|Year : 2015 | Volume
| Issue : 3 | Page : 212-217
A hermeneutic phenomenological interpretation of the lived experiences of nursing students with regards to death and dead bodies
Chinomso Ugochukwu Nwozichi
Department of Adult health Nursing, School of Nursing, Babcock University, Ilishan Remo, Ogun State, Nigeria
|Date of Web Publication||12-Jun-2015|
Chinomso Ugochukwu Nwozichi
Department of Adult health Nursing, Babcock University, Ilishan Remo, Ogun State
Source of Support: None, Conflict of Interest: None
Background: The experience of death and dead bodies usually generates psychological reactions among nursing students. This study attempted to interpret the lived experiences of nursing students with regards to death and dead bodies. Materials and Methods: Using a hermeneutic phenomenological approach, texts from the reflective diaries of nursing students were interpreted in relation to their experiences with death and dead bodies during their clinical postings. The interpretation involved three stages: Naive reading, structural analysis, and comprehensive understanding. Reflective diaries of 12 students met the inclusion criteria and thus were used for the interpretation. Results: Three themes emerged from the structural analysis; (i) personal reflection on harsh reality, (ii) unavailability of required support and abandonment, (iii) identification of individual strength and weakness based on experience. Conclusion: Nursing students expressed some emotional reactions that require the attention of their instructors. Nurse educators should always be available to support the students during clinical exposures. End-of-life components of the nursing curriculum should be improved.
Keywords: Dead bodies, death, experience, nursing students
|How to cite this article:|
Nwozichi CU. A hermeneutic phenomenological interpretation of the lived experiences of nursing students with regards to death and dead bodies. CHRISMED J Health Res 2015;2:212-7
|How to cite this URL:|
Nwozichi CU. A hermeneutic phenomenological interpretation of the lived experiences of nursing students with regards to death and dead bodies. CHRISMED J Health Res [serial online] 2015 [cited 2020 Apr 2];2:212-7. Available from: http://www.cjhr.org/text.asp?2015/2/3/212/158677
| Introduction|| |
Death is the permanent end of the life of a biological organism. The death of a patient is a phenomenon frequently experienced by nursing students and professional nurses.  Evidence has shown that a significant gap exists in the undergraduate nursing education in relation to coping with experiencing dying and dead patients.  This has led to the difficulties experienced by nursing students in dealing with death and they report feeling anxious and unprepared to be with a patient who is dying or dead.
Various programs have been developed to assist registered nurses cope with dying and dead patients.  However, the nursing students seldom gain from these programs. Studies on nurses' attitude towards caring for terminally ill-patients indicate that death and dying create fears and anxieties among professional health care providers.  The attitude of nurses toward death has been linked to their attitude toward the care of the dying patient and they have used a number of coping strategies, especially avoidance, to cope with their own personal fears of death.  Emotional skill training and death-education programs have been advocated to be included as part of the professional nursing curricula. 
Interestingly, Terry and Carroll  in their study found that nursing students expressed their experience with every death in clinical practice as a learning experience but also a potential source of emotional distress. In some cases, some students reported experiencing flashbacks after encountering death and hence tend to develop avoidance. From their findings, Terry and Carroll  reported that students felt unsupported by their mentors and also felt that the dying and their families were inadequately cared for.
Nursing students experience grieving as they encounter death therefore they require careful step-by-step attention to help them go through the grieving process successfully.  Being a nurse entails caring for the well, sick, and dying. Perhaps sometimes prepare the bodies of the dead before they are handed over to their families. According to Birkholz, et al.  "death is a personal issue for each nurse and each nurses' unique perspective can affect each patient under the nurses' care."
According to Ricoeur, , hermeneutics is the theory of the working of understanding in relation to the interpretation of texts and realize the meaning in human existence. While exploring the in-depth experience of student nurses, a narrative format, such as use of diaries, should be used to describe their experiences in details without the pressure of being subjected to interviews.  A hermeneutic approach was also adopted by Allchin  to identify and clarify the characteristics of the experiences of student nurses while providing care for dying persons.
Huang et al.  in their study with 12 Taiwan nursing students, using a descriptive approach, to explore their first encounter with death during clinical postings. Their findings showed that nursing students experience feelings of terror and self-affirmation when providing care to the dying patients. The students also faced difficulties seeing a patient suffering. The participants expressed the need for teaching and receiving supports at the moment of a patient's death and the bereavement period that follows.
The exploration of the lived experience of nursing students with death and dying could help in designing strategies to monitor and mentor them. It is in light of this that the researcher sought to assess and interpret the lived experience of undergraduate nursing students with regards to death and the dead.
| Materials and methods|| |
This a qualitative study with a hermeneutic phenomenological approach as described by Ricoeur  to assess and interpret the lived experiences of undergraduate nursing students with regards to facing death and the dead during their initial clinical posting and to analyze the feelings and thoughts behind their stories.
