them. Now, however, I do not think about that much. I concentrate on the job itself; we are losing our emotions in time and the reactions we give when we see death will eventually be gone too. (SU4.NURS.3-2)

Theme 3.2: Changes in the Ideas About Terminal/Dying Patients

It can be inferred from the statements they articulated during the interviews that, based on their clinical experiences, students believe that the dying process is being dragged out in the hospital environment. They emphasized the fact that they cannot decide if it is better for patients to spend their last days at home or in the hospital, and that their thoughts have changed with their clinical experiences. Besides, the students also believe that they have started to instrumentalize dead bodies in clinical education.

An example of a statement regarding the sub-theme of “not wanting the dragging out of the dying process” is as follows:

Among terminal patients, there are those with irreversible conditions, and I believe what should be done for those patients during that period is to relieve their pain. Those patients just need to be comforted but somehow, I don’t know why, we consistently try to make them live longer. We mostly get no return on those efforts anyway. The family is not informed about the situation either. I mean, let’s say, the patient wants to die with the patient’s family nearby. Healthcare providers don’t even question that. (PU1.NURS.4-3)

Students who experienced “vacillating between the preferability of dying in hospital and dying at home” based their ideas on the concepts of “comfortable death” and “quality care.” The following statement exemplifies the utilization of these concepts:

I see at the hospital, the patient is tied to lots of machines. You know about the condition of that patient in the first place, you know that they will die. At home, on the other hand, while waiting for the death of especially elderly patients, death is more meaningful; the spirituality is stronger, and the relatives are more familiarized with it. Besides, it is a more relieved and comfortable death. (SU4.NURS.3-1)

One student reported that dead bodies are used as instruments for their education, and they expressed their concerns about this fact in these statements:

… the ones who die in the clinics should not become toys for intern students (…) for example, there was a patient who died in the intensive care unit and 5 different persons performed CPR on that patient one after another. I sutured a patient after tracheostomy. It shouldn’t be this way. (PU1.NURS.4-5)

Discussion

The findings of this study are discussed under three contexts: first encounter with death, clinical experience of terminal patient care, and changes after clinical experiences.

First Encounter With Death

In the study, it was found that when the students first had an encounter with death in a clinical environment, they experienced fear, sadness, and despair; some of them cried and some saw death as a normal process. In a study conducted by Edo-Gual et al. (2014), nursing students reported having experienced frustration and sadness when encountering death. In a study conducted by Göçmen Baykara et al. (2016), it is reported that students perceived death as a normal process, and in Heise and Gilpin’s (2016) study, nursing students stated that they felt bad and surprised during their first encounter with the death of a patient. From the studies in the literature, it can be understood that, similar to the findings of our study, some students experience negative feelings when encountering instances of death while others find the process to be normal. These findings are not surprising considering the fact that the reactions to death are affected by a number of factors including individuals’ perceptions of death, their values, beliefs, past experiences, and cultural characteristics. Accordingly, the present study indicated that the students who had experienced the loss of a relative approached dying patients in a distinct manner, and that their personal experience with death had impacts on their perspective of it.

In the present study, students reported having failed to notice the moment the patient dies and to discern the physical changes that occur in the patient at the moment of death. This may be related to the fact that students mostly provide care to the patients in good condition during clinical practices. In a study conducted with third-year nursing students by Ranse et al. (2018), it was reported that the students could easily identify the physical changes in dying patients. This was associated by the authors to the fact that the students had experience in caring for dying patients. In a qualitative study conducted with first-year nursing students by Ek et al. (2014), participants stated that they were not well-informed about the dying process and that the fast transition of a living being to a dead body frightened them. It is, therefore, supposed that the more students gain experience in caring for dying patients, the more skilled they would be in managing the process.

