Zhou et al.

BMC Nursing (2022) 21:74

https://doi.org/10.1186/s12912-022-00846-w

RESEARCH Open Access

A qualitative study of phenomenology

of perspectives of student nurses: experience
of death in clinical practice
ShiShuang Zhou1, LiZhen Wei2, Wei Hua3, XiaoChong He1* and Jia Chen2*

Abstract
Aim: To describe the experiences of student nurses in confronting the death of their patients, and to understand
how they cope with these events and to what extent there are unmet needs that can be addressed in their trainings.
Methods: Semi-structured interview method was used to collect data from Chinese nursing students and then
Colaizzi’s seven-step analysis method was applied to identify recurrent themes in their responses to patient deaths.
We listened the tape repeatedly combined with observations of their non-verbal behaviors, then transcribed them
with emotional resonance, and entered them into Nvivo. After that, we extracted repeated and significant statements
from the transcriptions, coded, then clustered codes into sub-themes and themes which were identified by the com-
paration with transcriptions and re-confirmation with our participants.
Results: After confirmation from the interviewees, five themes emerged: emotional experience, challenge, growth,
coping and support.
Keywords: Death experience, Death education, Nursing students, Qualitative analysis

Introduction the death of patients leads to compassion fatigue for

Death is a sensitive topic in the majority of cultures [1, 2]. nurses [3]. Additionally, when nurses actually experi-
Particularly in Chinese traditional culture, people regard ence patients’ deaths, some negative feelings including
death as taboo and ominous, and they usually avoid talk- guilt, depression, frustration, sadness, incompetence,
ing about it. However, death is an inevitable and natural helplessness and distress come over them [4–7]. Hiding
part of life. feelings and working continuously are common coping
Nurses take on a profound responsibility to look after strategies they choose, as they are worried that show-
dying patients in clinical settings. Moreover, with the ing their feelings may influence other’s perceptions of
increase in elderly populations in China, the need for their professionalism [4, 7]. These negative emotions can
medical care keeps growing. When providing this care, decrease the quality of care delivered and increase attri-
nurses have to face patients’ sudden or expected death. tion rates [7, 8]. Cevik and Kav have found that nurses’
Researchers have identified that excessive exposure to negative attitudes toward death are associated with lack
of education [9], and nurses also claim that they do not
have adequate training, support or preparation regarding
*Correspondence: [email protected]; [email protected]
1
to death [10, 11]. Becoming qualified nurses, sufficient
Department of Nursing Aministration, School of Nursing, Army Medical
University, Chongqing, China
training related to death and supports to deal with death
2
XiangYa Nursing School of Central South University, 172 TongZiPou Rd, are required [12, 13] .
Yuelu District, Changsha, Hunan 410000, China
Full list of author information is available at the end of the article

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Zhou et al. BMC Nursing (2022) 21:74 Page 2 of 11

