To be a nursing student is, in many ways, to be a

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1 CE Caring for the Dying Nursing Student Perspectives Lynn Allchin, PhD, RN v The purpose of this hermeneutic study was to identify and clarify the characteristics of students experiences in providing care for dying persons and their families during these students clinical rotation in adult health nursing. The goal of the study was to elucidate and clarify the depth of students experiences in caring for dying patients and their families to enhance the utility of death and dying content for nursing students. After the completion of Institutional Review Board approval procedures, the investigator collected data through single, individual interviews conducted with 12 students who had cared for dying persons during their clinical rotation in adult health nursing. Using Giorgi s method of data analysis, three major themes were identified: initial hesitancy and discomfort, reflective musings, and personal and professional benefits. Recommendations are made to increase both didactic and clinical end-of-life content in undergraduate nursing programs (a consistent recommendation in nursing literature for at least 30 years) and to hold debriefing sessions for all students caring for the dying in any setting. K E Y W O R D S dying end-of-life care nursing education nursing students qualitative research To be a nursing student is, in many ways, to be a beginner over and over again. New experiences greet nursing students in every clinical situation. Some new experiences generate students anxious anticipation, for example, taking vital signs on a real patient, or teaching home-going instructions for the first time. Alternatively, some experiences generate dread in a student; packing a wound or addressing a patient s severe pain can be disturbing for novice nurses. Students often view caring for dying persons and their families as one of the most disturbing and potentially unpleasant things that nurses do. Authors of one study 1 showed that while nurses see end-of-life (EOL) care content as important during their undergraduate education, schools of nursing are often inadequate in preparing nurses to provide EOL nursing care. The purpose of this hermeneutic study was to detail the characteristics of students experiences in providing care for dying persons and their families during their Lynn Allchin, PhD, RN, is Assistant Professor of the University of Connecticut School of Nursing, Storrs, CT. Address correspondence to Lynn Allchin, PhD, RN, University of Connecticut School of Nursing, U-2026, 231 Glenbrook Road, Storrs, CT ( lynn.allchin@uconn.edu). The author declares no conflict of interest. 112 JOURNAL OF HOSPICE AND PALLIATIVE NURSING v Vol. 8, No. 2, March/April 2006

2 clinical rotation in adult health nursing. The question guiding the study was, What are nursing students lived experiences of caring for dying persons during a clinical rotation? Addressing this question is an important precursor to designing appropriate EOL content in undergraduate nursing curricula. v BACKGROUND For at least 30 years, 1-6 nurse educators have emphasized that nursing students need curriculum content that focuses on dying, death, grief, and loss. Nursing students themselves have long recommended death education in their curricula. 3 When they are implemented, those curricula appear to influence students learning experiences. Yeaworth et al 2 focused on the differences between first year and senior nursing students in their attitudes toward death and dying. They found that senior students who had completed specific coursework in death, grief, and loss, and who had received counseling, were better able to relate, with more acceptance to dying persons, than were freshman students. Milton 5 studied the experiences of Canadian nursing students to uncover students concerns about caring for the dying. Participating students reported true feelings of inadequacy 5(p301) in their ability to provide both patients and their families with emotional support. Milton suggested a curriculum that would provide students with the ability to provide emotional support to dying patients. Beck 7(p413) found that nursing students have feelings of personal inadequacy and limited clinical experience caring for dying patients, which result in death anxiety for the students. Her recommendations included an increase in death and dying content in nursing curricula, consistent with the recommendations of other authors. Unfortunately, these recommendations have not always been actualized; more recently, Mallory 8 has again recommended EOL nursing content within undergraduate didactic and clinical courses. This study builds on published work regarding students experiences with dying patients and their families. The goal of the study was to elucidate and clarify the depth of students experiences in caring for dying patients and their families to enhance the utility of death and dying content for nursing students. v METHODS Hermeneutic phenomenology 9,10 is a philosophy and a research method that serves as a useful framework for studying individuals experiences with complex phenomena. Phenomenology assumes that individuals in a relationship can share common meanings through language and communication. Thus, phenomenologic researchers look to participants lived experiences and use their expert ability to describe those experiences for study data. The benefit of phenomenologic research is that it couches the description of the phenomena of study in the words of the participants, helping researchers to access experiences as they are lived. Description from this perspective provides key insights into essential components of complex experiences. As we experience the world around us, we make interpretations of those experiences. Our interpretations are influenced by our history and our ability to understand what we have experienced. 