“I love my garden, books and children. However, everything will be gone with death. As I don’t want to die, I am afraid of being dead.” This is what Tolstoy said about man’s analysis on death. He said that if our life is full of these worldly desires and is designed to satisfy these desires, death can be interpreted as a cut-off from the happiness from satisfying these desires, and therefore, death is existence of fear (1).

One of the important roles a nurse can play is to help terminally ill patients to end his or her life with dignity (2). When doctors and nurses encounter patients facing the pain of death, they experience the limits of medical care and the agony of patients indirectly. The nurses are also expected to help the patients to recognize well and positively accept death (3).

As patients are being confronted by death and their family members have various kinds of physical, psychological, social and spiritual pain, they need the terminal care service from highly skilled nurses. Thus, the nurses caring for terminally ill patients are required to deliver high-quality terminal caring service based on the knowledge, skills and response strategies to death (4). In addition, the previous studies have shown that the nurses caring for patients on the verge of death are also in terrible pain and difficulties (5).

In particular, it has been reported that in the case of nurses working at a cancer ward, a newborn babies ward, an ICU (Intensive Care Unit) for adults and other wards with high percentage of dying patients, the nurses suffer severe stress and pain (6). In particular, novice nurses are more affected by the terminal care than the experienced ones (7).

The nurses, whose vocation is to care for the dying patients, can successfully provide terminal nursing care only when they realize the right meaning of death. Hence, their experiences of facing the process of patients’ deaths are very important. As for the newly employed nurses, they have to adapt themselves to a new environment and new job and can get a lot of stress due to an unfamiliar nursing service (7). Therefore, a deep understanding of death and the experience of caring for terminally ill patients during the internship at the hospital will help the new nurses deliver proper caring service to terminally ill patients.

According to Kim et al. (8) the clinical practice education in Nursing Science puts more focus on the issues of how to learn specific skills, such as the essentially required kind of nursing skills for Nursing Science and why the skill is important. Also, Nursing Science puts more focus on how to apply critical thinking, which is the basis for acquiring new skills, rather than on the issue of how to accurately practice specific skills. However, understanding and caring during the death process are not included in the internship. Thus, the nursing students just apply their individual understanding about death when joining the hospital practice related to death or experiencing the death of patients. Accordingly, it is easily assumed that those students feel a sense of powerlessness about themselves. Therefore, the death of patients they encounter during the hospital practice comes as a more severe fear, confusion and shock to them than to new or existing nurses. So far, the death-related studies targeting the nursing students have mainly included the study on attitudes to death (9), the research study on perceptions toward death (10), and the quantitative research on death studies (8) and hospice education (11). However, there have been a few in- depth studies about the nursing students’ experiences of first encountering the death of patients.

The purpose of the phenomenological study is to drive meaning by examining the structure of perception toward lively experiences by each individual regarding specific phenomena (12). To that end, this study intends to understand and explain the experiences of nursing students from their point of view by asking a question to them, “What is your first experience of patient’s death during the clinical practice?” As a result, this study attempts to provide basic data of education programs necessary for those students to identify any issue when facing the death of a patient and the acceptance of terminal care.

1. Study Design

This study was designed to examine nursing students’ experience of first encountering the death of patients during clinical practice. The study is a phenomenological qualitative research where data collected from direct interviews with the research subjects was analyzed by using Colaizzi’s (13) method.

2. Samples and Setting

Out of all the nursing students who experienced the death of patients during clinical practice, senior female students who took classes from the Department of Nursing Science in P University located in Y City were selected as the subjects for this study. They understood the purpose of this study and wanted to voluntarily joined it. It was promised that the data recorded after gaining approval and a letter of consent would not be used for anything else other than the purpose of this study; the identities of the subjects would remain anonymous, and all collected data would be destroyed immediately after the end of the study. Those subjects were also given the explanation that they could withdraw from their participation from the study at any time.

When it came to the data collection process, interviews with those students were made until the point of theoretical saturation where no new category appeared at all (14). The data of eight students who showed a repetitive concept was used for the analysis. The general characteristics of the study participants included the average age of 22.5±0.76 years old, four atheists, two Christians, one Catholic, and one Buddhist.

3. Researchers Training Process

In order to enhance the reliability and validity of the researchers and the tool of qualitative study, the researchers earned prescribed credits via a class on qualitative study methodology during their doctoral studies. Additionally, the researchers attended qualitative study workshops and academic conferences on qualitative study held by E University in September 2010, S University in December 2010, and E University in June 2011 with local and foreign erudite scholars on the qualitative study being used. The researchers of this study also accordingly acquired knowledge on data collection and analysis technology and promoted academic advancement and skills through several post presentations on qualitative studies.

