Nurse Education Today 41 (2016) 1216

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Nurse Education Today

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Nursing students' perceptions of caring for dying people, after one year in
nursing school
Jane sterlind a,b,, Charlotte Prahl a,b, Lars Westin c, Susann Strang d,e, Ingrid Bergh c, Ingela Henoch a,e,f,
Kina Hammarlund c, Kristina Ek c
a
Ersta Skndal University College and Ersta Hospital, Palliative Research Centre, Stockholm, Sweden
b
Ersta Skndal University College, Department of Health Care Sciences, Stockholm, Sweden
c
University of Skvde, The School of Health and Education, Sweden
d
Sahlgrenska Academy, University of Gothenburg, Institute of Health and Care Sciences, Sweden
e
Angered Hospital, Sweden
f
University of Gothenburg Centre for Person-Centred Care (GPCC), Sahlgrenska Academy, University of Gothenburg, Sweden

a r t i c l e i n f o a b s t r a c t

Article history: Aim: To describe Swedish nursing students' perceptions of caring for dying people after the rst year of a three
Received 7 June 2015 year in a nursing programme at three university nursing schools in Sweden.
Received in revised form 20 February 2016 Methods: Interviews (n = 17) were undertaken with nursing students at the end of their rst year. A
Accepted 15 March 2016 phenomenographic approach was used to design and structure the analysis of the nursing students' perceptions.
Results: The analysis resulted in ve categories: 1) from abstract to reality, 2) from scary to natural, 3) increased
Keywords:
knowledge can give bad conscience, 4) time limits versus fear of end-of-life conversations, and 5) meeting with
Death
Dying
relatives.
End-of-life care Conclusion: Nursing students need to be prepared both theoretically and within practice to encounter death and
Nursing education dying and to care for dying persons. By combining their theoretical knowledge of dying and death with their own
Nursing students encounters of death and dying people in practice, the students can be supported to develop an understanding of
Perceptions dying and death as a natural part of life rather than something frightening.
2016 Elsevier Ltd. All rights reserved.

1. Background In Sweden, registered nurses (RN) must complete a three-year

Caring for dying persons is an essential part of all nursing care. How-
ever, this is not an easy part of nursing because death and dying are
topics often surrounded by silence and described as something that
nurses do not talk about, either with the patient or with their colleagues
(Dwyer, 2008; Dwyer et al., 2010; sterlind et al., 2011). Furthermore,
nurses are described as being unlikely to discuss their theoretical and
practical knowledge about this issue with others (Prahl, 2010).
Modern medicine has provided opportunities for people to survive
acute illness and to live longer with severe and chronic illnesses
(Lunney et al., 2003). With an increasingly aging population (Seale,
2000), nurses are more likely to meet death and dying people in private
homes, in nursing and care homes, hospitals or other medical facilities.
Caring for dying people places great demands on both professional ex-
pertise and personal maturity and can involve nurses having to confront
their own mortality (Kllstrm-Karlsson et al., 2008).
Corresponding author at: Ersta Skndal University College, Palliative Research Centre
and Department of Health Care Sciences, Sweden.
E-mail address: jane.osterlind@esh.se (J. sterlind).
Bachelor of Science programme in nursing. This is required before
their registration as nurses by the National Board of Health and Welfare.
Although nurses acknowledge that it is their duty to meet and inter-
act with patients at the end of life (Browall et al., 2010), they need to be
prepared for this aspect of their role.
Nursing students have been described as having experiencing dif-
culties in dealing with death and dying (Mallory, 2003; Parry, 2011;
Edo-Gual et al., 2014; Gillan et al., 2014; Strang et al., 2014) and in feel-
ing comfortable when caring for dying patients (Parry, 2011; Sampaio
et al., 2015). Learning to cope with death and dying and to care for
dying people has been described by Slj as a learning process that is
linked to each individual person's ability to learn (Slj, 2000). Slj
continues to say that this learning occurs continuously, even if there is
no awareness of it. However, studies have shown that students have
limited opportunities to acquire knowledge and reect on their experi-
ences of caring for dying people which limits their learning opportuni-
ties and awareness of learning (Lloyd-Williams and Field, 2002;
Johnson et al., 2009).
