- A survey of over 2,000 nursing students found that 41% had experienced a patient death. - Of those who experienced a death, 64% did not receive any debriefing to help them process the experience. - Most students felt unprepared to care for dying patients and their families. They wanted more education on end-of-life care.

1. Nursing Students’ Perceptions After Experiencing a Patient Death
Nursing Students’ Perceptions After Experiencing a Patient DeathNursing Students’
Perceptions After Experiencing a Patient DeathAIM The purpose of this study was to
examine, on a national le vel, nursing students’ per ceptions afterexperiencing a patient
death. BACK GROUND Death is a highly stressful experience for nursing students.Debriefing,
which routinely occurs with a patient’ s demise in the simulation setting, typically does not
happen inactual death situations. METHOD A mixed-methods design using quantitativ e and
qualitative questions as par tof an anonymous sur ve y was sent to the membership of the
National Student Nurses’ Association. Ofappr oximately 55,000 members, 2,480 r esponded
to the surve y. RESUL TS Experiencing a patient death as astudent occurr ed for 41 percent
of participants in the nationally r epresentativ e sample. Of those whoexperienced a patient
death, 64 per cent did not receive any debriefing. CONCL USION Most nursing students
didnot feel pr epared to car e for a dying patient and the patient’ s family. Students need and
want mor e education onend-of-life nursing car e.ORDER NOW FOR ORIGINAL,
PLAGIARISM-FREE PAPERSHeadnoteAbstractAIM The purpose of this study was to
examine, on a national le vel, nursing students’ per ceptions afterexperiencing a patient
death. Nursing Students’ Perceptions After Experiencing a Patient DeathBACKGROUND
Death is a highly str essful experience for nursing students. Debriefing, which r outinely
occurswith a patient’s demise in the simulation setting, typically does not happen in actual
death situations.METHOD A mix ed-methods design using quantitativ e and qualitative
questions as par t of an anonymous sur ve ywas sent to the membership of the National
Student Nurses’ Association. Of appr oximately 55,000 members,2,480 r esponded to the
sur ve y.RESUL TS Experiencing a patient death as a student occurr ed for 41 percent of
participants in the nationallyrepr esentativ e sample. Of those who experienced a patient
death, 64 per cent did not receive any debriefing.CONCL USION Most nursing students did
not f eel prepared to car e for a dying patient and the patient’ s family.Students need and
want mor e education on end-of-life nursing care.My Patient Died: A National Study of
Nursin gStudents’ Perceptions After Experien cing a P atientDeathHeise, Barbara A ; Wing,
Debra K ; Hullinger, Amy H R .Nursing E ducation P erspectives ; New
York Vol. 39, Iss. 6, (No v/Dec 2018): 355-359.DOI:10.1097/01.NEP .0000000000000335>
6/17/2019 My Patient Died: A National Study of Nursing Students’ Perceptions After
Experiencing a Patient Death – ProQuesthttps://search-proquest-
com.ezproxy.brenau.edu:2040/docview/2132190303?accountid=9708 2/10KEYWORDS
Death E ducation – Debriefing – Nursing E ducation – Nursing Students – Death E ducation –

2. DebriefingMost nurses experience patient death during the course of their car eers. The
nurse is the primary health careprovider inv olved in caring for patients and their families
at the endof-lif e (EOL) and throughout the dyingprocess, including postmor tem care
(Bryant, 2008). Nurses pr omote a “good death ” by pr oviding physical,emotional, and
spiritual car e while also advocating for the cultural pr eferences of dying patients and
theirfamilies.Death is an emotionally char ged issue for anyone. For register ed nurses,
death is also a high-str ess situation(Leighton & Dubas, 2009; Zheng, Lee, & Bloomer ,
2016), with most experienced nurses able to vividly r ecall theirfirst death of a patient
(Anderson, Kent, & Owens, 2015; Kent, Anderson, & Owens, 2012). F or nursing
studentswho are just learning the RN r ole and responsibilities, the death of a patient is
often a for eign, frightening, andover whelming experience that ma y have long-term eff ects
on their pr ofessional and personal liv es (Kent etal.,2012).LITERATURE REVIEWPatient
death is a commonly r eported sour ce of stress and anxiety for nursing students (Allchin,
