Nursing students' clinical experience with death: a pilot study.
Although debriefing in simulation settings is routine in nursing education, debriefing does not routinely take place in clinical settings with nursing students after a patient has died. This pilot study sought to explore nursing students' perceptions of their first experience with the death of a patient. Students reported emotional distress and feelings of inadequacy with regard to communicating with and supporting the family of the dying patient. Only half the students sampled reported debriefing by their clinical instructor or staff. Nurse educators must include debriefing and student support following a patient death in the clinical setting.
KEY WORDS Debriefing--End-of-Life Education--Nursing Students--Nursing Education
Across all practice settings, most nurses face death and dying during their professional careers. Death, particularly unexpected death, is an emotionally charged occurrence that is stressful for nurses (Leighton & Dubas, 2009). Even experienced RNs, years later, vividly recall their first experience with the death of a patient.
Nursing students often encounter death and dying during their clinical experiences. In a qualitative study by Terry and Carroll (2008) with 184 nursing student participants, 100 students (54 percent) told of their first experience with death as a nursing student. National prevalence estimates of nurses who experienced the death of a patient during their nursing education have not been established.
Research on nursing students' experiences with death in the clinical setting is limited. Previous research indicates that nursing students have little support from clinical instructors at the time of a patient's death and later (Huang, Chang, Sun, & Ma, 2010). In an early study, Loftus (1998) reported that students experience strong emotions of disbelief, guilt, and anger connected with the sudden death of a patient. Parry (2011) confirmed that nursing students experience considerable anxiety, including feelings of being unprepared for the death of a patient. Students described not knowing how to reconcile their feelings with how they believed they were expected to react (Gerow et al., 2010).
Efforts to prepare nursing students for patient death through simulation have been efficacious (Leighton & Dubas, 2009; Leavy, Vanderhoff, & Ravert, 2011). High-fidelity simulation followed by debriefing as a group or individually has become a routine and highly valuable tool in nursing education. Debriefing is used to mitigate emotional reactions, account for actions, and review performance (Dreifuerst & Decker, 2012). However, even during formal debriefing sessions after simulated patient death, Leavy and colleagues found that there was often insufficient time for students to process emotions. Dreifuerst and Decker caution nurse educators that a balance must be achieved between emotional release and review of actions in order to achieve optimal learning.
Multiple expectations exist for RNs when caring for individuals and families going through the final stage of life. These are the same expectations of nursing students, who must meet not only the physical needs of the dying patient but also the emotional, spiritual, and sociocultural needs of patients and families during a challenging and often traumatic situation (Van Rooyen, Laing, & Kotze, 2005). Communication skills are a large part of this process. Research indicates that patients and families want their questions answered honestly. They want to receive bad news in a sensitive manner, express emotions and preferences in their own way, to be involved in decision-making, to be informed about what to expect in the dying process, to die in peace and dignity, and to know that the sanctity of the body will be respected after death (Campbell, 2009; Wenrich et al., 2001).
It is important for nursing students to learn how to cope with the death of a patient and offer support to the patient, family, and friends of the patient throughout the dying and grieving process. The purpose of this pilot study was to examine nursing students' perceptions of their first experience with death in a clinical setting and to determine if curricular changes are needed to better prepare students to cope effectively as nurses.
The design for this study utilized descriptive mixed methods. Following institutional review board approval, undergraduate nursing students in semesters 2 through 6 of a baccalaureate nursing program (N = 306) at a western university were emailed a brief description of the project and an invitation with a link to the online survey should they wish to participate. Nursing students who had experienced the death of a patient in the clinical setting were eligible to participate.
The online survey included demographic questions as well as quantitative and qualitative questions. For example, quantitative questions asked students to identify what clinical course they were in when the death of the patient occurred and whether they were debriefed following the death. Qualitative questions included the following: a) Describe your experience when a patient you cared for in clinical died, b) How did you feel when your patient died? c) Describe how your instructor interacted with you after your patient died.
Quantitative data were analyzed using descriptive statistics (frequencies and measures of central tendency). Using a content analysis approach, qualitative data were coded using an iterative process to ultimately code statements for common themes (Hsieh & Shannon, 2005).
Of the 306 nursing students who were emailed the survey, approximately 10 percent responded (n = 33). Of the 33 students, 29 were female, all but 1 were Caucasian, and 9 were married. Eleven of the 33 students were ages 18 to 20 and 16 were ages 21 to 23; no students were older than 29. Only 25 of the 33 students completed the survey; it is not known why the others did not complete it.
Most respondents reported previous experience with death prior to nursing school, usually of a family member (n = 17,68 percent) or a friend (n = 6, 24 percent). Six participants identified experiencing a patient death in a previous employment setting.