In a study by Parry (2011), nursing students' rst encounter with a
dying patient was described as emotionally demanding, that they
lacked the necessary skills for the situation, and that the mentors' atti-
tude to death was crucial for dening their experience. The nursing

http://dx.doi.org/10.1016/j.nedt.2016.03.016
0260-6917/ 2016 Elsevier Ltd. All rights reserved.
 J. sterlind et al. / Nurse Education Today 41 (2016) 1216
students were affected by the physical suffering of patients, and sudden
death was more difcult to encounter than the expected death of older
patients. In another study by Ek et al. (2014), rst-year nursing stu-
dents' experiences of death and caring described how they could have
fears of losing control and not being able to support the dying patient
and the relatives in an appropriate and sensitive way.
There are few studies, especially in Scandinavia that explore nursing
students' perceptions of caring for dying people, compared to those
studies conducted outside the Nordic countries (e.g. Iranmanesh et al.,
2010; Smith-Stoner et al., 2011). Research in Sweden about this subject
is underdeveloped or under-reported; this study seeks to address this
gap.
2. Aim
The aim of the study was to describe Swedish nursing students'
perceptions of caring for dying people after one year of education in a
three-year Bachelor of Science in nursing education programme.
3. Method
Phenomenography (Dahlgren and Fallsberg, 1991) was used as a
methodology and a framework to analyse the interviews in relation to
the nursing students' perceptions of caring for dying persons. According
to Dahlgren and Fallsberg (1991) Phenomenography is a methodology
that describes variations of qualitatively different conceptions of a
phenomenon.
Phenomenography has primarily a qualitative empirical research
focus, which focuses on the way people experience the world and the
variation in this experience. Phenomenographic research focuses on
how things are perceived by persons and assumes that their ideas or ex-
periences of the world belong to a second-order perspective (Marton,
1981).
This study is part of longitudinal multi-centre project aiming to ex-
plore the development of nursing students' perceptions towards the
care of dying people during their education, that is, after one year of ed-
ucation, at the end of the second year, and at the end of their education
programme. In the rst study attitudes towards the care of dying
patients and death were measured by using the Frommelt Attitude
Toward Care of the Dying Scale (FATCOD) (Frommelt, 1991), validated
for use in Swedish (Henoch et al., 2014). The quantitative study raised
questions for further exploration through interviews. The ndings in
this study are based on interviews with nursing students at the end of
the rst year of their nursing programme.
4. Participants
All students who started their nurse education at three universities
in Sweden during the autumn of 2011 were invited to participate.
Two hundred and twenty-two students from a possible 245 students
participated in the project (189 women and 33 men). The same 222 stu-
dents who participated in the rst phase of data collection were invited
to participate in an interview. In this second phase of the study, 17 nurs-
ing students from 3 universities, located in 3 different cities in Sweden,
who had completed their rst year of nursing school, agreed to be
interviewed. Sixteen participants were female and one was male, all
17 were born in Sweden and were aged between 20 and 40 years.
The 17 students had all completed their rst period of practice in a
nursing home. They were supervised by registered nurses when they
practiced nursing care. During placement, students participated in su-
pervised reection with teachers from their universities. All students
had been given lectures about aging. At one of the universities, students
(n = 8) had been given a lecture on the natural signs that death is
imminent before their practiceplacement in nursing home.
13
5. Ethical considerations
The study received approval by department heads and the student
organisation, and received ethics approval by the Regional Ethics
Committee (Dnr 426-08, T999-11). All students were given verbal and
written information about the study and gave their written consent to
participate in the study.