Background analysts attempt to make sense of their own experience

Nursing students are being prepared for future nurs- and those of the research participants simultaneously.
ing careers. Some studies have shown that undergradu- This study adhered to the checklist of COREQ (Supple-
ate students should be prepared for accompanying death mentary File 1).
(Munoz-Pino, 2014). Before they become qualified
nurses, they need training in clinical practice settings
where they may encounter patients’ deaths. However, Sample
most nursing students’ attitudes toward death include Participants were recruited through purposive sam-
escape, death anxiety and fear as shown in previous pling from four primary hospitals of Hunan province
quantitative studies [14–16]. Students’ anxiety may come in China between 20 March 2019 and 15 May 2019. We
from their roles of caring [17], handling the dead body issued research recruitment notices via the Internet to
and lacking preparation [18]. To our knowledge, most the nursing students being trained in those hospitals. The
studies discuss nursing students’ feelings after patients’ inclusion criteria were: (1) Nursing students in clinical
deaths and in particular the first-time nurses encoun- practice or had just finished their practice a month ago.
ter a death experience in a patient [12, 15, 16], The first (2) Nursing students who had clear memories of their
experience may not be as memorable for some students experiences of patients’ death during their clinical prac-
as later experiences. Therefore, we decided to focus on tice. Participants who satisfied all inclusion criteria were
the experience of death that created the strongest memo- given information about this study including its purpose,
ries. These most memorable experiences will cause vivid method, and the promise of confidentiality. They had
memories and effects that persist. Our study will iden- right to choose whether to participate and drop out. The
tify nursing students’ the most memorable death experi- participants in this study had no prior relationships with
ence in clinical practice, with attention to the influence the researchers, as friends or in their training. The final
of this experience on their general outlook as nurses, the sample size was 19 nursing students (Table 1).
coping skills they employ to deal with such experiences,
and their unmet needs. We hope to provide information
Data collection
that will assist educational faculties and clinical teachers
A semi-structured interview method was used. An inter-
about how they can assist nursing students who experi-
view outline (Table 2) was based on literature review and
ence death in the clinic setting.
experts’ opinions. Any additional themes not included
in the initial outline, were added during the interview.
Methods Moreover, the participant’s answer to one question could
Aim be a guide to asking other questions. The main interviews
How nursing students remember and make sense of their were conducted with individual participants in quiet and
most memorable experiences of patients’ deaths, in par- undisturbed university psychological counseling rooms.
ticular those which have had great and persistent effects After obtaining permission agreements from nursing stu-
on them. dents, all interviews were audio record and the research-
ers made field-notes to describe the sounds, tones,
Design expressions and postures of the participants. Each inter-
Phenomenology both as an philosophy and research view lasted between 60 and 90 min. At the completion of
method is a valuable tool for researchers to under- 19 interviews the team established that no new informa-
stand the experience of people and “what” is hidden in tion was being introduced and we ceased data collection.
those experiences [19]. We conducted our qualitative
study using an interpretative phenomenological analysis
approach. This approach, which derives from phenome- Data analysis
nology and hermeneutics, combines psychological, inter- Data analysis was based on Colaizzi’s seven-step analysis
pretative and idiographic components. It has been widely method (Table 3) which has been shown to be rigorous
used in many areas, for example pedagogy, medicine, and and robust [23]. Colaizzi’s seven-step analysis method
psychology [20, 21]. Participants’ experiences, under- provides researchers with clear, logical and sequen-
standings, perceptions and views are the main interests tial steps [24, 25]. Our analysis included non-verbal
of this approach [22]. The interpretative phenomeno- responses recorded in field-notes to help the investiga-
logical analysis method needs the collaboration both of tors understand their verbal expression and the deeper
researchers and participants to understand the experi- meanings of their experiences. Above all, our analysis
ence, and it has been called a double hermeneutic as synthesized phenomenological description with our own
empathic interpretations.
Zhou et al. BMC Nursing (2022) 21:74 Page 3 of 11

Table 1 Characteristics of participants

N Education Age Sex Practice time Area of residence Religious faith Received
background (Month) palliative
courses

N1 A 18 Female 9 R No Yes
N2 B 22 Female 6 U No Yes
N3 B 20 Female 7 U No Yes
N4 A 19 Female 9 R No No
N5 B 21 Female 8 U No No
N6 A 19 Female 9 R No Yes
N7 A 18 Female 9 U No Yes
N8 A 20 Female 7 U No Yes
N9 B 21 Female 9 U No Yes
N10 B 21 Female 9 U Yes No
N11 B 22 Female 9 U No Yes
N12 B 18 Female 9 U No Yes
N13 B 18 Female 9 R No Yes
N14 B 20 Female 7 R No Yes
N15 B 21 Female 6 U No Yes
N16 B 21 Female 7 R No Yes
N17 B 23 Female 9 R No No
N18 B 20 Female 9 R No No
N19 B 21 Female 7 U No No
A:Junior College; B: Bachelor
R:Rural area; U:Urban area

Table 2 Interview guideline

Questions

1. What comes to your mind when you hear the word death of a patient?
2. Have you ever thought about patients’ death during your clinical practice? (If “yes”, ask their feelings and thoughts).
3. Tell me about your experience with the patient’s death.
4. Could you describe one of patients’ death scene that impressed you most?
5. What were your feelings at patients’ death time?
6. What were your feelings after a patients’ death?
7. Did you have any changes after experiencing patients’ death? (If “yes”, ask their changes in thoughts and daily life)
8. What did you do to cope the death experience?
9. What did you need after experiencing the most impressive patients’ death?
10. Do you think there is another question I should have asked and do you have a question for me?

Table 3 Colaizzi’s seven-step procedure of data analysis

Steps

1. Listen to the tape time and again and transcribe them into transcriptions, then read their words repeatedly combining with the non-verbal com-
munications till feelings resonate.
2. Extract Significant statements which are relevant to the death experience of nursing students from each transcript.
3. Formulate meanings from significant statements and code them. Codes should be approved by all researchers.
4. Cluster these codes.
5. Confirm findings and identify difference by comparing transcriptions and sub-themes, themes more than once.
6. Describe the theme and essence of nursing students’ experience by their own statements to insure the validity of study.
7. Return each transcript and result to participants to affirm the findings.
Zhou et al. BMC Nursing (2022) 21:74 Page 4 of 11