2006; Carson,2010; Edo-Gual, T omásSábado, Bar dallo-Porras, & Monfor te-Royo, 2014;
Gallagher et al., 2014; P arry, 2011; Zhenget al., 2016). Nursing students’ r eactions to their
first patient death often include negativ e emotions, such as fear,sadness, frustration,
anxiety , helplessness, and guilt (Neiderriter , 2009; Parry, 2011; P oultney, Berridge, &
Malkin,2013; Zheng et al., 2016). Although many students experience a patient death during
their education, f ew feeladequately pr epared to interact with a dying patient and his or her
family in the clinical setting and to cope withthe experience (Gallagher et al., 2014; Zheng et
al., 2016). Curr ent nursing education is generally consideredinadequate to prepare nursing
students for EOL car e (Cava ye & W atts, 2012; Gillan, v an der Riet, & Jeong, 2014;Kent et
al., 2012; Schlair et, 2009; Wallace et al., 2009). After their first death experiences, students
fr equentlystate that they were not r eady to pr ovide EOL car e, expressed difficulty
communicating with the dying patient orfamily, and did not r eceive sufficient suppor t from
clinical instructors and staff. Nursing students r eportedincreased str ess and anxiety due to
f eelings of inadequacy and lack of pr eparation (Cava ye & W atts, 2012; DosSantos &
Bueno, 2011; Gallagher et al., 2014; Huang, Chang, Sun, & Ma, 2010; P arry, 2011; Zheng et
al., 2016).Nursing students who had positiv e first death experiences indicated that helpful
factors included a suppor tiveclinical instructor or staff member , role modeling, and
postclinical debriefing (Carson, 2010; Gallagher et al.,2014; Huang et al., 2010). Debriefing
is commonly included in simulated EOL training but often does not occur inthe clinical
setting (Thompson, 2005). The oppor tunity to discuss the death experience with an
instructor ma yhelp nursing students cope with the experience and increase competence
and confidence for future care of dyingpatients.Nursing students must r eceive adequate pr
eparation and suppor t to provide quality EOL car e in the clinicalsetting and be equipped to
cope with patient death. Most studies on nursing students and their experience withpatient
death have inv olved small samples of nursing students. This sur ve y is the first to examine
nursingstudents’ per ceptions of their first experiences with patient death on a national le
vel. By understanding students’experiences and the need for suitable pr eparation, , and
debriefing, nurse educators ma y be better able toguide nursing students through their first
experiences with EOL car e and patient death.THEORETICAL FRAMEWORK> 6/17/2019 My
Patient Died: A National Study of Nursing Students’ Perceptions After Experiencing a

3. Patient Death – ProQuesthttps://search-proquest-
com.ezproxy.brenau.edu:2040/docview/2132190303?accountid=9708 3/10Benner’s
(1982) seminal work, F rom No vice to Exper t, delineates fiv e levels of nursing pr oficiency.
AlthoughBenner’s theor y of nursing did not include nursing students, her delineation pr
ovides insight on a pr elicensurenursing student who could be classified at a pr enovice le
vel. Le vel 1 is the no vice RN who has no experience inclinical situations such as EOL car e.
At this le vel, the no vice nurse does not ha ve the discr etionary judgment todetermine
which par ts of the situation are most relevant. The no vice nurse f eels most comfor table
with objectiv etasks, such as taking vital signs, rather than a mor e advanced skill of helping
the dying patient and family tocope. Le vel 2 is the adv anced beginner who has mar ginally
acceptable performance. Nurses at Le vels 1 and 2need mentoring b y expert nurses.At Le
vel 3, the competent nurse has been pr oviding EOL car e for approximately two to thr ee
years. T ypically , thisnurse pr ovides conscious, deliberate planning to achie ve efficiency
and or ganization, and no mentoring isneeded. However , the competent nurse is still unable
to r ecognize which par ts of the EOL situation ar e mostimportant.At Le vel 4, the pr oficient
nurse is able to see EOL car e for the dying patient and the family as a whole. This
nurseknows what to typically expect during EOL car e and can modify the plan as
needed.Finally, at Level 5, the nurse is an exper t who intuitively hones in on salient issues.