6. Data collection
Data were collected by conducting individual semi structured inter-
views during the spring of 2012 by six of the authors (XX, YY, ZZ, XY, XZ
and YX). All interviews took place at the University where the student
was enrolled.
As there were several interviewees, an interview guide was devel-
oped comprising different themes, for example; students' perceptions
of death and caring for dying persons, and students' perceptions of
how health care professionals meet the needs of dying persons and
their relatives. These themes were developed following a review of
the literature (e.g. Mallory, 2003; Parry, 2011; Edo-Gual et al., 2014;
Gillan et al., 2014; Strang et al., 2014; Sampaio et al., 2015). The
interviews lasted between 25 and 45 min and were tape-recorded and
transcribed verbatim.
7. Analysis
As we followed a phenomenographic approach, the focus of the in-
terviews was on the students' perceptions of death, dying and caring
for dying people. The analysis was completed by following seven steps
described by Dahlgren and Fallsberg (1991). At rst the text was
read several times to get a feeling for the wholeness; a process of
familiarization to allow the researcher to become acquainted with the
text in detail. Secondly, the parts of the text that described perceptions
of death and caring for dying persons were marked, in a process of
condensation. The most signicant statement was selected from each
excerpt to give a short representative version. The selected excerpts
were then compared and revised in order to identify variation and sim-
ilarities, making a comparison. In the next phase, grouping, individual ex-
tracts were grouped together as a pool of meanings and interpreted.
Thereafter, the next phase comprised articulating, that is, preliminary
descriptions of the essential similarities within the different groups,
preliminary labels, were formulated. Finally, in the labelling phase, the
groups were named to make the most signicant content visible, and
categories describing students' perceptions of death and caring for
dying persons were formulated. The rst author (J) and the second au-
thor (CP) carried out the interview analysis. During the analysis, the au-
thors worked back and forth between the different steps to reach
agreement on the categories.
8. Rigour
A conscious effort was made to address rigour by being true to the
principles of phenomenographic inquiry (Sin, 2010). In addition, a full
description of the participants and of how data were collected has
been provided. Because there were several interviewers, an interview
guide was used. In order to enhancing rigour, the analysis was continu-
ously discussed with the rest of the research group throughout each
phase of the process. We have also provided a detailed description of
all steps in the research process.
9. Findings
The ndings are presented in ve categories which describe varia-
tions in the students' perceptions of caring for dying patients: 1) from
abstract to reality; 2) from scary to natural; 3) increased knowledge
can give bad conscience; 4) time limits versus fear of end-of-life
14 J. sterlind et al. / Nurse Education Today 41 (2016) 1216
conversations; and 5) meeting with relatives. Each category is
presented below.
9.1. From abstract to reality
Death was initially described as an object of study, an abstract thing
that became more real during the rst year of nursing school. The
students described that during their practice education they could be
present and follow the staff and see what a dead person looked like in
reality but also learn what the term death means.
I also believe that just to look at a dead body could help you to handle
what you see. There are not so many people who have seen a dead body
I think that it has been good. To prepare oneself for one's task, to see
that this is a dead person. This is how we look when we are dead.
[(ES8)]
Another student described a situation when a person who had died
had been washed and dressed after their death. The student described
this as an interesting and valuable learning experience because it was
the rst time that she had ever been confronted with death.
I had the opportunity to join the staff in a room where a person who had
died was made ready. This was really interesting since this was the rst
person I saw, who had died
[(ES2)]
Students who had been studying nursing for one year perceived
dying and the death as something interesting to study, but experienced
difculties in using the word death. Instead, they used other words as
metaphors, for example, his mother went home, or they referred to the
dead person as someone who doesn't exist anymore.
9.2. From scary to natural
The students perceived that their practical nursing education
promoted a sense of preparedness and gave them the opportunity to
practice how to meet and care for dying patients.The students described
death as a natural event.