Participants and method of data collection
Before the initial clinical postings of 1 st year, BSc Nursing students each and every 1 st year students were asked to keep a reflective diary on their individual experiences with death and the dead as they practice on the wards. The students were trained on how to effectively keep the reflective diary using several practical examples with clinical scenarios. Due to the nature of the study, the students were allowed to record their experience in an unstructured format to aid free and in-depth expression.
After a period of 2 months of clinical postings, the reflective diaries were retrieved from the students. A total of 12 reflective diaries met the inclusion criteria and thus were used for the interpretation.
Method of data analysis
Due to the design adopted in this study, an interpretive approach was adopted to uncover meanings from the experiences of the nursing students. According to Dempsey and Dempsey  while validity, reliability, and generalizability should be avoided in qualitative studies, truth and accuracy are preferred. As much, the result of a study is considered credible if other experienced researchers recognize that they are sufficiently trustworthy to be relied upon. 
There was no statistical analysis in this study as Ricoeur  is of the opinion that it is always possible to argue either for or against an interpretation, and that the credibility of an interpretation lies closer to the logic of probability than the logic of empirical verification. The analysis in this study followed the principles of the hermeneutic arc proposed by Ricoeur  which included concepts of naive reading, structural analysis and in-depth interpretation of meaning. However, a manual calculation was used to present participants socio-demographic characteristic in frequency and percentage.
This study was approved by the ethical review committee of the college. All students gave their informed consent and confidentiality of information was assured.
| Result|| |
A total of 12 reflective diaries were selected for interpretation. [Table 1] shows the socio-demographic information of participants. Majority (66.7%) were between the age of 17 and 19 years were females (66.7%), had no previous experience with death (83.3%) and chose health related profession as initial choice of career (75%)
Personal reflection on harsh reality
This was a major theme derived from the structural Analysis ([Table 2]). It describes the internalization of the students emotions based on their experiences. The participants reported that experience with death and the dead reminds them of their own immortality. This feeling is mixed with some degrees of uncertainty and evolutionary component. Dead people were seen to be accompanied with dangers…. Like predators.
Sub-theme: 1. Fear of the unknown
Diary 7…." I was really scared …… I think fear of dead people come from fear of the unknown. People don't really know their state when they die and hence, cannot accept the inevitability of their own immortality.
Diary 9. Oh my God…at first, I could not stand it. I can personally say that I have huge fear for dead human bodies…….of course I cannot explain. I know they won't jump out and attack me, neither would they harm and it's not about my own immortality. And again, I think the movie industry has a lot of questions to answer for inflicting fear among people about death by depicting that dead people come back to life……like zombies.
Diary 10. ' hmmm. Initially, I thought I was in a different world until I realized this is part of the things I have to deal with as a nursing students and eventually as a professional nurse.
Diary 12. Well, I think it's really awful to deal with the cold body. I can manage to sit there and wait and be present as long as the patient is breathing, but once he/she is dead, I find it extremely upsetting….
Sub-theme: 2. Source of new experience
Diary 2.I don't think it's unusual to feel this way. It was definitely a new experience. The dead patient was not my patient, and I did not see him die. I only saw the dead body during the post-mortem. The experience was surreal…I was speechless and really did not know what to think or feel. I am sure, I would be more emotional when I experience the death of a patient that I am actually caring for.
Diary 3…. I felt clinically and scientifically neutral. I recognized it's a learning experience. However at the same time, I also wondered if it was normal to feel this way. Am I in shock, professionally mature or just plain cold? I know death is definitely a part of nursing and it will cross our paths often.
Sub-theme: 3. This life is nothing……it could be me
Diary 11….and a very important reflection came to me…. being a nurse is not a guarantee that one won't die… how do I want to be treated when I am dying or dead…When I came back from the canteen, I saw his lifeless body. I unintentionally shouted: "This life is nothing….it could be me.
Unavailability of required support and feeling of abandonment
Students expressed the felt needs to be supported by their instructors and guides. They reflected the feeling of total abandonment when having to deal with the dying patient or their dead bodies. The roles of the nurse instructors include rendering their support to the nursing students whenever they witness an unusual experience. This theme also describes their perception of the supports a dying patient and families need during the critical period.
Sub-theme 1. 'I am on my own'
Diary 1.……and precisely, I watched my first patient die during clinical rotation. We sat and watched her heart stop and listened to the family cry out emotionally….it's like I am in a wrong place. If I continue here, I am on my own.