Exper t nurses have a deepunderstanding of EOL car e and the many ways that dying
patients and their families appr oach death. They offermany wa ys to understand, cope, and
accept the final phase of lif e, which, for most people, is a totally unchartedpassage. Expert
nurses in EOL car e often stay in this field because the y feel the y can coach patients and
familiesthrough a v ery difficult and often not discussed par t of life.Nursing students do not
ha ve the experience to per form the advanced roles of an exper t nurse caring for thedying
person and family . Along with competent clinical skills, exper t nursing skills required
during EOL car einclude advanced communication skills to determine patient pr eferences,
adv ocacy for patient and family topromote dignity , advanced pain management skills,
compr ehensive suppor tive car e to the patient and family toalleviate suff ering, constant
assessment to ensur e interventions ar e congruent with patient wishes, andpromoting the
dying patient’ s autonomy and right to self-determination.Some nursing students ha ve pr
eviously experienced the death of a family member . However , the death of apatient is diff
erent and ma y requir e a le vel of r esponsibility that was not pr esent for the family
member. Inaddition, caring for someone who is dying, as well as caring for the dying
patient’ s family, requir es adv ancedclinical skills that a nursing student does not y et
possess.METHODA cr oss-sectional descriptiv e surve y design was used for this study .
Following appr oval fr om the univ ersityinstitutional r eview boar d and National Student
Nurses’ Association administration, nursing student members ofNational Student Nurses’
Association (appr oximately 55,000 members) wer e emailed a brief description of
theresear ch project and an invitation to par ticipate with a link to the online questionnair e.
An implied consent formwas available to be viewed b y participants befor e beginning the
sur ve y. P articipant r esponses wer e collectedusing Qualtrics online sur ve y softwar e.Par
ticipants wer e asked to answer six demographic questions and 14 sur ve y questions about
their experienceregar ding a patient death during their time as a nursing student. T wo

4. open-ended questions asked participantsto describe their experience and indicate what the
y would have lik ed to be taught r egarding EOL car e of a patient.> 6/17/2019 My Patient
Died: A National Study of Nursing Students’ Perceptions After Experiencing a Patient Death
– ProQuesthttps://search-proquest-
com.ezproxy.brenau.edu:2040/docview/2132190303?accountid=9708 4/10Estimated
time commitment for par ticipants was 15 to 20 minutes. This ar ticle reports the r esults of
thequantitativ e questions in the sur ve y.After the r esponse period had ended, quantitativ e
data were downloaded fr om Qualtrics to SPSS v ersion 22 (IBMCorp., 2013). Quantitativ e
data were reviewed for missing v alues and outliers befor e further analysis
usingappropriate descriptiv e statistics and plots. Descriptiv e statistics for demographic
variables and surve yquestions wer e calculated. Chi-squar e test of association was used to
examine r elationships of selectedcategorical variables.RESULTSDescriptiv e statistics for
demographic characteristics of the par ticipants are repor ted in table form in T able
1.SampleA total of 2,804 individuals r esponded to the invitation to par ticipate and started
the surve y. A total of 2,480 (88.4per cent) completed the sur ve y. Most r espondents (80
per cent) were female, half wer e under age 27, and themajority were white (67.6 per cent).