Rigor varied from the period in relation to time of death. These

All researchers had learned about qualitative research included anticipatory imaging of patients’ deaths, wit-
methods and interview techniques and had interview nessing death and dealing with the aftermath of witness-
experience. The interview outline was approved by three ing a patient’s death.
experts, including a professional psychologist, a nursing
teacher who briefs student nurses about death experi- Anticipations of experiencing patients’ deaths
ences, and a clinical nursing teacher. In order to collect before entering clinical practice
comprehensive data, another interviewer observed the We asked how they felt when, prior to clinical practice,
interviewees’ expressions and asked supplementary ques- they imagined patients’ deaths. Some students had never
tions to confirm the feelings evoked during the telling of thought of death before, and therefore had not prepared
their experiences with death and views appropriately. for a death experience.. Several students expressed taboo
Following to the seventh procedure of Colaizzi’s anal- and fear, with no confidence about how to deal with
ysis method, we sent participants transcripts for their death. Only one student thought death as an natural
comments and suggestions. In data coding stage, two event. In the culture of China, people rarely use words
researchers coded independently to ensure consistency. related to death and dying in normal discourse. For many
If there were any differences, the third researcher would Chinese, discussing death is regarded as taboo. Nursing
determine the final coding. We interviewed the partici- students in China will learn postmortem care in basis
pants and analysed the data using their mother language, nursing courses, but that subject takes less than 45 min
Chinese. In reporting the results, nursing students’ words class time. It was understandable that most nursing stu-
were translated into English and The Revised Standards dents have these reactions when asked to imagine a
for Quality Improvement Reporting Excellence (SQUIRE patients’ death.
2.0) (Supplementary File 1) were applied. We confirmed
that all methods were carried out in accordance with rel- “In my family, we never talk about death, it is
evant guidelines and regulations. taboo”---N2

“I can’t understand Postmortem Care. Traditionally,

Ethic
death is not such a good thing .”----N13
This qualitative study was found to be of minimal risk
and was approved by Institutional Review Board (IRB)
“ I felt terrible when imaging that I would face death
with IRB Approval Number: 2019020. As death is a dis-
patients before entering clinical practice, ”---N19
tressing topic for the participants, the interview would be
stopped if we found interviewees with uncontrolled and
“I think that I can’t cope with it, I can escape it, I
disturbing emotional responses. One of interviewers is
don’t want to encounter it, and it will make people
a professional psychological consultant who could offer
feel uncomfortable.”---N2
supports to the participants. We left contact informa-
tion for a professional psychological team to support the
interviewees who needed help after the interview. “I think it is normal for a person to be born, grow
up and die; sickness and death, it’s a nature thing.
So I will feel ok if I face death patients in clinical
Results practice” ----N1
Data saturation was reached after interviewing 19 interns
whose information can be seen in Table 1. Their mean
age was 20 years with a range from 18 to 24 and most of Feelings witnessing a patient’s death
them (n = 13) had taken courses related to palliative care. A majority of students were frightened and helpless. Stu-
Eventually, five themes and thirteen sub-themes were dents voiced curiosity about how a dead body changes
emerged (Table 4) with the guide of Colaizzi’ analysis physically, but they were startled when they saw it. Nurs-
method. The emerged themes included: (1) emotional ing students’ feelings varied by age of a patients’ death
experience, (2) challenge, (3) growth, (4) coping, and (5) and their relationship with the deceased. For younger the
support. patients, they expressed strong feelings of pity. When they
experienced the failure of an attempt to save a patient’s
Emotional experience life, they felt helpless or expressed regret. As nursing
The focus of this project was on nursing students’ students, they also had curiosity about the changes that
the most memorable experience with the death of a occur after death and wanted to confirm the knowledge
patient and we found that the content of their feelings they got in class. Even students who had never cared for
the patient felt scared or startles when just saw the body.
Zhou et al. BMC Nursing (2022) 21:74 Page 5 of 11

Table 4 Themes and sub-themes of the most impressive death experience among nursing students
Themes Sub-themes Details

1. Emotional experience Anticipations of experiencing patients’ deaths before entering Taboo

clinical practice Fear
Unprepared
Natural
Acceptance
Feelings witnessing a patient’s death Scared
Curious
Startle
Regretted
Helpless
Feelings after patient death Dread
Guilty
Sadness
Pity
Upset
Worry
2. Challenge Cognition Blind denial
Obsessive thinking
Somatization Poor appetite
Sleeplessness
Visual illusion
Habit Irregular of diet
Refuse to meat
Profession Empathy fatigue
Emotion contagion
Knowledge gap
3. Growth Personal growth Attention of health
Awareness of cherish
Professional growth Life responsibility
Professional identity
4. Coping Exploratory method Sharing with trust one
Writing down
Avoidant method Do not remind death experience
Transformation to other things
Avoidance
5. Support Clinical teachers Give ear to students
Provide experience relating to death
Provide positive coping methods
Education Knowledge about death
Skills to deal with death