Yes. I think so, it is a natural part, and it has become even more natural
now when one has worked and thought about it. It is in a way a part of
life. So it becomes less dramatic in a nice way, I think.
[(ES3)]
According to the students, their nursing knowledge provided them
with a theoretical basis and prepared them to meet dying people.
They no longer felt that encountering death was scary.
I believe, partly, I have learned so very much during the rst year,
medically speaking, and it feels quite good to have that as some kind
of basic knowledge.
[(ES6)]
Death was not seen as being as frightening as it was earlier; it could
be perceived as something good. It was something that relieved the
person from suffering from pain or other bothersome symptoms.
I have been prepared and have got a quite different picture of dying, that
it doesnt have to be as scary or it can be beautiful or something nice.
[(SAG1)]
After one year of education, the students' perceptions of caring for
the dying and encounters with death started to change. They now per-
ceived that death could be nice, peaceful and beautiful. This contrasted
with their earlier perceptions where death was perceived only as
frightening.
9.3. Increased knowledge can give bad conscience
Increased knowledge is the most often perceived as something good
among the students; however, sometimes increased knowledge could
give the students a bad conscience. They gave examples of situations
before they began the nursing programme about the care they had pro-
vided to people who were dying, for example, as carers working in
home care. They then lacked the knowledge they have currently, and
thought they should have done more for the dying person than they did.
Now it's tough to work in home care after everything during this year
[rst year in nursing school] has really etched because I do not want
to miss anything ... so now at work I really have feelings of deep regret
because I now feel that I haven't done enough, which is something one
shouldn't feel. I have done what is demanded of me, but I still feel that
I should have done much, much more.
[(ES 5)]
The students wished they had knowledge about death and caring
for dying people earlier so that they could have met the people's
needs in a more appropriate and sensitive way. Increased knowledge
has given them the opportunity and skills to reect upon their former
role as carers which could be an important learning opportunity for
the development of their skills for the future.
9.4. Time limits versus fear of end-of-life conversations
Being with a dying person and facing the person in a calm and ap-
propriate way was perceived as being important among the nursing
students.
Then you realize how important it is to meet the person in the right way.
If you, on the other hand, have seen it from the other side, you are even
more humble. I believe the task is to be there at the just moment, in a
way. Not to run, but to be calm and natural.
[(HIS1)]
At the same time the students perceived that it could be a dilemma
when they noticed a person seeking contact with them and they
thought or were told by the carers or supervisors that there was not
enough time to stay and talk.
Often there isn't enough time to stay and I have worked with someone in
the caring staff when we have entered the patient's room to change incon-
tinence pads and maybe make a bed or brush teeth, well At that time
that person has been seeking contact and wants to talk and initiate dis-
cussions. Some [carers] have just rushed away and it sometimes it has
happened that they have told the patient that there is no time for this.
[(HUS2)]
Balancing between the needs of different patients was a challenge,
and the perceived time allowed for conversations about difcult ques-
tions, such as existential questions, was described as being limited.
The students perceived that the staff blamed this on not having the
time to talk, but they also said that it could be caused by a fear of having
to meet people's existential needs.
A central perception among the students was that it was difcult to
talk with a dying person, a situation they had not earlier experienced.
They found that it was tougher to talk about existential questions with
the person than it was to talk about medical questions.
This about care, to speak with someone in this situation have I never
done, it would be a bit uncomfortable in the beginning, so I think I am
a bit less good on this just before the person has passed away. But then
the caring with talking, I believe, is difcult, this talking about medical
issues I believe is easier, but the part about caring could be difcult,
because you aren't used to it and you don't know what to say.
[(HES2)]
 J. sterlind et al. / Nurse Education Today 41 (2016) 1216
This not knowing what to say was one reason for the students' fears
when caring for a patient at the end-of-life. The students perceived
that they did not know how to answer to those questions and hoped
that the persons themselves could come up with the answers. Another
strategy was to ask questions in order to get the person him/herself to
talk about the situation.