A majority of the r espondents (60.7 percent) reported being single, and abouta quar ter
(26.8 per cent) reported being married. Most (57.6 per cent) of the students said they were
in bachelor ‘spr ograms; about a quar ter (25.9 percent) reported being in associates pr
ograms. Participants came fr om ever ystate in the United States as well as the District of
Columbia with mor e populous states (e.g., CA, FL, NY, P A, andTX) pr oportionally r
epresented in the sample.Descriptiv e statistics for questionnair e items are repor ted in T
able 2. A majority (65.8 per cent) of respondentsrepor ted being pr esent at a death outside
of their nursing experience; almost 41 per cent reported being pr esentat a death as a
nursing student. The majority of those who experienced a patient death (62 per cent)
experiencedthat death early in their nursing programs.Responses for Students Who
Experienced a DeathThe remaining questions wer e directed specifically towar d those who
reported experiencing a patient death as astudent (n = 1,148). Slightly mor e than a quarter
of those respondents (26.8 per cent) said they needed helpcoping. Only one thir d of these
students r eceived debriefing.A chi-squar e test of association was used to examine the r
elationship between reporting the need for helpcoping with a patient death and r eceiving
debriefing. Of the 1,148 students r espondents, 33 (2.6 percent) hadmissing data and were
excluded fr om the test. The test was not significant, x2(df = 1, n = 1,115) = 1.19, p =
.275,indicating that ther e did not seem to be an association between needing help coping
and r eceiving debriefingafter experiencing a patient death as a student. A majority
(194/306, 63.4 per cent) of those who reportedneeding help coping did not r eceive
debriefing.Par ticipants wer e asked to rate their le vel of pr eparation on a scale of 1 to 4 (1
= pr epared, 2 = somewhatprepar ed, 3 = pr epared, 4 = v ery pr epar ed) in se veral ar eas
related to death and dying: pr ocess of death and dying,EOL care, and wa ys to cope with the
death of a patient.* Thirty-six per cent of nursing students ask ed if they felt pr epared with
the pr ocess of death and dying r eportedthey wer e less than pr epared (not pr epared or
somewhat pr epared).> 6/17/2019 My Patient Died: A National Study of Nursing Students’
Perceptions After Experiencing a Patient Death – ProQuesthttps://search-proquest-

5. com.ezproxy.brenau.edu:2040/docview/2132190303?accountid=9708 5/10* Perceptions
of being pr epared to pr ovide EOL car e resulted in 45 per cent feeling less than pr epared
(notprepar ed or somewhat pr epared) and 47 per cent felt prepared or v ery pr epar ed.*
Ask ed if the y felt pr epared to cope with the death of a patient, most nursing students (45
per cent vs. 35percent) f elt less than pr epared (unpr epared or somewhat pr epared).Only
24 per cent of the nursing students r eported that their nursing curriculum (what the y
learned in class)prepar ed them in general EOL car e. Only 17 percent felt that the
curriculum pr epared them to cope with the deathof a patient. P articipants wer e asked
who helped them pr epare to deal with issues surr ounding patient death(process of death
and dying, EOL car e, and ways to cope with death of a patient); options for each categor y
wereas follows: no one, clinical instructor , clinical staff, other nursing students, friend or
family member , and learnedin nursing class. Learned in nursing class and clinical instructor
wer e among the top-ranked answers in mostcategories. The top answer to who pr epared
respondents to cope with the death of a patient was ” no one.”Clinical instructors wer e
referr ed to as pr eparation r esources for EOL car e (19 percent), process of death anddying
(17 per cent), and coping (17 per cent) in these areas.Par ticipants wer e asked to rate their
le vel of pr eparation on a scale of 1 to 4 (1 = unpr epared, 2 = somewhatprepar ed, 3 = pr
epared, 4 = v ery pr epar ed) in se veral ar eas related to communication: communication
with dyingpatient, communication with patient’ s family, and communication with members
of the health car e team. Themajority (57 percent) of nursing students f elt less than
prepared (unpr epared or somewhat pr epared) tocommunicate with a dying patient; only
23 per cent reported f eeling pr epared or v ery pr epar ed. Again, the majority(64 per cent)
of par ticipants felt unprepared or somewhat pr epared to communicate with the dying
patient’ sfamily. Howe ver , par ticipants f elt more prepar ed to communicate with
members of the health car e team (45percent vs. 35 per cent). Nursing Students’
Perceptions After Experiencing a Patient DeathPar ticipants wer e asked who helped them
pr epare to deal with issues surr ounding communication(communication with dying
patient, communication with patient’ s family, and communication with members ofhealth
car e team); options for each categor y were as follows: no one, clinical instructor , clinical
staff, othernursing students, friend or family member , and learned in nursing class. The top
answer to who pr eparedrespondents for all the communication questions was ” no one.”