9 Using hermeneutic phenomenology in this study, the investigator clarified students understandings of the process of working with dying patients and their families. Participant descriptions help to clarify objective information and subjective meanings that are important to include in the death and dying content offered to nursing students. Sample and Setting Junior-level nursing students who had cared for dying persons during a clinical rotation in adult health nursing in a large New England university participated in the study. Recruitment of volunteers consisted of personal contact by the investigator at the beginning of the semester to all junior-level nursing students in a large classroom setting and of periodic announcements about the study via the nursing Web site. The sample consisted of 12 female baccalaureate junior nursing students. Data Collection After the completion of Institutional Review Board approval procedures, the investigator collected data through single, individual interviews conducted with 12 students who had cared for dying persons during their clinical rotation in adult health nursing. Dying person was defined as any hospitalized person not expected to JOURNAL OF HOSPICE AND PALLIATIVE NURSING v Vol. 8, No. 2, March/April

3 improve and recover from his/her illness or condition. The interviews from which data were collected were conducted privately in the investigator s academic office. The only formal direction posed by the investigator to guide the interview was, Describe your experience of caring for a dying person in your clinical rotation. Prompts such as Go on or Can you explain that more? were used to help participants expand on their descriptions and clarify their feelings. The 12 interviews varied in length from 15 to 45 minutes. Each participant was able to describe in detail her experience of caring physically and emotionally for the dying person and his/her family members. Each also spoke of personal thoughts and reflections that emerged at the conclusion of providing care for the dying patient in the context of the clinical experience. Interviews were concluded when the participant indicated that she had nothing further to add. Each interview was audiotaped and transcribed verbatim. The transcripts were analyzed using Giorgi s method. In this method, participants are asked to describe a specific phenomenon, in this case, caring for a dying individual during a clinical rotation. The investigator trusts that volunteering participants will give a truthful account of the experience as they perceived it. The investigator then listens to the audiotape and reads, and rereads, the transcript, identifying the substance of what the subject has provided about the phenomenon of interest. A description of the participant s meaning is completed and meaning units 11(p252) are formed. After this, the researcher takes the meaning units from the language and context of the participant to a language where individual statements are refined into an expression that is summative of participants meanings. Finally, it is this collective statement that describes the phenomenon for these participants. v FINDINGS Although initially hesitant and uncomfortable, the 12 female nursing students who had cared for a dying person during their clinical rotation in adult health nursing found that both personal and professional benefits emerged with reflective musing on the experience. Participants described three major themes regarding caring for the dying. These themes were: (1) initial hesitancy and discomfort, (2) reflective musings, and (3) personal and professional benefits. Each participant addressed at least two of these themes during her interview. Participants frequently indicated that they had nothing else to say, prompting the investigator to turn off the tape recorder, only to think of more to add (and to prompt a restarting of the tape recorder) once they reflected a bit further about the experience. Initial Hesitancy and Discomfort Each participant noted that, at first, she was hesitant to care for a dying person. Students expressed discomfort in not knowing how to interact and how to implement care for dying persons and their families. As one student stated, I just kind of felt at a loss because, you know, I really didn t know what I should be doing or what my place was with the family. This sentiment is repeated by another student who said, I m a student so it s not like I really knew how to act or not act or what to say, I wanted to say something, but I didn t know what. This discomfort was complicated by