Accompaniment needs of nursing students related to the dying patient

S leu te lw o o rd e : B egeleiding, studentverp leegkundiges, dood, sterw ende pasien te , klin iese leeromgewing Abstract: Curationis 28(4): 31-39 Nurse educators are responsible for accompanying students towards becoming capable, competent professional nurses who are a credit to themselves, their patients, colleagues and profession. Student nurses need, therefore, to be taught to render comprehensive nursing care to patients in all stages of their lives, including when they are dying. Being confronted with human suffering and death is challenging and traumatic. Those exposed to such events on a daily basis need to have a solid foundation of self preservation to see past the pain of suffering and to bring light and hope to those in need. A young student nurse will only experience positive growth and development in these circumstances if she is also cared for and guided with understanding. The researcher utilized a qualitative, explorative, descriptive and contextual design based on the phenomenological approach to enquiry. The following question was asked at the beginning of each unstructured phenomenological interview: “How was if for you to care for a dying or deceased patient?” The central theme identified that student nurses experience turmoil in their different relationships in their accompaniment of the dying patient. Guidelines based on the central theme and sub-themes that emerged from raw data, as well as literature, are offered as strategies to promote/enhance optimal accompaniment of student nurses caring for the dying patient.


Introduction
Death is a universal and individually unique event of the human experience.In today's social climate, death is viewed as something to be avoided at all costs.Medicine with its technological advances pursues immortality.These scientific advances do not change the fact that death is a part of every human existence.Dying was once considered to be a normal part of the life cycle.Today it is often considered to be a medical problem that should be handled by health care providers.Technological advances in medicine have caused the care of those who are dying to become depersonalised and mechanical (DeLaune and Ladner, 2002:424).
Nurses are looked upon to humanise the care of the dying.Nurses spend more time with patients who are facing the end of life than any other member of the health care team and, th erefo re, play an important role in the initial stages of bereavement -the grief experienced with the loss o f a sig n ifican t other.B ereavem ent is a universal norm al response to a loss, draining on a person both emotionally and physically.
Each patient has to do his own dyingwe cannot do it for him.Each dying patient is unique and there is no ultimate guide for health care professionals (Luthert and Robinson, 1993:90).A person's imminent death creates conflicts and tensions in those caring for him.The n urse's individual reactions to death inevitably affect his/her ability to give optimum care to a dying patient and his family.Exploring these reactions is essential to the nurse's professional growth and development (Jacobi in Earle, Argondizzo and Kutscher, 1976:2).Kiger (1994:680) states that, on entering their first clinical allocation, student nurses expect to experience difficulty with the emotional care of dying patients and dealing with the pain of seeing them suffer and the shock of seeing a dead body.Concern is expressed as to how they will communicate with relatives, what to say or how to tell them that their loved one has died.
In S outh A frica, one faces death frequently due to the increased incidence of violence and terminal illness.For example, according to the UNAIDS/ World Health Organisation annual report, "AIDS epidemic update 2003" , Auto Immune Deficiency Disease Syndrome (AIDS) claimed an estimated 3 million lives in 2003.Moreover, an estimated 5 m illion people acquired the hum an immunodeficiency virus (HIV) in 2003bringing the estimated number of people globally living with the virus to 40 million (UNAIDS, 2003).Closer to home, the Eastern Cape Departm ent o f Health reported the Eastern Cape Province to have an estimated 534 251 HIV positive individuals, a prevalence of 8,3 percent (Zuzile,2003:19).N ursing stu d en ts are faced w ith challenging new experiences, such as caring for the dying patient, from the beg in n in g o f th eir train in g and, consequently, need a co n sid erab le degree of guidance and support.

Problem statement and research questions
The researcher, while accompanying second year students in the clinical nursing environment, heard a student verbalise "I t' s just a case o f the unknown, I think you just have to get used to it."S tudent nurses have m entioned difficulties in communicating meaning fully with the dying patient, as well as not knowing what to say to the patient's family after the patient has died.
Student nurses appear to avoid coping with dying patients by becoming tough, cynical and uncaring.The researcher, in his first year as a student nurse, experienced the death of a patient while giving a bed-bath.The next occasion the researcher was in the ward, a second patient died during a bed-bath.Although this was not the re se a rc h e r's first ex posure to death, it re su lted in trem endous anxiety regarding bedbathing p atien ts and gave rise to q u estio n s such as " W hat did I do wrong?"

Research objectives
The objectives of the study were to:  1994:150).

Student Nurse
For the purpose of this study, a student nurse is an individual enrolled for the first two years of the four-year Baccalaureus Curationis programme.Throughout this study reference to the personal pronoun 'her' and 'she' will include both genders.

Accompaniment
A planned and deliberate intervention by the clinical mentor, including all those activities that occur in a purposeful fashion according to the identified needs of the student, to facilitate development of self-reliance and independence (Kotzê, 1998:10).