Diary 3….Everybody has to deal with their personal feelings when a patient died, coupled with when relatives weep bitterly….even the nurse and sometimes doctors are affected, I really feel so. But as a student, I need someone, perhaps the instructor I respect most, to guide me through all these.
Sub theme 2-intention of quitting
Diary 8.….and actually, I have seen some hideous corpses….not a pretty site. One in particular I remember: A man's face of anguished horror. Prior to death and prior to my seeing him, I had not witnessed the deliberate attempt to save him by the physicians through massaging his chest. Only the aftermath, a grizzly site. (I'll spare the details, your imagination would probably paint a more gruesome portrait). I am very uncomfortable and I don't want to change my mind. But if I cant handle this, I may have to leave this profession.
Sub-theme 3 interplay between sympathy and empathy
Diary 5… of which most of the time I have had to be strong and unfeeling to continue…. but its always a nightmare when death could have been prevented. I just feel that no matter how certain a patient's death could be, every attempt needs to be made to save him or her.
Diary 6. I remember an instance, I came into this man's room with his family members at the bed side, the man looking out of breath and grimacing, I attempted to return the oxygen mask to his face but he rejected, the family confirmed that he knows what he's doing. After his death, I came to know that the man had continued to smoke all his life knowing well the consequences.. even at that, he should have been supported.
Diary 12. I don't see them as dead bodies, I still see them as my patients
Theme 3-Identification of individual strength and weakness based on experience
The students who have had to cope with the death of a close relative in previous times expressed it as a source of adjustment for them in their present clinical experiences with death and the dead. The students who could not cope with previous experience identified their weaknesses. This is where the assistance of the mentors comes in. They identified frequent exposure as a means of coping with the death experience.
Sub-theme 1. It is impossible to tell until you get your feet wet
Diary 9. I never really had a problem with death. Until when my mother passed away unexpectedly and I was the one who was with her… it still creates a shock in me even up till this very moment. Although I joined nursing because of her death, I still do not wish to have things to do with dead bodies…
Sub-theme 2: Development of individual coping
Diary 4: Most of the time, I was aware of what I was about to witness. I would panic at first and then tell myself its part of my training… just do it. When it came down to it, I have always done it as if on autopilot
Diary 8. Knowing my patient was no longer suffering is usually the thought that saves my sanity…. although it was difficult when my dad died, but then he had suffered for too long, so just needed to rest. This has always molded my thought in relation to the death of my patient.
Diary 10.…. Initially, it was nerve wrecking, but when I requested for frequent exposures, I am surprised it is not as bad as I have expected.
| Discussion|| |
From the findings of this study, it was observed that fear of the unknown was a major concern among the students in relation to their experiences with death. They expressed that in reality, the dead bodies forcefully bring to their consciousness the fearful inevitability of their own demise and not being in the position to know what happens after physical death.
Personal reflection which was a major theme that emerged has been described to be important in dealing with individual's experiences with death. Self-reflection from this study yielded mixed responses. To some, it was a way of coming to terms with reality and to others, it compounded their fears. According to Liu et al.  students can learn their fears of death and possible reactions towards dying patients through self-reflection. This could be facilitated by exposing them to workshops on life and death issues. Liu and colleagues further explained that the foundation of facilitating students' self-awareness is a safe environment for them to gain experiential knowledge of the dying process and end-of-life. This would not only help students grow personally, it will also increase their motivation.
Findings from the present study have revealed that the students need adequate support and monitoring when they are experiencing death. They experience different emotional reactions as a result of their encounters with death. This is in line with the findings of Huang et al. who reported that nursing students had feelings of dread, terror, hardship, state of being scared, emotional breakdown whenever a patient is dying. However, the students coped with acceptance, avoidance, growth and escape which is synonymous with the coping styles of the students in the present study.
These students should be adequately mentored by both the educators and the staff nurses. The need for this is indicated from the findings of this study where students reported that even while they were having hard times, they had to deal with it alone because their instructors were not always available to them and the staff nurses have their own emotions to handle. Due to this situation, it has been advocated that nursing students be exposed to death education. Loerzel and Conner  reported in their findings that death and dying course could increase students' confidence in dealing with this experience. In the same vein, Mooney  has found that death education was effective in reducing death anxiety among undergraduate students.
Nursing student might learn how to help family members grieve, but seldom learn how to deal with their own feelings of sadness and loss. Jiang et al.  reported that even when nursing students could cope with their grieve, they rarely shared their experiences with others. Fear has been identified as a major issue in nursing. 
Another interesting finding from this study was that the students considered their experiences with death and dead bodies as a source of learning experience. This corroborates the findings of Terry and Carroll  who reported that students expressed that every death in clinical practice was a learning experience to them. Same result was reported among nurses by a previous researcher. 