Because I had no idea about what to answer. So I just thought, okay, it
might be easier if I ask a little more. Then maybe the person can nd
the answers by himself. I don't know, I have never died during my life
(laughter).
[(HIS2)]
The quote above indicates that humour was used as a way to cope
with conversations about dying and death. In all, the students' difcul-
ties were in knowing how to put the conversations into words to best
meet the person's questions, and it was argued that it was because
they had not been exposed to dying.
9.5. Meeting with the relatives
Meeting with the relatives was perceived as a major task and one
that was expected from them as future nurses. The nursing students
perceived that they had gained knowledge of how to talk to the relatives
in their rst experiences of practice education, but they also felt that the
task needed more preparation and practice exercises before they were
expected to perform these duties as student nurses.
The hardest thing for me is to handle issues with people near to the
patient. I think it is very difcult to handle their sorrow, how to become
what we call personal or private. I don't know how to get prepared for
this
[(ES7)]
. nities to do the good things one wants to (Juthberg et al., 2007). For ex-
Based on the students' perceptions, being better prepared for one of
the most central tasks in nursing is important because relatives seem to
see nurses as people with whom they can only discuss medical ques-
tions and not their own feelings. The students perceived that by actively
listening to what the relatives have to say and by being curious about
the medical aspects of death itself, they will have much to contribute
in such meetings with relatives.
I believe that as long as you listen to the persons and what they have to
say and have knowledge within your working area, and can reply to
their concerns and show that you care about what they say. Then to re-
ply depending of what they want to hear or need to hear. So I also be-
lieve that something you learn is to handle relatives who are angry or
sorrowful in connection with who they are standing near is very sick
or dying.
[(HES 2)]
To encounter the relatives, who are feeling vulnerable and threat-
ened, for example, the loss of a loved family member, was perceived
by the students as a demanding task.
10. Discussion
The ndings of this study show that caring for dying people is often
perceived as difcult. During their rst year of clinical practice the stu-
dents perceived themselves as spectators when faced with a dying per-
son they describe death as something abstract; something which, over
time, becomes more real. The students' perceptions changed from see-
ing the dying person as an object to seeing the person as an individual,
a living being with all that implies. This nding is similar to results
that emerged in Strang et al. (2014) study about emotionally demand-
ing issues concerning the care of dying persons. During the nursing
15
programme, the students gradually start to take a more active part in
the care of a dying person and describe it as the need to face death slow-
ly; that they need time to prepare themselves to both care for a dying
person and to care for the deceased by participating in the preparation
of the body. This nding is supported by Wallace et al. (2009), who
found that a common perception among nursing students is that to pro-
vide comfort and care is a primary task for nurses.
The students perceived themselves as spectators in nursing care; it is
difcult for them to talk about death and to use the word death in con-
versation with a dying person. Words other than death were often
used, for example fell asleep, kicked the bucket or went away.
This nding might mirror a western perspective of death and dying.
Death and dying are often silenced (sterlind et al., 2011) and held at
bay. Issues related to death, dying and caring for dying persons are sel-
dom addressed by professionals (Lloyd-Williams et al., 2007). In our
study, students felt afraid and did not know what to say to dying pa-
tients, ndings similar to those of Parry (2011), who found that students
felt unprepared and did not know what to say to patients and relatives.
One student described not being able to say anything and another felt
that they were only able to hold the patient's hand and listen (Parry,
2011). Dying people could therefore be left alone in silence at the end
of life (Whitaker, 2004; Dwyer, 2008). However, being able to know
when to be silent, holding hands and to listen to dying persons thoughts
is an art that needs practice. It is therefore an important part of student's
clinical education. Supervising nurses have a responsibility to guide and
encourage the nursing students in the development of their communi-
cation skills.