Clinical Experiences of Terminal Patient’ Care

Clinical practices give students the opportunity to reinforce theoretical knowledge and, in this way, ensure the retention of information (Kolb, 2014). Within this context, it is believed that involvement of students in caregiving to dying patients can develop their skills in the management of the process. In this study, however, students pointed out that they were mostly excluded from the terminal patient care. In Heise and Gilpin’s (2016) study, it was found that nursing students were not ready to provide adequate support to terminal patients and their families. A study by Abu-El-Noor and Abu-El-Noor (2016), on the other hand, indicated that nursing students did not want to provide care to dying individuals or to communicate with patients’ relatives when the patients died or afterwards. These findings were attributed by the authors to the feeling of inadequacy in students regarding the knowledge and skills they possessed.

The participants in our study reported not wanting to be involved in terminal patient care as the number of nursing interventions to be performed on these patients is quite high due to their increased need for care, and they did not feel competent enough to carry out these interventions. This perception of incompetence that mostly results from the lack of knowledge and skills that are required in the process may lead to anxiety in students (Edo-Gual et al., 2014; Heise & Gilpin, 2016). Accordingly, the findings of this study indicated that the inadequacy in communication skills affected the students’ approach toward terminal patients and their relatives. Students expressed that they did not know what to say to dying patients or their relatives, and thus, they avoided them. Ek et al.’s study (2014) revealed that students felt inadequate at communicating with patients. Similarly, in Österlind et al.’s (2016) study with students who had completed one year of education in nursing school, students did not know how to answer the questions posed to them when caring for dying patients. There are several studies in the literature that yielded similar findings relevant to the communication problems in nursing students and a common emphasis thereof is on the need for the educators to receive feedback from students on their opinion regarding the process. Educators are called to assist students in getting involved in the process by encouraging them to explicitly express and learn how to cope with their feelings (Heise & Gilpin, 2016; Huang et al., 2010). In our study, it was found that educators preferred to keep students away from terminal and dying patients probably because they feared that they would be inadequate at managing the attitudes of students toward these patients or just because they disregarded the issue on the whole. In our study, students reported that they were sent to rooms that had terminal or dead patients for any kind of procedure without being given any proper briefing about them. During clinical education, nursing students obtain preliminary information about the patients they are supposed to care for by consulting nurses or reading patient files before going into the patient’s room (Polat et al., 2018). Aydın and Argun (2010) found in their study that nursing students asked nurses about the patients in the clinic, and expected their support in acquiring the necessary knowledge and skills but most of the time failed to get what they expected. Students who participated in the study conducted by Edo-Gual et al. (2014) pointed out the fact that the theoretical education they had about terminal patient care was not adequate and that they needed extra guidance from nurses during clinical education. These findings, which are compatible with those of our study, show that nursing students need stronger support from nurses during clinical education. Accordingly, most studies emphasized the importance of nurses performing regular patient visits with nursing students and cooperating with educators in the standardization of procedures for clinical practice (Polat et al., 2018).

Nursing students mostly participate in the process of clinical practice with nurses, and their skills and attitudes are substantially influenced by them (Polat et al., 2018). Participants in our study pointed out the fact that health professionals were behaving inattentively when caring for dying patients. Likewise, 25% of the nurses who participated in a study conducted by Demir et al. (2017) reported that, the principles of good death were not followed for dying patients at the hospitals they worked for. It is believed that one reason for this may be the health professionals’ tendency to consider death as an ordinary process due to encountering it almost on a daily basis (Dag & Badır, 2017).

Changes After Clinical Experiences

Most of the students who participated in the present study emphasized that they started to contemplate the concept of death more often. In addition to having the basic education on caring for dying patients, nurses also need to develop insight into their own behaviors in order to be able to provide proper care to dying patients (Ferrell et al., 2000). Nurses who are not able to face and accept their own mortality may estrange themselves from dying patients and their relatives or project their fear of death onto them (Ferrell et al., 2000; İnci & Öz, 2012). Therefore, the fact that the students in our study started to think about the concept of death more frequently is not surprising. Similarly, other studies in the literature also mention an increase in such mental processes in individuals who have encountered the death of a patient for the first time (Edo-Gual et al., 2014; Ranse et al., 2018). Within this context, it is essential that clinical education is structured in a way that would enable students to scrutinize their thoughts and feelings regarding death and dying patients and consider death as a normal process.