Death
For the purpose of this study, death will be considered as having occurred in one Of the three ways described by Hector and Whitfield (1982:10).The patient may die quite suddenly, sometimes with no previous symptoms.The patient may die from a fatal disease, like advanced cancer, where it is possible to note the signs of approaching death and to forecast the likely time of death.Thirdly, the patient may be placed on a life-support machine fo llo w in g an accid en t or sudden emergency and the criterion of brain death is invoked to decide if death has occurred.

The Dying Patient
Within this study, the dying patient will refer to the period where the nurse cares for the patient up until the time the patient dies, as well as the period after death until the deceased patient has been removed from the nurse's care.

Research design and method
The following discussion focuses on the research design and research method utilized in this study.

Research Design
The research study fo llo w ed a qualitative, explorative, descriptive and co n tex tu al d esig n based on a phenomenological approach to inquiry, reflecting the experiences of student nurses related to the accompaniment of the dying patient and care of the patient after death.

Research Method
The collection of data and the analysis of data were implemented and divided into two phases.
Phase 1 U n stru ctu red p h en o m en o lo g ical interviews were conducted with second year nursing students whilst exposed to the clin ical learn in g en v iro n m en t.Purposive sampling was used and data were collected by means of a combination o f u n stru ctu re d p h en o m en o lo g ica l interviews, personal journals kept by participants and the researcher's field notes.Data were analysed according to the descriptive analysis method of Tesch (1990cited m Creswell, 2003:192).

Phase 2
Once the data had been interpreted, guidelines were developed for the clinical mentors and ward staff to provide optimal accompaniment for student nurses in the clinical environment.These guidelines should assist clinical mentors and all staff members working with student nurses in m aking the experience o f death less threatening.

Sample population and method
The research population for this study com prised 59 second year nursing students who were all registered as students at the U n iv ersity o f Port E lizab eth (now know n as N elson M andela M etro p o litan U niversity [NMMU]).The sample for this study comprised six of these students who had all experienced the death of a patient in the clinical learning environment within the previous six months.Furthermore, the students were all English or Afrikaans speaking, as these were the languages u n d erstood by the research er, the participants and the independent coder.This avoided loss of information during the process of interpreting, transcribing and coding of interviews.Four of the participants were Caucasian, one was Black and one was Coloured.All of the participants were 18 years of age or older.
Purposive sampling was used in this study.Yegidis and Weinbach (1996:122) refer to purposive sam pling as the selection of participants according to their ability to give the researcher access to some specialised insight or a particular perspective, experience, characteristic or condition that he wishes to understand.Consequently, the researcher approached the second year class lectu rer and requested her to explain the proposed research study to the class and to ask for volunteers to participate in the study.The researcher received the names of the volunteers via the lecturer.Those who met the criteria were then approached to participate.

Data collection and analysis
D ata was co llected by m eans o f unstructured, individual phenom eno logical interviews that were recorded using a dictaphone.The researcher posed the following central question to each participant: "How was it fo r you having to care fo r a dying or deceased patient?" Interviewing continued until saturation of data was reached, which was evidenced by repeating them es.The interviews were transcribed verbatim.The re searc h er kept field notes and p artic ip a n ts w ere asked to keep a personal journal for two weeks following the interview.The personal journal of each participant was added to their interview and analysed as a part of the interview.
The interviews and personal journals w ere analysed acco rd in g to the descriptive analysis method of Tesch 33 Curationis November 2005 (1990( in Creswell, 2003:192):192).Clean sets of transcribed interviews, field notes and participants' personal journals were given to an in d ependen t coder experienced in the field of qualitative research.The independent coder was asked to assist with identifying the them es related to studen t n u rse s' experiences in accompaniment of the dying patient and caring for the patient after death.On completion, consensus on the identified theme and sub-themes was reached between the researcher and the independent coder.Both agreed that data saturation had been achieved and there was no need for further interviews to be conducted.

Literature control
The review of literature serves to inform or support the study, esp ecially in conjunction with the collection and analysis of data.The findings from previous studies form the basis for com parison w hen in terp re tin g the findings from the current study (Brink, 1996:76).In qualitative research, literature should be used inductively meaning that it should not direct the questions asked by the researcher.Related literature was incorporated into the final section of the study, where it was used to compare and contrast with the results that emerged from the study (com pare C resw ell, 2003:31-33).

Trustworthiness
According to Agar (1986in Krefting, 1991:215), a different language is needed to fit the qualitative view of research, namely one that will replace validity and reliability with terms such as credibility, accuracy of representation and authority of the researcher.In order to assess the worth o f findings regarding student nurses' experiences of caring for the dying patient, Guba's Model (in Krefting, 1991:215) was u tilised to ensure trustworthiness using the four identified aspects, namely truth-value, applicability consistency and neutrality.