When they had taken care of that patient, they experi- “I was just curious to know whether the state of
enced sadness and difficulty to say goodbye, as intimacy death was similar to what we had learned. So I went
had developed between nursing students and patients. to touch his hand. I was also very startled. His eyes
were not closed...”---N11
He was just a baby that he had not yet enjoyed the
beauty of the world, I want to take one last look at
“When I witnessed a patient struggling, I could do
him.---N07
nothing but stand by and watch, which made me feel
so helpless. ”---N12
I felt nothing but...Umm...sort of pitiful because he
was such a young man, only 27 years old! ”---N16
“The patient didn’t come back, he should have been
able to come back, and I felt very guilty that I didn’t
I saw a man lying there with a piece of cloth on his
do a good job”---N4 (A student has done cardiopul-
back even though I was just going to pick something
monary resuscitation for the patient)
up next to him, but I was really scared because that
was really scary.”----N16
Zhou et al. BMC Nursing (2022) 21:74 Page 6 of 11

Feelings after patients’ death Somatization

The nursing students’ feeling of fear towards death was Mental experiences and states may become somatic
constant from the moment of a patient’s death to a symptoms. Students negative responses included poor
period that depended on the circumstances of death. appetite, sleeplessness and visual illusion. These somati-
Even though a patient’s body had been moved to another zation symptoms lasted about 1 week.
location, the place of death could be dreaded long after- Some students said that they could see the dead
wards. After observing that poorer patients gave up their patients’ soul in the enclosed space. Different theories
treatments due to high medical costs, some nursing stu- of death may help to interpret their responses. Monism
dents keenly felt the unfairness that some should die for reckons that human beings are material, while the dual-
lack of money while others with more resources could ism believes that human beings are composed of soul and
live. Patients’ deaths also trigger nursing students’ worry body, and that the soul can continue to survive after the
toward their family members. death of human beings. Those who are in favor of dualism
believe that the soul is released from the body after death
“I was afraid to go to that ward alone every time
and can roam more freely. Individuals’ opinion toward
I was on night duty. That thing really made me
death was affected by traditional culture. For example,
feel dread”(said with eyes changed more bigger)
in China, we have Chinese Memorial Day to go to the
---N11
departed loved ones’ grave to remember them. Perhaps
the nursing students who had visual illusion for death
“I just thought it unfair, someone can have chance to
patients believed the soul of dead patients still alive.
survive but he just can’t! His life cannot be decided
by himself ”---N8 “... I lost my appetites.”---N11

“ And now, I sometimes worry that, what if my fam- “I was exhausted, but I couldn’t fall asleep.”---N17
ily or lover leaves? What shall I do? Where shall I
go?---N15 “Sometimes, I can see the dead patients’ soul espe-
cially in enclosed space such as in an elevator”.---N4
Challenge
The memorable death experience not only affects nursing Changes of habits
students’ emotional experience but also other aspects of When a person has emotional and cognitive changes
nurses’ lives, including cognition, somatizations, habits or even physical symptoms, his lifestyle may change, at
and profession. We identified these subjects as a theme least temporarily. Some nursing students said their liv-
called challenge. ing habits were changed by the experience of patients’
deaths. For example, their diet became irregular or they
Cognition refused to eat meat. The deceased undergo physical decay
The patients’ death was obsessively in mind for some after death when the temperature and the color of skin
nursing students who would constantly recall the death. changes. So the dead body would look just like meat in
Thoughts questioning their capacity to handle future supermarket and it is understandable that some nursing
professional work were occurring in nursing students’ students had such reactions toward pork.
minds. Nursing students felt helpless when experiencing
patients’ deaths and lacked the confidence to deal with “These days I cannot eat and sleep as usual”---N11
such deaths in the future.
“I couldn’t have meat for a long time. And I even felt
“After experiencing such a thing, I feel that I have scared when fresh meat came in sight.”---N6
no ability. I am afraid that I will work alone in the
future and I don’t know how to do it.”---N12
Profession
“I usually forgot my meals, lying in my bed, ignoring Nursing students’ said that their emotion was strongly
my roommates calling me for lunch, with my mind affected by the family members of the deceased. This
going blank except for the patient’s death”---N1 can be called emotional contagion which is an psy-
chological phenomenon where people “catch” feelings
“...with the patient’s death always reflecting in my from one another like they would a cold. Because of
mind”---N17 “emotional contagion”, nursing students catch the
emotions of the crying family members easily, which
Zhou et al. BMC Nursing (2022) 21:74 Page 7 of 11