students lack of knowledge about whether the person or family knew of the diagnosis and/or prognosis. Clearly, responses of the participants suggested that students experiences were complicated by their lack of certainty about their own roles in dealing with dying patients. The experience of uncertainty is not uncommon among students enacting nursing roles for the first time. This uncertainty is magnified with dying patients and their families. As one student noted about caring for the dying, I don t know if that is something that you can teach somebody or if it just comes naturally. Some participants expressed feeling awkward being involved with others at a very personal time. How to be involved with the family was expressed as I wonder if I should have been more there for the husband as well. This sense of awkwardness seemed to subside for participants who were able to care for a dying patient for more than one day. Feelings of discomfort and intrusion subsided as students got to know their patients better. Getting to know the patient also had effects on the student participants. One student said, I think I have had other people before who wereiterminal and that was hard, but this guy was harder because I did talk to him and he was just this great guy who I didn t want to leave at the end of the day. Reflective Musings Study participants indicated that their experiences of caring for a dying patient did not stop when they left 114 JOURNAL OF HOSPICE AND PALLIATIVE NURSING v Vol. 8, No. 2, March/April 2006

4 the patient s side. Instead, they thought about their experiences after the clinical day had ended, many on the drive home or later in the day. They reported that in their reflections, they combined personal experiences with loss, grief, and death with their experience with the dying patient and his/her family. Their reflections about their own experiences included remembering a parent s or grandparent s death and experiences with friends who had lost parents to death. Some participants found themselves emotionally upset and crying about their own losses, again in response to their experiences with the dying patient. Empathetic feelings for the dying person and his/her family also emerged for study participants. Because most of the dying persons did not actually die in the presence of the attending studentsvthe study participantsv the participants expressed a desire to know what actually happened to the patients for whom they had provided care. Study participants expressed concern about a range of topics that left them feeling concerned and sad. These topics included the patients quality of life ( I felt bad for her anyway and she wasn t going to have any quality of life even if she did wake up or just live ), personal loss ( So I was sad when I left because I thought I might never see him again ), and death itself ( It is sad to think that he died ). One participant summed up the experience for everyone when she said, But it was very draining emotionally. And as another participant demonstrated, talking about the experience was important. She stated, I just didn t have the opportunity to talk about it but I was really sad and I wanted to share it with people. Personal and Professional Benefits According to study participants, despite associated discomfort, anxiety, and sadness, caring for a dying person was beneficial to them as they learned about becoming nurses. Some participants viewed this clinical experience as an opportunity they were glad to have had. For them, the situation was one of anxious anticipation, providing a new and unknown experience to strengthen their repertoire of clinical skills and to support their potential professional development as nurses. Yet, the experience was clearly complex and challenging. Even participants who were relatively comfortable with the experience expressed that comfort over a range of reactions. As one participant so tellingly noted, In a sense, I m kind of glad I went through that (italics added), and another said, Iin the morning I was like, oh my gosh, on hospice. That was a little bit hard. But I think all the students should get the experience before they graduate. Caring for dying patients and their families was not the stuff of just another clinical day. Having the opportunity as a student to care for a dying person ( I think I need more experience in how to talk to the familyii don t know what to say to them and how to react to them. I don t feel like I m ready to do that yet ) helped to ease anxiety about what the experience would be like when they, in fact, as nurses, will be expected to provide that care as a component of their nursing positions. Participants personal reflections of loss, death, dying, and grief helped them, both in dealing with the clinical situation and in addressing their own losses. One participant noted, Iwhat I experienced was valuable. It s made me stronger. A significant benefit of the experience of providing care for a dying person was the support and presence of the clinical instructor and the staff nurse. Participants expressed relief in knowing that they were not alone during the experience. Dealing with aspects of the unknown was frightening. One student participant said, We were shadowing nurses. I felt