Strategies to ensure trustworthiness
The strategies to ensure trustworthiness w ere cred ib ility , tra n sfe ra b ility dependability and confirmability.These are summarised in Table 1.1

Ethical considerations
The rights of the individual to not be harmed, to give informed consent, to The researcher accom panied second year students in the clinical environment when they were exposed to death and dying.

Reflexivity
The researcher kept field notes throughout the research process, which allowed him to assess his own behaviour for biases and preconceived assumptions.

Triangulation
The researcher compared data collected by multiple methods namely interviews, participants' journals and the researcher's field notes.

Member checking
The researcher conducted a literature control and a pilot study.

Peer examination
The researcher held discussions with im partial colleagues and the independent coder.

A u th o rity o f the researcher
The researcher has: undergone training in research methodology; conducted qualitative research; been supervised by two people with extensive experience in qualitative research.

Transferability
Nominated sample A purposive sampling method was used.

Dense description
The research method and design have been fully described.

Dependability Dependability audit
Personal logs and field notes were used and kept.
Code re-code procedure C onsensus discussions took place betw een the research er and independent coder.

Confirmability Confirmability audit
An independent coder analysed the data.
T rian g u latio n and reflexivity Data were collected and analysed by means of a combination of transcribed interviews, participants' personal journals and the researcher's field notes.voluntary participation, confidentiality, anonymity and justice (Holloway and W heeler, 1998:39) were considered throughout the research study.Second year students were invited to participate after being fully informed about the study.The re searc h er selected participants according to set criteria from the volunteers who subm itted their names to him.The researcher conveyed to participants that they were free to withdraw from the study at any time without being penalised.At no time did he engage in deception about the nature of the study (Creswell, 1998:132).

Identified themes/results of the study
One central theme identified was that In accompaniment o f the dying patient, the student nurse experiences turmoil in different relationships -intrapersonal, interpersonal and transcendental.This theme and its sub-themes are identified in Table 1.2.

Discussion of themes
The participants in this research study described their feelings and experiences related to their accompaniment of dying patien ts in the clinical learning environment as follows.

Central theme: In their accompaniment of the dying patient, student nurses experienced turmoil in different relationships
The often young and inexperienced student nurses entering the nursing profession are not fully prepared for the challenges awaiting them in the clinical setting.Some of these challenges, such as caring for dying patients, invoke overwhelming feelings and emotions in clu d in g shock, fru stratio n , helplessness, self-doubt, anxiety, fear, inadequacy and guilt, as well as feelings of personal loss and grief.Student nurses v erb alised how they noted m ore ex p e rien ce d nurses have becom e 'immune' to death and do not want to follow suit.Quint (in Loftus, 1998:642) states that it is the first experience of care of the dying that may help to form the nurse's attitudes to further experiences.Time should, therefore, be spent on ensuring th at the studen t is w ell supported during this period.The sub themes follow:   (1985:497) describes how student nurses ex p erien ced intense and usu ally unrealistic self-blame and guilt when a death occurred after some minor error or discourtesy on their part.

Student nurses experienced personal loss causing feelings of grief
Nurses, especially students who are responsible for basic nursing care, can spend a great deal of time with patients at a period in their lives when they are m ost v u ln erab le.S tudent nurses verbalised how they experienced grief due to the personal loss felt with the death of a patient."The longer you spend with a patient, the more attached you get.And then you actually miss them when they 're gone ".Lees and Ellis (1990:956) explain that, as it is the student nurses who provide the bulk of the hands on patient care, they feel the loss o f a friend more than trained staff when the patient dies.

Student nurses experienced feelings and emotions that lead them to use positive as well as negative coping mechanisms
Student nurses in this study described being able to share experiences with their peers (fellow nursing students, for the most part within their same year group), but preferred not to discuss experiences with others.Lees and Ellis (1990:953) found that student nurses reported to having good friends outside of nursing, of whom the majority were considered supportive, but friends within nursing were the most supportive group.
The student nurses found it easier to cope with death by crying, using self talk, praying and believing that there is a better place after death.Student nurses revealed that they tended to bottle up their feelings and distance themselves from patients and their colleagues (other nu rses, not including peers

c) Bottling up of feelings
There is a general perception amongst student nurses that the more experienced nurses have become 'immune' to death.Student nurses are determined that they do not want to follow suit."1 couldn' t believe that she was actually a sister caring fo r people because she is very hard and very insensitive.I never want to become like that, so hard that I do n ' t care if somebody dies." Kiger (1994:684) found th at there is a fa ilu re to acknowledge feelings associated with death and dying in the ward and trained staff made it clear that first year students were too junior for their views to have any value.The result was that student nurses developed distancing strategies, worrying at the same time that they might become hard and, as a result, would become unable to nurse with feeling.