However, increased knowledge can also awaken feelings of having a
bad conscience among the nursing students. The lack of skills to care for
dying persons in an appropriate way before they began their studies in
the nursing programme is one example described in the study. Having a
bad conscience usually occurs when there is an imbalance between
what is perceived to be a good and acceptable thing to do and opportu-
ample, students who had worked as home helpers, without having
former clinical education, and who had previously cared for dying peo-
ple experienced bad conscience remembering how they had acted in
earlier encounters. Even if students have a desire for knowledge of
how to meet the dying people's needs in practice, theoretical knowl-
edge can prepare them for learning these skills without awareness of
this (Slj, 2000). Students need to be prepared both theoretically and
practically to encounter death, dying and to care for dying people. To-
gether with their own learning about dying and death, students can
be helped to not just see death as something frightening, but also to
see death as a natural part of life (Edo-Gual et al., 2014). From the inter-
views we could see a change in perceptions during the rst year of ed-
ucation. Now, death could also be seen as being beautiful (cf. Aris,
1981).
University faculty have little (or no) control over whether there are
dying patients for students to care for in the clinical environment. One
way to prepare students for caring for dying patients before their clinical
placements and for future clinical practice is by employing simulation
(Gillan et al., 2013). Providing clinical supervision with time for reec-
tion together with trained nurses, as well as supervised reection to-
gether with teachers from the university, could also be ways to
increase nursing students' preparedness for their forthcoming profes-
sion (Ek et al., 2014; Strang et al., 2014).
11. Limitations
There are some limitations that need to be considered. Data were
collected mainly from female students in their thirties (mean 31 years
old), from three universities, and it can be assumed that only those
with an interest in the subject area agreed to participate. We did not col-
lect data on culture or ethnicity which could decrease the generalizabil-
ity of the ndings. The ndings should therefore be interpreted with
16 J. sterlind et al. / Nurse Education Today 41 (2016) 1216
caution. On the other hand, the results do represent the perceptions of
participants from universities in three different geographic areas in
Sweden. The students were interviewed individually. While individual
interviews give in-depth responses to the topic, focus group discussions
might have provided even more variations of perceptions about caring
for the dying and perceptions of dying and death. Despite these limita-
tions, the results of this study do provide valuable insight about how
rst-year nursing students perceive how they learn about encountering
death and caring for the dying.
Because six authors conducted the interviews, this might be seen as
a limitation; however, the use of an interview-guide was used to reduce
this limitation. To enhance the rigour of the research, two authors
analysed the data and the ndings were continuously discussed with
the rest of the research group.
12. Future research
There is a need for future research to illuminate how perceptions
about death, dying and caring for dying people are developed during
undergraduate nursing education programmes. Perceptions of death,
dying and caring for dying people is a crucial part of all nursing. Further-
more, it would be of interest to examine how the topic, death and dying,
is delivered in programmes for nurses who are in specialist roles. There
is also a need for studies about supervisors in clinical practice settings in
order to gain their perspectives on how nursing students are supported
to care for dying people. For example, how do supervisors in clinical
practice support undergraduate nursing students? What kind of sup-
port do clinical supervisors need? There is a need to develop data collec-
tion methods including observations and to combine observations with
interviews in order to understand this area more clearly.
13. Conclusion
This study contributes to the development of nursing education by
illustrating that rst-year nursing students' perceptions of death and
caring for dying people are dynamic and change over time, provided
they are given appropriate support when they are confronted with
death and dying for the rst time. This understanding is valuable, both
for clinical nursing supervisors and for nursing teachers at university,
to encourage students to reect on issues, alone, together with other
students, and together with their clinical nursing supervisors in practice
and with their teachers at the university. There is a need for more stud-
ies and, ultimately, interventions that increase students' readiness, as
pre-registration nurses, to meet the support needs of dying persons
and their families. It is crucial for educators and practice supervisors to
think about how universities and practice settings can best prepare
nursing students for meeting death and dying in their forthcoming
work as nurses.
13.1. Conict of interest
There are no conicts of interest in this study.
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