the nurses really kind of eased you into each situationi. Having access to the instructor for both physical and emotional help was seen as desirable ( Iit is easier that I had someone with me ). Students appreciated the knowledge and expertise of both the instructor and the staff nurse in caring for the dying. As one participant noted, It was good for me because I wasn t just put in the center but guided through it. Another, more tentative in her description of the experience, noted, I was glad that I was able to do it while I still had an instructor with me. The importance of a sense of connection with the dying person and his/her family members, as well as with nursing instructors and staff members, was clear in the participants descriptions of their experiences with dying patients. Attention to relationship as an important component of the experience of caring for dying patients and their families was clear in the participants descriptions ( I kind of liked being there for part of it, for family and the patient before they died and I was glad I got to know somebody like him in the first place ). JOURNAL OF HOSPICE AND PALLIATIVE NURSING v Vol. 8, No. 2, March/April

5 v DISCUSSION Data from study participant interviews revealed three important themes: (1) initial hesitancy and discomfort, (2) reflective musings, and (3) personal and professional benefits. From the perspective of the investigator, consideration and further hermeneutic analysis of these three themes suggest important content foci in death and dying curricula. Study participants demonstrated that they integrated their experiences in caring for dying patients and their families into their broader nursing and life experiences. As students reflected on the care they had provided to dying patients and their families, they addressed the expectations inherent in their roles as nurses, including the complexity of communication in caring for dying persons and their families. Student participants identified their need to be with others for support, reassurance, guidance, and knowledge both during the experience and afterward. The overlap of this experience with their personal experiences of loss, grief, death, and dying and the importance of this experiencevthe caring itself and their reflection on itvto their own personal and professional development were recognized by these undergraduate nursing students. That nurses will care for dying persons and their families, across all healthcare settings, is an unavoidable reality. Students learning to be nurses can benefit from the richness of the knowledge and skills inherent in providing care to dying patients and their families, and, without question, they will benefit as well from having developed those skills before graduation. Certainly, graduate nurses cannot be experts in providing care to dying patients, but teaching basic knowledge, providing relevant experiences, and helping students to garner the wisdom entailed in the experience are within the realm of a thorough nursing education. v IMPLICATIONS AND RECOMMENDATIONS Based on the common themes elicited from participant interviews and the investigator s further analysis of notions common across those themes, the following recommendations are made. First, because of the inherent richness of working with dying patients and their families, and the potential benefit of these experiences to students, clinical rotations should be structured appropriately to include EOL experiences for each student. The instructor s active role in addressing student and nurse roles in the experience, and the complexity of communication; the relevance of support from others; the influence of the experience on students professional development; and the tie-in of the clinical experience with individual students personal experiences with death, grief, loss, and dying will strengthen the experience overall. Clinical experience is an essential mainstay in the education of nursing students. This experience typically includes providing care for dying patients and their families. Hospice and palliative care units are, of course, ideal areas for students. However, many deaths occur in intensive care units, emergency departments, and general surgical units, as well as in extended care facilities such as nursing homes. It is imperative that students have multiple experiences with diverse populations to learn about dying from a multicultural perspective. As a consequence of the complexity of the experience of caring for dying persons and its influence on student learning, a second recommendation is that EOL theory and practical EOL care information be incorporated into both didactic and clinical courses in nursing programs. The integration of EOL theory into undergraduate nursing curricula may be best accomplished through the dedication of a specific course to the topic. When EOL information is spread through multiple courses, its impact may be diluted. Certainly, content may vary depending on the skills and the comfort of the individual instructor, as well as on competition with other course content for a place in the presentation queue. For programs in which it is not possible to designate one course to EOL nursing carevadmittedly a challenge in the busy curriculumvone