The findings from this study have shown that nursing students had different views about their experiences with death and dead bodies. The reason for this could be due to differences in various culture.  Therefore, educators and instructors should be aware of individual differences and cultural variations among students when attempting to help them understand and cope with their experiences. Also, it was found that previous experience has a major role to play on how the students perceive their current clinical exposures. Preparing the students adequately before clinical posting would get their minds ready to face any experiences.
| Limitations|| |
This study was conducted among students from an institution which could reduce the generalizability of the findings. Also, the small sample size may not really reflect the opinions of the general population of nursing students. The absence of a statistical reliability could be a limitation.
| Conclusion|| |
This study has explored and interpreted the lived experiences of nursing students in relation to death and dead bodies. In line with previous studies, the present study has found fear as a predominant emotional disposition among nursing students. It is therefore recommended that nursing students be adequately prepared to deal with death before being exposed to clinical setting. Also, nurse educators and instructors should periodically assess the students coping abilities and help them develop better strategies to cope with the new experiences. End-of-life component of the nursing curriculum should be improved to bridge the gap that currently exists in the education of nursing students.
| Acknowledgment|| |
My profound gratitude goes to the nursing students who devoted their time to participate in this study, despite their tight schedules.
| References|| |
Iranmanesh S, Savenstedt S, Abbaszadeh A. Student nurses' attitudes towards death and dying in south-east Iran. Int J Palliat Nurs 2008;14:214-9.
Mutto EM, Errázquin A, Rabhansl MM, Villar MJ. Nursing education: The experience, attitudes, and impact of caring for dying patients by undergraduate Argentinian nursing students. J Palliat Med 2010;13:1445-50.
Kwekkeboom KL, Vahl C, Eland J. Companionship and education: A nursing student experience in palliative care. J Nurs Educ 2005;44:169-76.
Gama G, Barbosa F, Vieira M. Factors influencing nurses' attitudes toward death. Int J Palliat Nurs 2012;18:267-73.
Braun M, Gordon D, Uziely B. Associations between oncology nurses' attitudes toward death and caring for dying patients. Oncol Nurs Forum 2010;37:E43-9.
Aradilla-Herrero A, Tomás-Sabado J, Gómez-Benito J. Death attitudes and emotional intelligence in nursing students. Omega (Westport) 2012;66:39-55.
Terry LM, Carroll J. Dealing with death: First encounters for first-year nursing students. Br J Nurs 2008;17:760-5.
Jiang RS, Chou CC, Tsai PL. The grief reactions of nursing students related to the sudden death of a classmate. J Nurs Res 2006;14:279-85.
Birkholz G, Clements PT, Cox R, Gaume A. Students' self-identified learning needs: A case study of baccalaureate students designing their own death and dying course curriculum. J Nurs Educ 2004;43:36-9.
Ricoeur P. Interpretation and Ideologies. 4 th
ed. Rio de Janeiro: Frasisco Alves; 1990.
Ricoeur P. Interpretation Theory: Discourse and the Surplus of Meaning. Fort Worth, T.X: Texas Christian University Press; 1976.
Charalambous A, Kaite C. Undergraduate nursing students caring for cancer patients: Hermeneutic phenomenological insights of their experiences. BMC Health Serv Res 2013;13:63.
Allchin L. Caring for the dying: Nursing students' perspectives. J Hosp Palliat Nurs 2006;8 Suppl 2:112-7.
Huang XY, Chang JY, Sun FK, Ma WF. Nursing students' experiences of their first encounter with death during clinical practice in Taiwan. J Clin Nurs 2010;19:2280-90.
Ricoeur P. From Text to Action - Essays in Hermeneutics II. London: The Arthrlone Press; 1991.
Dempsey PA, Dempsey AD. Using Nursing Research: Process. Critical Evaluation and Utilization. New York: Lippincott; 2000.
Kvale S. Interviews: An Introduction to Qualitative Research. Sage, CA: Thousand Oaks; 1996.
Liu YC, Su PY, Chen CH, Chiang HH, Wang KY, Tzeng WC. Facing death, facing self: Nursing students' emotional reactions during an experiential workshop on life-and-death issues. J Clin Nurs 2011;20:856-63.
Loerzel VW, Conner N. Advances and challenges: Student reflections from an online death and dying course. Am J Hosp Palliat Care 2014; [Ahead of print]
Mooney DC. Tactical reframing to reduce death anxiety in undergraduate nursing students. Am J Hosp Palliat Care 2005;22:427-32.
Nwozichi CU. Why are chemotherapy administration errors not reported? Perceptions of oncology nurses in a Nigerian tertiary health institution. Asia Pac J Oncol Nurs 2015;2:26-34.
[Table 1], [Table 2]