may impact their work performance and even daily Professional growth
life. However, a number of students indicated a fear Students’ death experiences promoted the sense of
of empathy fatigue over the long term after repeatedly responsibility for patients’ lives. The feeling of being
experiencing patient deaths. Furthermore, as voiced by entrusted with patients’s lives, increased their sense of
our interviewees, there are difficulties in transforming professional identity as nurses.
theory into practice, which is a challenge for nursing
“Responsibilities are crowding in on my mind; I think
educators.
it my duty to help and save struggling lives, which is
“I can’t control my emotions...I was deeply affected part of my job.”---N9
by them [death patients’ family members], then cried
with them together .”---N10 “I think actually, as a nurse, I could do many things
for dying patients, even though just little things such
“We will face patients’ death all the time as medi- as touching them or talking with them.” --- N18
cal workers. We can’t save everyone. Firstly it makes
me depressed, as for long term, when I experienced
Coping
much, I am afraid that I will be indifferent and
After experiencing patients’ death, nursing students
numb.”---N9
talked about some methods they used to cope their feel-
ings. There were two kinds of methods nursing students
“Having experienced these losses, I found out that
used, one was an exploratory coping method, other one
what I have learned from books cannot be applied
was an avoidant coping method.
correctly to the clinical circumstances, where you
face things that are much more complicated than
Exploratory coping method
the example learned from textbooks.”---N7
Most students expressed their sadness, fear, and anxi-
ety after experiencing the incident. Sharing with trusted
Growth people and writing down their experiences acted as
Growth refers to nursing students having positive an exploratory coping method alleviate these negative
responses and learning from the most memorable expe- feelings.
rience of encountering death. This theme had two sub-
“Of course, I’m afraid and worried. But I have to
themes, personal and professional growth.
face it. Sometimes, I will talk to my friends and fam-
ily about it, which helps me relax.”---N9
Personal growth
Several respondents reported changes in attitudes toward
“...write something down to record.”---N7
death. The passing of other individuals’ lives would make
people think more about life. The death experience pro-
moted nursing students’ growth in the aspects of life and Avoidant coping method
existence. Some students begun to devote more attention Contrary to exploratory coping method, avoidant cop-
to improving their health and had an greater awareness ing methods means that a person does not want to be
of the preciousness of life. reminded stressful incidents. Some avoided contact with
the dying patients and clinical situations where patients’
“Maybe these things taught me that, to be or not to
death had happened or was expected to occur. When the
be, that is not a question, instead, that is a truth that
inpatients related to this situation were in the need, the
death has already been settled by nature.”---N16
nursing students would be hesitating and fearful which
may affect their job performance.
“After so many patients’ leaving, I found that being
alive had even greater value”---N15 “Actually, I don’t share it with others or remind it,
because I don’t think it is necessary. And it’s not such
“You have no idea what is waiting for you when wak- a good thing.”---N18
ing up tomorrow, death or sunrise? Life is valued the
most.”---N6 “ I dare not go to that room but I must; so I immedi-
ately run out of the room.”---N11
“Tell yourself to cherish life. Then, health is the most
important thing, and more importantly, we should “I avoided to go to the place where death
cherish the time with family and friends.”---N7 happened.”--N6
Zhou et al. BMC Nursing (2022) 21:74 Page 8 of 11

Support entering clinical work. Actually, the emotional experi-

Nursing students claimed a unmet need for support ence of nursing students who experienced memorable
and put forward some suggestions for education. patients’ death varies with the context of the event.
Hard feelings such as fear, being startled, feeling help-
Clinical teachers less, and overwhelmed by sadness were almost always
The students claimed that they hoped their tutors expressed by student participants in our study. These
would listen to them and tell them some practical, feelings often occurred in situations where a patient
emotional experiences and some positive coping meth- suddenly and unexpectedly fell ill before death. These
ods, particularly when they were depressed after expe- feelings are consistent with earlier researches report-
riencing patients’ death. As for the authors, when we ing that negative feelings for death were common when
were students experienced patients’ death, we were also facing a patient’s painful suffering [16, 26], Huang et al.
eager for the help of our teachers, maybe just a comfort 2010). These emotions occur when nursing students
word. experienced patients’ deaths reported and while caring
for dying patients [1]. The better relationship between
“At that time, I was in a low mood. I didn’t have nursing students and patients, the stronger negative
any desire to do anything. I just wanted the clinical emotions after patients’ death. Moreover, the age of the
teacher to listen to our interns’ voices and comfort death patient also influences nursing students. Pity and
them.”---N4 awareness of cherished aspects of life often accompa-
nies the death of young patients. When nursing stu-
“I just hope I can hear the instructors tell us how dents did something in the process of death rescue, they
their experiences in those years helped them adjust would deeply experience feelings of guilt after patients’
to this process.”---N15 death because they thought it was their bad perfor-
mance that led to patients’ death. If students just stood
“I hope the teachers can say some positive words by, they would also feel guilty as well as helpless. In our
instead of saying that they are used to numbness study, the main feeling expressed frequently at all three
because have more experience.”---N9 time points was fear, an important emotion in other
studies [26]. Nursing students in Western or other
Education
Asian countries with different cultures would also have
Students called for specific training. For example, “I negative emotions toward patients’ death. Researchers
think schools or hospitals should arrange some courses have confirmed that these negative emotions will affect
for life and death education to teach us how to deal bet- nursing practice, attitudes towards death and dying
ter with death incidents during internship and even [17], and even their professional identity [8, 13, 15]. The
later work.”---N16. the future. main reasons of bad emotional experiences reported by
our interviewees were lack of death-related skills and
knowledge.
Discussion
In addition to emotions, students also had challenges
The results of this study showed that the most memo-
regarding to cognitive, somatic, behavioral and profes-
rable experience of a patients’ death has affected intern
sional aspects. Taboos about death, lack of confidence in
students in several ways, including both emotional and
their ability to handle death and obsessive thinking death
behavioral adjustments. First of all, emotional expe-
experience made students choose to avoid contacting
rience of patients’ death in our study were associated
death and postmortem care. Students had somatizations
with three periods: imagining patients’ death before-
after experiencing patients’ death which directly influ-
hand, at the point of death, and after patients’ death.
enced their daily life and habits. Empathy fatigue, emo-
Unlike previous studies which focus on the feelings
tion contagion and gaps between practice and knowledge
just after patients’ death, we identified the temporal
were also mentioned by nursing students. These chal-
aspects of that experience. While [8] (Liu and Su, 2011;
lenges suggest that it is necessary for educators to help
Anderson et al., 2015). Three time points could help
nursing students resolve the difficulties caused by the
educators understand nursing students’ feelings toward
memorable experience of patients’ death .
death more deeply. As the topic of death in Chinese
Our results also found that nursing students’ death
culture is surrounded by taboo, Chinese find it difficult
experiences were opportunities both for professional
to talk about death with each other. Nursing students
and personal growth. Unoz-Pino (2014) points out that
feel that taboo and the fear that goes with the taboo,
encountering death is a significant experience for stu-
and feel unprepared to imagine patients’ death before
dents to understand life and death. Indeed, in this study,
Zhou et al. BMC Nursing (2022) 21:74 Page 9 of 11