Students r esponded that their curriculumprepar ed them to communicate only 18 per cent
of the time when communicating with the dying patient, 20percent of the time when
communicating with the family of a dying patient, and 18 per cent of the time
whencommunicating with the health care team. Clinical instructors helped pr epare
students to communicate with thedying patient (15 per cent), the family of the dying patient
(14 per cent), and the health care team (18 percent) ofthe time.Nursing students wer e
asked specifically about what the y would like to be taught about EOL car e. The numberone
answer from students was mor e education on how to communicate with the dying patient
and family .Students wanted more education on EOL car e in general, including the activ ely
dying process and suppor tiveresour ces for the family and the patient. Students also
wanted education on postmor tem care of the patient.Students r equested debriefing and
education on how to cope with a patient death. The y suggested moreeducation on EOL car e

6. earlier in the nursing curriculum with mor e educational activities involving death anddying
through simulation scenarios, faculty experiences, and e ven a hospice clinical.DISCUSSION>
6/17/2019 My Patient Died: A National Study of Nursing Students’ Perceptions After
Experiencing a Patient Death – ProQuesthttps://search-proquest-
com.ezproxy.brenau.edu:2040/docview/2132190303?accountid=9708 6/10It is significant
to note that the sample was fairly r epresentativ e of nurses in the United States, both in
terms ofgeography and in terms of race. P articipants came fr om ever y state and the
District of Columbia. Nearly one thir d(31.9 percent) identified with racial gr oups other
than Caucasian.Nationally, nursing students (41 per cent) reported being pr esent at a
patient death. This high per centage ofindividuals who experience a patient death as a
student highlights the impor tance of death education. Despitethe sensitive nature of the
topic of death itself, nurses need to be pr epared for the almost ine vitable deathexperiences
they will encounter. Current recommendations str ongly encourage nursing schools to
educatestudents about EOL car e (Ferrell, Mallo y, Mazanec, & Virani, 2016). Death
education ma y be integrated intonursing curricula, particularly for concept-based nursing
pr ograms. Nursing Students’ Perceptions After Experiencing a Patient DeathMore work
needs to be done to help students cope with patient death. Ask ed who helped them cope
with thedeath of a patient, the top answer was “no one.” Clinical instructors wer e repor ted
to pla y a leading r ole in thetraining of nursing students in all ar eas regarding death and
dying. Giv en that clinical instructors ar e frequentlyadjunct faculty who r eceive lower le
vels of pr ofessional de velopment than r egular faculty in the academicsetting, it is possible
that many clinical instructors ar e insufficiently prepared to guide students in matters
ofdeath and dying, communication with family and medical staff, and debriefing. Clinical
instructors spend mor eone-on-one time with students than almost any other instructor in
nursing school. They are also uniquelypositioned to obser ve student interactions with
patients and patients’ families.The Institute of Medicine (2015) publication Dying in
America specifically identifies a lack of communicationskills, interpr ofessional education,
and curricula focused on palliativ e and EOL care in nursing education. TheAmerican
Association of Colleges of Nursing (2016) r ecommends competencies and curricular
guidelinesregar ding EOL issues, including communication with dying patients and families
and assisting the patient, family ,colleagues, and one’s self to cope with the dying pr ocess,
grief, and bereavement. Role modeling, simulation, anddebriefing ma y be the most
efficacious wa ys to prepare students to deal with the challenges associated withpatient
death (K eene, Hutton, Hall, & Rushton, 2010). In addition, intr oducing students to critical
reflectivepractice early in their academic endea vors ma y increase their r esilience while cr
eating cultural meaning for thedying process (Hodges, K eely, & Grier , 2005). As Benner
(1982) noted, no vice nurses (and we would add prenovicenurses) need mentoring, par
ticularly in the advanced skills needed for EOL car e.LIMITATIONSIt ma y be noted that a siz
eable proportion (11.6 per cent) of those who began the sur ve y did not complete it. Itma y
also be noted that many of the questions dir ected to those who experienced a patient death
as a student (n= 1,148) had high rates of missing data (around 20 percent). Patterns of
missing data for those questions wer eexamined. Most individuals completed all of the
questions (n = 902, 78.6 per cent). It was found that a largemajority of missing answers wer

7. e attributed to a consistent set of individuals (n = 224, 19.5 per cent), who, itseems, simply
did not complete most of the questions. A small per centage of individuals (n = 22, 1.9
percent)chose not to answer between one and six questions but completed the
others.Although it is not possible to determine specific r easons for noncompletion, it may
be possible to speculate. Thetopic of experiencing a patient death during schooling has the
potential to be emotionally difficult to think aboutand discuss. It may be that the
emotionally difficult natur e of the topic led some individuals to not complete thequestions.