Moreover, the researchers issued their results in academic journals about the qualitative study and reviewed literature for theoretical sensitivity. Also, they contemplated this study after hearing from the other researchers in charge of clinical practice at the College of Nursing, and the experiences of the students described in the clinical practice conferences.

4. Data Collection

Prior to the study, approval was obtained from the Institutional Review Board of P University Hospital (IRB No: E-2012006). When deciding the period of data collection, the principle of data collection specified by the phenomenological study was followed. The research period started on the date of gaining approval from the IRB (January 27^th, 2012) and ended on the date of theoretical saturation agreed on by the researchers (March 6^th, 2012).

Each in-depth interview was conducted by using semi- structured questions. At the request of the subjects, the two- week long interview schedule was informed in advance at a common room for students. Researchers interviewed 8 participants at least 4 times (2 times/ week) were interviewed and in addition, 3 participants were interviewed twice more. Additionally, a text message about the interview time and location was sent one day before the scheduled interview.

It took about one hour to have one round of interview. The interview was recorded with prior consent from the participating students and the recorded interview was transcribed and analyzed. The interviewer tried to maintain objectivity throughout the interview to ensure frank answers from the participating students.

The main questions to the students included, “What is your first experience of patient’s death during the clinical practice?” For the nonverbal expressions of participants, the notes from the recording was referred to. When any data was found to be unclear by the researchers, a direct meeting was made with the students to check the unclear data and the data was analyzed to the extent that there were no different opinions on the relevant meaning of the statement.

5. Data Analysis

This study employed Colaizzi’s (13) method of phenomenological analysis and the analysis process was composed of the following stages:

1) 1st stage: Listen to the recorded interview repeatedly and then transcribe the recorded interview as it is. Then, have in- depth interviews several times about the transcribed contents. After that, read what was recorded several times and make the participants read what was transcribed to ensure the validity of the study’s data.

2) 2nd stage: Construct meaning by inferring abstract statements based on meaningful statements discussed by the researchers. At this time, make an effort to increase the generalization ability through an objective research without any opinion of the researchers being reflected by marks of parenthesis.

3) 3rd stage: Read repeatedly the abstract statements generated from the second stage to categorize common attributes.

4) 4th stage: Describe essentially and generally the meaning of the experience of the patients’ death that the nursing students faced during their clinical practice at the hospital as a part of verifying the categorization.

6. Reliability and Validity

This study intended to ensure validity based on the four criteria offered by Guba and Lincoln (15), such as credibility, auditability, fittingness, and conformability. In order to secure the credibility of data, epoche and bracketing were used to directly express what the participants experienced when facing the death of patients. The auditability was designed to make the researchers consistent throughout the research process and was secured by transcribing and quoting what the participants said based on the phenomenological analysis method suggested by Colaizzi (13). When it comes to the fittingness, general and disease-related characteristics of the participants in the study were described to increase the possibility for a reader to apply it to other similar cases. In general, conformability means the neutrality of the study’s results, and in this study, conformability was found to be gained as the credibility, auditability and fittingness were already ensured.

As a result of this study, the essential structure of experience was divided into eight categories that targeted the senior students who were attending the College of Nursing. At this time, this study generated 15 clusters of themes by finding common attributes from 52 meaningful statements made and those clusters were arranged into eight categories (Table 1).

Table 1 . Themes, Theme Clusters & Category..

Themes	Theme clusters	Category
- I stood at the starting line for the 100-meter dash, expecting I would come first in the sprint, but I felt as if I could not take off at all, and rather, somebody brought me down.	Practice different from what I was expecting	“Desire to evade the reality of death”
- My body and mind got frozen and I felt as if I turned white.	Unexpected death of patients scared me stiff
- Am I visible to others?	An invisible person	“Powerlessness”
- I felt myself as a burden that I wanted to move from the current place to another one.	Encumbrance
- This was the first time for me to witness the death of a patient. Thus, it was really terrifying. - Terrified and scary thoughts struck me frequently.	Scared, terrified and embarrassed	“Changed emotion from the anticipation of recovery to the fear of death“
- A shadow of terror gradually crept up on me.	Terror-stricken by death
- The patient has gone to the realm of God, thus being able to rest in peace.	A peaceful death	“Various interpretations on death”
- I will live a life without regrets.	Looking back upon life
- We should have revitalized the patient.	Evasion of acceptance of death	“Limitations of nursing practice”
- The nurse who experienced the failure of death at the moment of and after the death looked very stressed.	Bitter ending
- I thought that not the patient but the nurses would die!	Whose death?	“Resentment of lack of nurses”
- Why doesn’t the school teach terminal caring skills?	Terminal care	“A longing for knowledge about death”
- I desired to know more about death and was just gaining ideas about death.	Knowledge of death
- This practice gave me a chance to realize that unexpected death is the duty of a nurse!	Terminal care as a duty of nurse	“A motivation for self growth”
- I have come to the realization that the death is not a failure of nursing but just a series of jobs.	Rediscovery of nursing care