death acted as stimuli to nursing students who would Kong, which provides a safe environment and lets nurses
take on difficult experience, give meaning it, and then discuss and share feelings and information towards death
achieve growth [17, 18]. Their personal growth was evi- has been proved as an effective teaching strategy [31].
denced by change of awareness towards health and the Death Issues Workshop offered for registered nurses in
value of life. If students are guided appropriately, death Australia during their first year of practice greatly reduces
experience could motivate their responsibility of life and death anxiety and increases coping skills in caring for
further improve their career identity. Similarly, previous themselves and their colleagues [32]. A death education
studies also provide evidence that encountering death of course of 20 credit hours based on dealing with a sudden
a patient can be rewarding [17]. patient death conducted in China could help emergency
When focusing on nursing students’ coping after expe- nurses’ cope with sudden death with effective behaviors
riencing death, we found two diverse coping methods. [33]. However, in China the death education is still at the
Exploratory methods can be seen as a positive way to deal theoretical level. Such education should be focused on the
with stress incidents [1]. Some students tended to share known vulnerabilities and needs of nurses and on proven
their experience with others to alleviate negative emo- ways of handling death in clinical practice. Nurse educa-
tions. We also noticed that those students (N6/N11) who tors should increase the awareness of death education,
applied avoidant methods after experiencing patients’ pay attention to death education for nursing students in
death were more likely to have difficulties in emotion and clinical practice and satisfy students’ unmet needs.
physical symptoms. According to Edo-Gual et al. teach-
ing nursing students how to manage their emotions is
beneficial for them to deal with death in the future [13]. Limitations
This study also highlighted nursing students’ great All our participants were female, although we tried to
demands for supports to cope with the memorable find male nursing students to take part in our study, so
death experience in clinical settings. However, educa- our results cannot represent male students. Through
tors in clinical settings have not realized the transforma- exploring nursing students’ memorable experience of
tional importance of their supports for nursing students death, we detected several themes including growth and
[27]. Students reported that teachers told them how to coping, but could not identify the determinants of vari-
comfort patients in courses, but there was insufficient ations in those experiences. Future research should try
attention to the knowledge and skills need to adjust to identify the personal and situational factors that influ-
themselves to patient deaths. They expected their clini- ence the nature of death experience.
cal teachers to listen to them and provide experiences
relating to death and coping methods. Nursing educators
played an important role in helping students pull through Conclusions
challenges caused by memorable patients’ death experi- Nursing students have negative emotions towards
ence and promoting their growth. Similarly, previous patients’ deaths. Moreover, this inevitable experience cre-
studies evidenced that supports from clinical staff help to ates challenges for them in terms of irrational cognition,
develop the ability of nursing students to deal with death somatization, bad habits and professional crisis. How-
[13, 28], and improve students’ professional growth [29, ever, these challenges can be faced with clinical teachers’
30]. Paying more attention to death education in clinical supports. Memorable death experiences are meaningful
settings could be an ideal way to improve students’ skills for nursing students as they encourage them to cherish
and attitudes [28]. life more and get a sense of professional identity. The
Currently, Chinese nursing schools do not have spe- unmet needs emerged from students’ perspectives are
cific death courses, but only cover postmortem care as associated with the lack of supports from clinical tutors
a part of basic nursing or palliative courses. We found and shortage of death knowledge and skills. Indeed the
that the nursing students who had not received palliative education related to death is where the nursing profes-
were more likely to have negative feelings and challenges. sion in China needs to focus in the future. If educators
However, most participants attending palliative courses can tailor effective supports and death education, these
before also had negative emotions, challenges, avoidant challenges can be addressed effectively.
coping methods and need for supports which has also
been reported in earlier studies [31]. This indicates that Supplementary Information
the palliative courses cannot replace the death educa- The online version contains supplementary material available at https://​doi.​
tion. Many researchers all over the world have aimed at org/​10.​1186/​s12912-​022-​00846-w.
exploring the death education method. A death education
Additional file 1.
course named Problem-based learning (PBL) in Hong
Zhou et al. BMC Nursing (2022) 21:74 Page 10 of 11