class in each course might be dedicated to EOL issues for the specific population, for example, adults, children, or the community at large, in the course. Third, group or individual debriefing sessions after EOL clinical experiences are appropriate for providing support to students who have been exposed to the rigors and challenges of caring for dying patients and their families. Students may need to process the experience and will benefit from the support that a guided opportunity to discuss the experience can have. Furthermore, although the need to talk about what happened may not be evident to a given student, members of the nursing faculty are obliged, as part of their own professional roles, to assess student response 116 JOURNAL OF HOSPICE AND PALLIATIVE NURSING v Vol. 8, No. 2, March/April 2006

6 and the stresses that the experience may have placed on the student. An instructor, or another experienced person, can listen and constructively guide the student through the myriad thoughts and feelings not only of the experience itself, but also of other, perhaps more personal, thoughts of loss and grief. This processing can be accomplished in either individual or group venues. To this end, the investigator has implemented a weekly open house for students who have cared for dying persons during their clinical rotations. Students experiencing personal issues related to loss or grief are also welcome to attend these sessions. Besides the opportunity to review the clinical experience, various books and articles related to loss, dying, grief, and palliative and hospice care are available for loan. The open house provides a time to process experiences with death and dying. In addition, it provides an opportunity to refer those students whose responses to death and dying experiences have resulted in long-term emotional and/or physical sequelae. Finally, student experience with dying persons and their families cannot take place without the assistance of staff nurses. Feelings of dread and discomfort can be transferred from a staff nurse to a nursing student as easily as feelings of comfort and skill in caring for the dying. Communication between instructor and staff nurse about student skill and experience with the dying enhances the student experience. Having the student work alongside the nurse as the dying person is given care (physical, emotional, or teaching), instead of alone, can strengthen the student experience. v CONCLUSION Learning what nursing students are experiencing while caring for dying persons and their families during a clinical rotation in adult health nursing has given direction to undergraduate nursing curricula over time. Thematic analysis of students lived experiences adds to those curricula, as it identifies not only the personal experience of individual students but permits scrutiny of experiences that are common across students. The addition of EOL nursing care content to all nursing curricula seems essential because it addresses a reality that most nurses will face and it addresses the intricacies inherent in nursing situations, from the most banal to the most complex. If nurse educators can increase student knowledge, understanding, and acceptance of caring for dying persons and their families, then student comfort with the situation, confidence, and skills in EOL care will likely improve. This knowledge can be generalized across nursing situations, thus enhancing the level of practice of nurses in day-to-day situationsvmore knowledgeable and confident nursing students will lead to more knowledgeable and confident graduate nurses. The goal of adding EOL content to nursing curricula, as is always a goal of nurse educators, is to improve the care of individuals and their families as they face the experiences that are inherent in life. References 1. Ferrell B, Virani R, Grant M, Coyne P, Uman G. End-of-life care: nurses speak out. Nursing. 2000;30(7): Yeaworth RC, Kapp FT, Winget C. Attitudes of nursing students toward the dying patient. Nurs Res. 1974;23(1): Martin LB, Collier PA. A survey of nursing students. J Nurs Educ. 1975;14(1): Denton JA, Wisenbaker VB. Death experience and death anxiety among nurses and nursing students. Nurs Res. 1977;26(1): Milton IC. Concerns of final year baccalaureate students about nursing dying patients. J Nurs Educ. 1984;32(7): Caty S, Tamlyn D. Positive effects of education on nursing students attitudes toward death and dying. Nurs Pap. 1985;16 (4): Beck CT. Nursing students experiences caring for dying patients. J Nurs Educ. 1997;36(9): Mallory JL. The impact of a palliative care educational component on attitudes toward caring of the dying in undergraduate nursing students. J Prof Nurs. 2003;19(5): Heidegger M. Being and Time. New York, NY: Evanston, Harper, and Row; 1962 [ J. Macquarrie and E. Robinson (trans.)]. 10. Polkinghorne D. Phenomenology and the Human Sciences. Pittsburgh, PA: Duquesne University Press; Giorgi AP, Giorgi BM. The descriptive phenomenological psychological method. In: Camic PM, Rhodes JE, Yardley L, eds. Qualitative Research in Psychology: Expanding Perspectives in Methodology and Design. Washington, DC: American Psychological Association; 2003: JOURNAL OF HOSPICE AND PALLIATIVE NURSING v Vol. 8, No. 2, March/April