d) Gaining relief through crying
Crying is the most visible way of showing em otion and feelings of grief.Some student nurses prefer not to cry; they would rather avoid situations that could cause them to display such emotion.O ther stu d en t nurses w ill perm it themselves to continue with their duties, allowing the emotion to build up, and let it out with tears later on in privacy, away from the patients and their relatives.'77 was quiet fo r the whole day, but when I got home I just cried.Iju st couldn' t keep it inside anymore.Sometimes this thing happens to me in front o f the relatives, bu t I c o u ld n 't cry in fr o n t o f the relatives."Muir (2002:1) says sadness relating to the death of a patient is entirely normal and that a nurse should not feel that she is being unprofessional or feel asham ed about cry ing w ith fam ily members.e) P rayer and the belief in a H igher Being/God All of the student nurses in this study expressed the use of prayer and their religious beliefs as a major method of coping with the death of a patient and in coping with nursing patients while they are dying.This finding is discussed in more detail under sub-theme 3. f) Rem aining in control through self talk Talking to themselves, giving themselves encouragement or just verbalising their actions out loud, helped to keep the student nurses calm and take their minds off the reality of the immediate situation when managing the dead patient.One student shared "I was talking to myself, but hoping that she could still hear me, ju st talking away ....I think maybe it was fo r myself I was doing that, ju st to calm me down." After an extensive literature search, no data could be found to support the fact that students in other studies made use of self-talk to help them cope when nursing the dead and dying patient.

Relationships Due To Conflict Resulting
From Expectations Related To a Role

Model Not Being Met
Experienced nursing staff should be the role models for nursing students but the nu rsin g stu d en ts find th at these supposed role models conflict with their idea of what being a nurse is: "They are so-called registered nurses.I feel there are so many sisters who are like that.All o f the respondents em phasised strongly the value of gaining strength from spiritual beliefs and from being able to pray for a dying patient and believing that they will be in heaven/a better place after they die.One respondent described how she believes that it is essential that one have a set of beliefs in order to cope with caring for the dying patient: "I f you don' t have religion, you need to fin d a belief somewhere very quickly... but you need to believe in something to make it easier, because the moment you d o n 't believe in anything, and someone dies, you believe i t ' s final, that i t ' s such a tragedy, ...a belief still helps you to deal with it." The way in which student nurses created meaning through religious beliefs were praying for them selves and the patient, gaining strength through their own spirituality and believing in heaven/ a better place after death.
As students commented: " When I go home I pray fo r them.Then I 'm calm....probably because I can pray fo r them." "I t' s a sort o f relief that they've gone to a b etter place where they are now resting." Parkes (1985:947) observed that students who had strong religious beliefs, and construed death in these terms, seemed most able to accept the death of patients without undue stress.

Guidelines to optimise accompaniment of student nurses caring for the dying patient in the clinical learning environment
The guidelines recommended are based on the findings of the research.Guideline 1: Decreasing and alleviating intrapersonal relationship (relationship w ith self) turm oil by developing confidence in caring for the dying patient through establishm ent of supportive relationships.Guideline 2: Decreasing and alleviating interpersonal relationship turmoil by involving w ard sta ff in the accompaniment of student nurses.The involvem ent of all personnel in the accompaniment of student nurses will stren g th en and instil a sense of ownership in the personnel.Dunn andH ansford (1997:1305) While caring for dying patients, student nurses experienced powerful feelings and emotions such as fear, grief, frustration, anxiety and helplessness.They were

Table 1 .2: Identified Themes Related to Student Nurses' Experiences of the Accompaniment of the Dying Patient
Student nurses experienced

shock due to the unexpected nature of illness and unrealistic expectations of nursing
Student nurses

experienced frustration and helplessness related to the patient's apparent untimely death and the limitations of medical science
She is the dying patient's advocate and when his wishes do not correspond with what she feels is the best care for him, the student nurse suffers from feelings of frustration and helplessness.
Student nurses became frustrated and found it hard to come to terms with the 35 Curationis November 2005 said, "I 'd rather die instead o f them.I 'd do that any day." Virginia Henderson (in Kotzê, 2001:21) describes the nurse as a substitute for what the patient lacks to m ake him com plete, w hole or independent, by the loss o f physical strength, will or cognitive knowledge.So, I don know, that quite bothered me.I feel bad about it.I mean I just went on lunch maybe I could have said to her (trained nurse), 'Just give me the pills and I 'll go give it, ' but they don' t work that way, they don't let you tell them what

Theme 3: Student Nurses Experienced a Need to Find or Create Meaning through a Transcendental Relationship
Sub- state that participation in student nurse education should be an expected and valued part p f any registered n u rs e 's role.