Acknowledgements 9. Cevik B, Kav S. Attitudes and experiences of nurses toward

We appreciate the nursing students who participated in our study, as they death and caring for dying patients in Turkey. Cancer Nurs.
were willing to share the most impressive experiences of patients’ deaths and 2013;36:E58–65.
kept on ensuring our sub-themes and themes. Moreover, we are grateful for 10. Shaulov A, Baddarni K, Cherny N, Shaham D, Shvartzman P, Tellem R,
Professor James A. Wiley (PhD Professor, Institute for Health Policy Studies, et al. "Death is inevitable - a bad death is not" report from an interna-
School of Medicine, University of California, San Francisco.) who had contrib- tional workshop. Isr J Health Policy Res. 2019;8(1):79.
uted lots in editing and polishing this paper to be better. 11. Costello J. The majority of nurses first experience death in or before
their first year of practice, and the experience can provoke feel-
Authors’ contributions ings of helplessness, guilt and ongoing distress. Evid Based Nurs.
Guide and contributions to the conception: J,C; XC,H. Study design: SS,Z; LZ,W; Data 2013;16:91–2.
collection: SS,Z; LZ,W; W,H; Data analysis: SS,Z; LZ,W; W,H; Manuscript writing: SS,Z; 12. Liu YC, Su PY. Nurses’ early experiences with patient death: the results
LZ,W; XC,H. Draft the work and substantively revise: J,C; SS,Z. We confirm that all of an on-line survey of registered nurses in New Zealand. Int J Nurs
authors have read and approved the manuscript, and ensure that this is the case. Stud. 2012;49:1255–65.
13. Ek K, Westin L, Prahl C, Osterlind J, Strang S, Bergh I, et al. Death and
Funding caring for dying patients: exploring first-year nursing students’ descrip-
None. tive experiences. Int J Palliat Nurs. 2014;20:509–15.
14. Edo-Gual M, Tomas-Sabado J, Aradilla-Herrero A. Fear of death among
Availability of data and materials nursing students. Enferm Clin. 2011;21:129–35.
The datasets generated and/or analysed during the current study are not 15. Edo-Gual M, Tomás-Sábado J, Bardallo-Porras D, Monforte-Royo C. The
publicly available due this study need to be continued but are available from impact of death and dying on nursing students: an explanatory model.
the corresponding author on reasonable request. J Clin Nurs. 2014;23:3501–12.
16. Edo-Gual M, Monforte-Royo C, Aradilla-Herrero A, Tomas-Sabado
J. Death attitudes and positive coping in Spanish nursing under-
Declarations graduates: a cross-sectional and correlational study. J Clin Nurs.
2015;24:2429–38.
Ethics approval and consent to participate 17. Zahran Z, Hamdan KM, Hamdan-Mansour AM, Allari RS, Alzayyat AA,
Informed consent was got from every participants. The ethic of this study is Shaheen AM. Nursing students’ attitudes towards death and caring for
approved by IRB of behavioral and nursing research in School of Nursing in dying patients. Nurs Open. 2022;9(1):614–23.
CSU, IRB approval number:2019020. 18. Garrino L, Contratto C, Massariello P, Dimonte V. Caring for dying
patient and their families: the lived experiences of nursing students in
Consent for publication Italy. J Palliat Care. 2017;32(3–4):127–33.
NA. 19. Matua GA, Van Der Wal DM. Differentiating between descriptive and
interpretive phenomenological research approaches. Nurse Res.
Competing interests 2015;22(6):22–7.
The authors declare that there is no conflict of interest that could be per- 20. Larsson V, Holmbom-Larsen A, Torisson G, Strandberg EL, Londos E.
ceived as prejudicing the impartiality of the research reported. Living with dementia with Lewy bodies: an interpretative phenomeno-
logical analysis. BMJ Open. 2019;9(1):e24983.
Author details 21. Wawrziczny E, Corrairie A, Antoine P. Relapsing-remitting multiple scle-
1
Department of Nursing Aministration, School of Nursing, Army Medical rosis: an interpretative phenomenological analysis of dyadic dynamics.