Students who participated in our study pointed out the fact that in some cases, the dying process is prolonged, and that they are more concerned about the possibility of patients suffering due to the interventions performed during that time. Clinical experiences cause students to be anxious not only about themselves but also about the patients. The study by Edo-Gual et al. (2014) revealed that nursing students thought, in the cases where the patients and their relatives accept the reality of death, that patients should be asked where they would like the care to be continued. Accordingly, students who participated in our study also argued that it is everyone’s right to receive quality care, and it is possible for dying patients to complete the process at home as long as proper care is provided.

Conclusion

This study shows that during clinical education, students tend to think more about death, normalize death, and worry that they would become indifferent toward death. Students also mentioned that during clinical education, they did not have sufficient experience on how to approach terminal/dying patients, and thus, they avoided approaching such patients and their relatives. They suggested that clinical education may contribute to the adoption of a professional approach toward terminal patients provided that it is given more systematically with the right role models. Nursing students gaining awareness about their attitude toward death will contribute to the provision of quality care to terminal or dying patients. In addition, the study shows a lack of guidance on the part of teachers who also avoid patients and families who are considered terminally ill. It is believed that creating a clinical environment that would enable students to experience professional satisfaction is of great importance, and it is essential that students are supported by faculty members and clinical nurses to that end.

Footnotes

Acknowledgments

We are thankful the nursing students who agreed to contribute to the study.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article

ORCID iD

Şenay Gül

Author Biographies

Şenay Gül, PhD, WOCN, RN, is a faculty member at the Fundemantals of Nursing Department, Faculty of Nursing Hacettepe University, Turkey. She is interested in ethics issues on end of life, ethics education, qualitative research method, and pressure injury prevention.

Seyhan Demir Karabulut, PhD, is a lecturer at the Department of History of Medicine and Ethics, Başkent University, Turkey. Her research focuses on professional ethics for healthcare professionals, ethics education in nursing, ethical problems caused by advanced technology.

Handan Eren, PhD, is an assistant professor of Fundamentals of Nursing at the Yalova University, Turkey.Her primary research focuses on the nursing practice, and nursing education. Her research uses both qualitative and quantitative tecniques.

Mahinur Durmuş İskender, PhD, is a lecturer of department of medical services and techniques at the Kastamonu University, Turkey. Her primary research focuses on the nursing research. Her research uses both qualitative and quantitative tecniques.

Zehra Göçmen Baykara, PhD, is an associate professor at the Department of Nursing, Health Sciences Faculty, Gazi University, Turkey. She is interested in ostomy, nursing ethics, and professionalism.

Şükrü Keleş, PhD, is an assistant professor at the Department of Medical History and Ethics, School of Medicine, Karadeniz Tecnical University, Turkey. He is interested in applied ethics, moral discourse, and qualitative research method in bioethics.

Abdullah Yıldız, MD, Psychiatrist, BA in Sociology, is a current PhD candidate and research assistant at the Department of Medical History and Ethics, Ankara University School of Medicine, Turkey. His main reserach interests are in History of Science/Medicine, History of Psychiatry, Psychiatric ethics and Neuroethics, Philosophy of Medicine, Philosophy of Mind and Psychiatry, Medical Sociology.

Neyyire Yasemin Yalım, MD, PhD, is professor of Bioethics and retired from the Department of Medical Ethics and History Ankara University School of Medicine, Turkey. Founding member and the chairperson of the Turkish Bioethics Association, general secretary of the Agricultural and Food Association of Turkey and the chairperson of Bioethics Unit of the Turkish Philosophical Association. Her areas of interest are methodology of bioethics, ethics of science and technology, autonomy as a concept and its cultural connotations, patient safety and medical error, end of life issues, psychiatric ethics and ethics consultation.

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