This surve y also ask ed several open-ended questions in the format of typed r esponses. It
may be thatadditional time r equired to think about and formulate r esponses led some
individuals to giv e up rather thancomplete the entire surve y.> 6/17/2019 My Patient Died:
A National Study of Nursing Students’ Perceptions After Experiencing a Patient Death –
ProQuesthttps://search-proquest-
com.ezproxy.brenau.edu:2040/docview/2132190303?accountid=9708
7/10IMPLICATIONS FOR NURSING EDUCATION Nursing Students’ Perceptions After
Experiencing a Patient DeathStudents need and want mor e education on EOL nursing car e
as well as how to communicate with dying patientsand their families and postmortem care.
Most nurses, at some point in their car eers, will encounter a patient whois dying. Although
death is often not discussed in many societies, it is a conv ersation that needs to be held
inorder to ensur e that the dying patient’ s wishes are known.The Conversation Pr oject
(http://theconv ersationproject.org), which is dedicated to helping individuals talkabout
their EOL issues, giv es individuals the words to say to family members and to health car e
providers to star tthe conversation on what the y would like at EOL. Nurses pr ovide the
majority of car e and are uniquely positionedto help star t the conversation of patient pr
eferences and assist the patient and family thr ough the dying process.Dying is a deeply
personal experience. F or nursing students, the death of a patient, at the v ery beginning of
theircar eer path, is often a str essful and over whelming experience. Although debriefing
and mentoring tak e placeroutinely in simulation, the y do not happen most of the time in r
eal life. It is a double-edged swor d to tell novicenurses to car e about their patients while
asking those same nursing students to turn off caring when the patientis dying or has died.
Experienced nurses do a disser vice to novice nurses when the y tell them to “toughen up,
”rather than discuss their views of the dying experience. This lack of discussion and
acknowledgement of salientissues during the dying process may lead to nurse burnout and
compassion fatigue.In the clinical setting, nurse educators, par ticularly adjunct clinical
faculty, need to be trained in debriefingtechniques, critical reflection, and mentoring
nursing students as the y provide car e for those in the last phase oflife. Students need to be
exposed to the dying experience, but with exper t nurse mentors to role model and
guidethem through an often challenging situation (Österlind et al., 2016).For nursing
students, as suggested b y the respondents to this study , more simulation experiences with
patientdemise and debriefing need to be par t of the nursing curriculum. Allen (2018)
points out that, e ven in an EOLsimulation setting, nursing students caring for dying patients
experience incr eased stress. In our study , studentsrequested mor e EOL experiences thr
ough simulation and thr ough clinical experiences, such as hospice andpalliative care with
mentoring fr om their nursing faculty .SidebarThe authors have declar ed no conflict of inter

8. est.Copyright © 2018 National League for Nursingdoi: 10.1097/01.NEP
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proquest-com.ezproxy.brenau.edu:2040/docview/2132190303?accountid=9708
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