University, Chongqing, China. 2 XiangYa Nursing School of Central South Disabil Rehabil. 2021;43(1):76–84.
University, 172 TongZiPou Rd, Yuelu District, Changsha, Hunan 410000, China. 22. Quaroni L, Zlateva T. Infrared imaging of small molecules in living cells:
3
JiangNing Hospital, Nanjing, China. from in vitro metabolic analysis to cytopathology. Faraday Discuss.
2016;187:259–71.
Received: 28 August 2021 Accepted: 14 March 2022 23. Colaizzi R. Psychological research as the phenomenologist views it.
In: Existential-phenomenological Alterna-tives for psychology (Vale R
KingM, eds). New York, NY: Oxford University Press; 1978. p. 48–71.
24. Wirihana L, Welch A, Williamson M, et al. Using Colaizzi’s method of
data analysis to explore the experiences of nurse academics teaching
References on satellite campuses. Nurse Res. 2018;25(4):30–4.
1. Mastroianni C, Marchetti A, D’Angelo D, Artico M, Giannarelli D, Magna E, 25. Kwang-Ok P, SungHee P, Mi Y. Physicians’ experience of communication
et al. Italian nursing students’ attitudes towards care of the dying patient: with nurses related to patient safety: a phenomenological study using
a multi-center descriptive study. Nurse Educ Today. 2021;104:104991. the Colaizzi method. Asian Nurs Res. 2018;12(3):166–74.
2. Tasmeera S, Akhtar T, Afaq M. Does intensity of stimulus and culture 26. Marti-Garcia C, Ruiz-Martin L, Fernandez-Alcantara M, Montoya-Juarez
matter in death anxiety? Psych J. 2020;9(6):885–93. R, Hueso-Montoro C, Garcia-Caro MP. Content analysis of the effects of
3. Tornoe KA, Danbolt LJ, Kvigne K, Sorlie V. The challenge of consolation: palliative care learning on the perception by nursing students of dying
nurses’ experiences with spiritual and existential care for the dying-a and dignified death. Nurse Educ Today. 2020;88:104388.
phenomenological hermeneutical study. BMC Nurs. 2015;14:62. 27. Munoz-Pino IP. Experience of nursing students upon their first
4. Yi MJ, Lee JS. Nurses’ experiences of the death of patients in geriatric care encounter with terminally ill patients. Invest Educ Enferm.
hospitals. J Korean Acad Nurs. 2015;45:513–22. 2014;32:87–96.
5. Hinderer KA. Reactions to patient death: the lived experience of critical 28. Chua J, Shorey S. Effectiveness of end-of-life educational interventions
care nurses. Dimens Crit Care Nurs. 2012;31:252–9. at improving nurses and nursing students’ attitude toward death and
6. Kuhn T, Lazzari DD, Jung W. Experiences and feelings of nurs- care of dying patients: a systematic review and meta-analysis. Nurse
ing professionals in caring of the dead patient. Rev Bras Enferm. Educ Today. 2021;101:104892.
2011;64:1075–81. 29. Mpotos N, Decaluwe K, Belleghem VV. Automated testing combined
7. Chen FH, Hu WY. The impact of perinatal death on nurses and their with automated retraining to improve CPR skill level in emergency
coping strategies. Hu Li Za Zhi. 2013;60:87–91. nurses [J]. Nurse Educ Pract. 2015;15(3):212–7.
8. Anderson., K., Owens. Experiencing patient death in clinical practice: 30. Zhang WH, Li BH, Tong SM. Study on influencing factors of professional
nurses’ recollections of their earliest memorable patient death. Int J identity of nursing students at different internship stages. Chin Nurs
Nurs Stud. 2015;52:695–704. Educ. 2017;14(08):615–8.
Zhou et al. BMC Nursing (2022) 21:74 Page 11 of 11

31. Mok E, Lee WM, Wong FK. The issue of death and dying: employing
problem-based learning in nursing education. Nurse Educ Today.
2002;22(4):319–29.
32. Peterson JL, Johnson MA, Scherr C, Halvorsen B. Is the classroom
experience enough? Nurses’ feelings about their death and dying
education. J Commun Health Care. 2013;6:100–5.
33. Zhang H, Hu M, Zeng L, Ma M, Li L. Impact of death education courses on
emergency nurses’ perception of effective behavioral responses in deal-
ing with sudden death in China: a quasi-experimental study. Nurse Educ
Today. 2020;85:104264.

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