The two themes on perceptions of students identified in this study were described as devastating and frightening reactions that contribute to negative consequences in the care of dying patients, especially during first-time encounters. This could be attributed to the limited clinical, physical, mental psychological, and emotional preparation of the student nurses before exposure to the physical process of care of dying patients. This result is similar to another study that documented that caring for dying patients is a notable stressor for nursing students during clinical practice [18].
In this study, inadequate preparation could have influenced their understanding of the physical process as either hard or torturous experience as expressed by students in this study which later undermines its relevance or positive contribution as a learning opportunity. Studies have documented that there is inadequate provision of end-of-life education to nurses and limited exposure of student nurses to end-of-life care, even though early training could significantly prepare them for their future roles across various nursing units [9].
This concurs with a study done in Sweden that showed registered nurses struggled with understanding of palliative care and transfer of knowledge into clinical practice [19].As noted in another study Nursing students need to comprehend how to handle a patient's death, providing compassionate support to the patient's family, friends, and loved ones as they grapple with death and psychological trauma [11] since they tend to spend more time at the bedside with patients than other healthcare professionals.
However, the exposure of students to the physical process of care is clearly described as important in this study to build confidence and improve knowledge and skills. This is similar to study finding from Australia that showed the relevance of exposure of students to clinical environments and interpersonal encounters that evoke strong emotions. Such environments are good learning strategies and formal support approaches to knowledge development and emotion management which foster professional development and patient care [20].
Exposure of nursing students to care of dying patients therefore could have positive implications on professional progress among health workers which could also be attributed to knowledge exchange and transfer through interactions with senior health workers on wards of dying patients. This finding concurs with a study done in Switzerland in 2020 that showed professional skills improvement among nursing students exposed to caring for terminally ill patients [21].
Additionally, the understanding of the physical process of care and learning gains in such clinical placements seem to be linked to the personal values such as respect and trust. For instance; some participants with positive personal values who feel respected and trusted to care for the dying patient could employ more efforts and lessons learnt than their counterparts who feel un trusted and devalued. A meta-analysis done in 2016 showed that a comfortable and dignified death is important and dependent on the values of nurses in relation to respect for privacy, respect, spiritual peace, and hope [22]. Also, the findings concur with other studies that emphasize the impact of religious beliefs and faith on attitudes toward death and dying patients whereby Faith in God and the afterlife is often associated with a more favorable stance on death and dying, held by nurses, physicians, and the general populace [23].
Therefore, it is important to also consider to understand personal values of nurses and honor them to support nurses during clinical placement and assignments to care for the dying patients.
In this study, there was a notable shift in ideas about the survival of dying patients, the need for end-of-life care and the relevance of the clinical placement. The results are similar to findings in another study that showed even though nursing students often feared dealing with dying patients, concentrated training and palliative care simulations help students shift their attitudes and beliefs and improve the care they give [24].
In this study, the student nurses seemed to come to terms with the reality of death after the clinical placement unlike before when they seemed to live in denial of the fact of death. This result concurs with a study by [25] that recommended combining the students' academic grasp of palliative care with their practical encounters with death and dying people can be instrumental in assisting the student come to terms with the reality that dying and death is a natural part of life rather than something terrifying.
Findings in this study showed that student nurses recognized and valued the need for end-of-life care after the clinical placement. This concurs with findings in another study done from the Seattle-Tacoma area that showed nurses perceived that patients and families wanted their hopes to be supported at the end of life and often provided this support independent of interactions with physicians [26].
The nursing students in this study finally acknowledged the importance of the clinical placement for their skills improvement. This finding concurs with other studies that have documented consistent satisfaction in clinical placement experiences from student perspectives across semesters and years and significant learning of students in the areas of basic clinical skills ,clinical documentation, and collaborative care [27].
Studies have documented that Exposure to positive experiences in the care of end of life in a clinical setting yields expected learning outcomes for undergraduate nursing education while negative emotions decrease the quality of care delivered and increase attrition rates [11].
Student attitudes towards dying patients
In this study, nursing students displayed a compassionate attitude which steered them to act as informants for dying patients and cooperate with their relatives. In this study, the factors influencing student attitudes were not explored but some studies have shown that educational programs about death and caring for dying patients improved students’ attitude [16] and age, earlier care experience, experiences of meeting a dying person, and place of birth affect students' attitudes toward the end of life care [28].
In this study, the nursing students seemed to have developed empathic relationships with patients and relatives after frequent interaction with them which could have contributed to their resilience as described by continuation to care even after knowing the outcome of the patient. This is because the nursing students regarded themselves as resourceful persons, who were driven by empathy to relieve the patient of the great pain, and valued the responsibility of care of a patient for the sake of relatives. Empathic relationships between patient and nurse are likely to happen over time due to specific patient needs, nurses’ functions, attributes, and the patient’s reciprocity.
Additionally, the student nurses’ aspiration to provide comfort to end of life and spiritual beliefs could have influenced the empathic relationships displayed in this study. Studies have shown that nurses tend to continue to do their ‘utmost’ work to facilitate a dignified death by focusing on the patient’s comfort and supporting families, despite the complexities and emotional distress they encounter during the end of life care and religious beliefs influence nurses’ commitment and continuation of care[29].
Studies have shown that nurses who develop trusting relationships demonstrate a holistic approach to caring, show their understanding of patients’ suffering, are aware of their unvoiced needs, provide comfort without actually being asked, and are reliable, proficient, competent, and dedicated in their care[30]. Similar to other studies, the nursing students in this study were a source of comforting information to dying patients as a means to address loneliness and depression. Nurses can convey consolation to patients to find peace and reconciliation in the final stages of dying and in so doing may ease some of the existential and spiritual loneliness of dying as they stand with their patients in their suffering.
However, it’s important to note that information delivery may not always be smooth for nursing students, for instance, contrary to this study, a study in the USA showed that students faced challenges in communicating empathically due to dialectic tensions, the burden of carrying bad news, lack of skills for providing empathy, perceived institutional barriers, challenging situations, and perceived dissimilarities between the nurse and the patient delivery[31].
This highlights the need to ensure adequate training and mentoring of nursing students in communication skills so that they play they are able to provide consolation to dying patients and relatives. A study from Uganda in 2014 that showed communication challenges to patients and their relatives, staff shortages, and limited knowledge and resources were perceived as emotionally challenging to nurses and hindrances to their good performance in the provision of palliative care[32].
Studies have shown dying patients’ needs beyond medical treatment rotate around empathy, sympathy, compassion, responsiveness to emotional needs, maintaining hope and a positive attitude, and providing comfort through touch as the emotional support to make them feel unique and special amidst their complex social situation[33].
Similar to other studies the nursing students in this study expressed sympathetic concerns with relatives of dying patients. The participants in their sympathy were protective of relative’s feelings and hence ensured continuity of care for their sake in order not to demoralize them. Sympathy to relatives has been documented as a necessary dimension of care to ease the caregiver’s suffering and ensure compassion and satisfaction with the care provided[34]. Relatives tend to appreciate the sympathy given as emotional support that springs a positive impact to patient and his relatives and this contributes to improved quality of care at end of life.
Strengths and limitations of the study
This present study was the first of its kind among nursing students and thus provided baseline data.
A limitation of this study pertains to the self-report methodology employed for data collection. The responses provided by participants might have been influenced by social desirability bias, as well as their inclination to portray themselves positively. This potential influence could have implications for the accuracy and depth of the insights conveyed, potentially resulting in a less exhaustive comprehension of the perceptions and experiences under investigation