As part of the nursing clinical rotation, nursing students encountered the death of a patient in multiple settings, primarily during their gerontology [n = 9,36 percent), intensive care unit (n = 8,32 percent), medical-surgical (n = 3,12 percent), or Capstone (n = 3,12 percent) rotations. Most deaths occurred with older adults or with critically ill patients.
Two major themes emerged from the qualitative data: feeling emotional distress and feeling unprepared. The majority of students [n = 23, 92 percent) described emotional distress such as feeling upset, feeling sad, or other negative emotions such as feeling uncomfortable, bad, helpless, or guilty. Nine students used the word "shocked" (36 percent) to describe their personal emotions. One student stated: "I was pretty shocked.... I felt just kind of numb.... I also felt really overwhelmed.... I kind of just wanted to cry but I felt like I didn't want to make a scene or take attention away from the family." Another commented: "I cried for a long time just because I realized this is something I'll have to deal with in my career for the rest of my life."
Despite students' reporting the death experience as emotionally stressful, debriefing from the clinical instructor or from nursing staff after the student experienced a patient death was absent in 50 percent of the situations. Students commented that they would have liked more discussion with their clinical instructor after the death of a patient. One student commented: "I feel like my clinical instructor could have talked to me about the experience and at least asked how I was feeling about the situation." Some students commented that they did not know debriefing was even an option in the clinical setting. "I think it would have been nice to have been prepared beforehand for such experiences by telling students that they should debrief with their instructor and it's okay if this is a big deal."
The second major theme involved feeling unprepared to work with and support the family of the patient who died. Students frequently told of not knowing how to communicate or interact with the family. They reported that while it was emotionally difficult, they wanted to reach out to support the grieving family. One student commented: "It would have been helpful to have a little guidance on how to interact with the family when I was there.... I felt helpless."
Students are taught the academic side of death and dying through content on advanced directives and topics such as the signs and symptoms of the dying process. However, the nurse's role at the end of life is holistic and complex; the role involves offering not only physical care, but also the emotional, spiritual, and sociocultural support necessary to meet the needs of the patient and the patient's family. Although the majority of nursing students believed themselves to be prepared for the death of a patient from their didactic training, they admitted to feeling shocked and at a loss as how best to communicate with and support the family.
Students often feel a sense of inadequacy at the time of a patient's death and would prefer to have their instructor guide them through the experience (Allchin, 2006; Carson, 2010; Parry, 2011). Clinical instructors play an important role in debriefing nursing students, assisting them in reflection and achieving a sense of salience, understanding what is most important, regarding their patients' endof-life (EOL) experiences (Allchin; Huang et al., 2010; Loftus, 1998; Parry, 2011).
The process of reflection helps sustain both formal and informal caregivers who experience the death of a patient (International Work Group on Death, Dying and Bereavement, 2006). Reflection, in the form of debriefing, improves learning and critical thinking (Tanner, 2006). In nursing education, nursing students routinely receive debriefing when encountering the death of a patient in a simulation lab. However, in this real-life clinical setting, nursing students received systematic debriefing only 50 percent of the time, despite their describing the experience of the death of a patient as traumatic. EOL education for undergraduate nursing students continues to be needed for effective EOL care (Dos Santos & Bueno, 2011; Huang et al., 2010; Kent, Anderson, & Owens, 2012; Liu et al., 2011).
Limitations of Study
This pilot study had a small convenience sample from one BSN nursing school. With such a small sample, results are not generalizable to other types of nursing schools in other locations. Nursing students' clinical experiences covered the entire range, from infants to older adults in hospitals to long-term care settings. However, students' emotions and feelings of being unprepared are reflective of those found in previous research studies (Leavy et al., 2011, Niederriter, 2009; Parry, 2011; Terry & Carroll, 2008; Van Rooyen et al., 2005).
Recommendations for Future Research
A larger study using a national sample of nursing students is needed to determine not only the prevalence of nursing students' experiencing the death of a patient, but also how nurse educators might best support students through their first experience with death. The National Student Nurses' Association membership was asked to participate in a national study on nursing students' perceptions after experiencing a patient death; results are currently being analyzed.
Future research should explore types of support to give students after experiencing the death of a patient and the level of competency needed in part-time clinical adjunct faculty to support nursing students' first death experience.
Nurses will likely experience the death of patients through the course of their careers. Nurses are responsible for giving holistic support not only to the dying patient, but also to the patient's family.
Learning to cope effectively with EOL issues is an important foundational skill for nursing education. It is essential that students receive adequate support and debriefing following a patient death. Curriculum changes should include simulation debriefing after patient demise as well as debriefing in the clinical setting. Rather than rely on instructor discretion, nurse educators should consider implementing a standardized debriefing protocol in order to effectively teach students to cope with the death of a patient.
Allchin, L. (2006). Caring for the dying: Nursing student perspectives. Journal of Hospice & Palliative Nursing, 8(2), 112-117.
Campbell, M. L. (2009). Nurse to nurse: Palliative care. New York, NY: McGraw Hill Medical.
Carson, S. (2010). Do student nurses within an undergraduate child health programme feel that the curriculum prepares them to deal with the death of a child? Journal of Child Healthcare, 14(4), 367-374. doi:10.1177/1367493510374066
dos Santos, J. L., & Bueno, S. M. V. (2011). Death education for nursing professors and students: A document review of the scientific literature. Revista da Escuela de Enfermagem da USP [Journal of Sao Paulo University School of Nursing], 45(1), 265-269. doi:10.1590/S0080-62342011000100038
Dreifuerst, K., & Decker, S. (2012). Debriefing: An essential component for learning in simulation pedagogy. In P. R. Jeffries (Ed.), Clinical Simulations in Nursing Education: From conceptualization to evaluation (pp. 105-129). New York, NY: National League for Nursing.
Gerow, L., Conejo, P., Alonzo A., Davis, N., Rodgers, S., & Domian, E. W. (2010). Creating a curtain of protection: Nurses' experiences of grief following patient death. Journal of Nursing Scholarship, 42(2), 122-129.
Hsieh, H., & Shannon, S. (2005). Three approaches to qualitative content analysis. Qualitative Health Research, 15(9), 1277-1288.
Huang, X., Chang, J., Sun, F., & Ma, W. (2010). Nursing students' experiences of their first encounter with death during clinical practice in Taiwan. Journal of Clinical Nursing, 79(15-16), 2280-2290. doi:10.1111/j.1365-2702.2009. 03090.x
International Work Group on Death, Dying and Bereavement (IWGDDB). (2006). Caregivers in death, dying and bereavement situations. Death Studies, 30, 649-663. doi:10.1080/07481180600776036
Kent, B., Anderson, N. E., & Owens, R. G. (2012). Nurses' early experiences with patient death: The results of an on-line survey of registered nurses in New Zealand. International Journal of Nursing Studies, 49(10), 1255-1265. doi: 10.1016/j.ijnurstu.2012.04.005
Leavy, J., Vanderhoff, C., & Ravert, P. (2011). Code simulations and death: Processing of emotional distress. International Journal of Nursing Education Scholarship, 8(1), 1-13.
Leighton, K., & Dubas, J. (2009). Simulated death: An innovative approach to teaching end-of-life care. Clinical Simulation in Nursing, 5(6), e223-e230. doi:10.1016/j.ecns.2009.04.093
Liu, Y.-C., Su, P.-Y., Chen, C.-H., Chiang, H.-H., Wang, K-Y., & Tzeng, W.-C. (2011). Facing death, facing self: Nursing students' emotional reactions during an experiential workshop on life-and-death issues. Journal of Clinical Nursing, 20(5-6), 856-863. doi:10.1111/j.1365-2702.2010.03545.x
Loftus, L. A. (1998). Student nurses' lived experience of the sudden death of their patients. Journal of Advanced Nursing, 27(3), 641-648. doi:10.1046/j.13652648.1998.00602.x
Niederriter, J. E. (2009). Student nurses' perception of death and dying (Doctoral dissertation, Cleveland State University). Retrieved from http://rave.ohiolink. edu/etdc/view?acc_num=csu1246756404
Parry, M. (2011). Student nurses' experience of their first death in clinical practice. International Journal of Palliative Nursing, 17(9), 446-451.
Tanner, C. (2006). Thinking like a nurse: A research-based model of clinical judgment in nursing. Journal of Nursing Education, 45(6), 204-211.
Terry, L., & Carroll, J. (2008). Dealing with death: First encounters for first-year nursing students. British Journal of Nursing, 17(12), 760-765.
Van Rooyen, D., Laing, R,, & Kotze, W. (2005). Accompaniment needs of nursing students related to the dying patient. Curationis, 28(4), 31-39.
Wenrich, M. D., Curtis, J. R., Shannon, S. E., Carline, J. D., Ambrozy, D. M., & Ramsey, P. G. (2001). Communicating with dying patients within the spectrum of medical care from terminal diagnosis to death. Archives of Internal Medicine, 767(6), 868-874. doi:10.1001/archinte.161.6.868
Barbara A. Heise, PhD, RN, CNE, CQIA, is an associate professor at Brigham Young University College of Nursing, Provo, Utah. Laura C. Gilpin, BSN, RN, is a recent graduate of Brigham Young University College of Nursing. For more information, contact Dr. Heise at email@example.com.
|Printer friendly Cite/link Email Feedback|
|Title Annotation:||Research Brief|
|Author:||Heise, Barbara A.; Gilpin, Laura C.|
|Publication:||Nursing Education Perspectives|
|Article Type:||Author abstract|
|Date:||Mar 1, 2016|
|Previous Article:||Capital we must develop: emotional competence educating pre-licensure nursing students.|
|Next Article:||Nursing student perceptions of digital textbooks: a pilot study.|