Category 1. “Desire to evade the reality of death”

Practice different from what I was expecting: For young nursing students who anticipated working as nurses, the death they encountered during the clinical practice was a shock per se. They had expected the patients in the hospital to recover their health, but they fell into despair when facing the death of patients. Their first experience with the death of patients triggered only a negative image of the nursing career.

“This is not what I expected from nursing. I had never dreamed of seeing a person dying but I was placed in the situation. Do you understand what I felt at that time? It was like I stood at the starting line for the 100-meter dash, expecting I would come first in the sprint, but I felt as if I could not take off at all, and rather, somebody was bringing me down!” (Participant 1)

Some students were shocked by the gap between what they expected before and what they actually experienced, consequently considering changing their job.$$

“When I saw a nurse being busy running here and there, I doubted if I could handle the situation well. Although I cared for the patient as well as possible, if the patient was barely breathing and was being sent to the ICU, I asked myself ‘Why do I have to do the work?’…., it was really depressing I was coming to the conclusion that I might not do that and started looking for another job.” (Participant 4)

Unexpected death of patients scared me stiff: The participants experienced physical and mental changes and got petrified when they unexpectedly faced the death of patients without any preparation. At that time, they were not sure whether or not they chose the situation by themselves.

“I couldn’t take my feet off. I felt as if I was in a nightmare…….” (Participant 3)

“The atmosphere around me was getting hot due to tension in the emergency situation, but I only got frozen. My body and mind got frozen and I felt as if I turned white….it was not caused by something but… caused by the fact that I wanted to be separated from the situation.” (Participant 6)

Category 2. “Powerlessness”

An invisible person: The participants had received love and respect at home and school. On the contrary to what they had experienced, they were disappointed at themselves for not being able to be helpful at all. Worse still, they considered themselves as invisible people who were incompetent and meaningless at the moment when a patient was dying.

“Everyone, expect I, was doing something. At least, a nurse taking the OT for the new nurse moves equipment, prepares drugs, and opens an ampoules. Even family members were crying while watching the patient dying. Why am I here? Isn’t it a dream? Am I visible to the others? I checked whether or not to wear a cape that makes people become invisible once it is worn …….” (Participant 5)

Encumbrance: While seeing doctors and nurses dealing with the emergency situation where a patient was on the verge of losing his or her life, the participants felt they were not helpful at all, and consequently, did not have a sense of presence. Worse, they considered themselves as a burden that should be moved somewhere from an urgent and fearful space and they witnessed their self-esteem decreasing.

“Why am I here? When a nurse, doctor and family members were all tangled up together in a narrow hospital room to deal with the emergency situation, I was not a help to them at all. Rather, I was bumping into others. I felt myself as a burden that I wanted to move from the current place to another one.” (Participant 1)

Category 3. “Changed emotion from the anticipation of recovery to the fear of death”

Scared, terrified and embarrassed: The participants started their internship with an expectation that they could apply the theoretical knowledge they learned in schools to their work in the hospital. However, it was expressed that they felt scared and terrified when encountering the death of patients for the first time.

“I participated in this internship with a lot of dreams. But, after seeing the patient dying on the first day of the internship, I was dumbfounded and scared… This was the first time for me to witness the death of a patient, thus, it was really terrifying.” (Participant 7)

“I often had terrible dreams related to the dying patient and the scary scene occurred to me sometimes. (Omitting) If one of the family members is dead, how sad it is! Terrified and scary thoughts have frequently struck me.” (Participant3)

Terror-stricken by death: The death of patients was very traumatic for the participants. They remembered the death of patients they encountered during the internship and would meet later when being employed by hospitals as a moment of panic.

“My hands and legs were trembling when witnessing a patient dying. Furthermore, a sudden panic overtook me when I realized that I had to be there tomorrow and would have to be in front of the death of more patients after getting employed. Like the animation I watched when I was young, where my neighboring area got colored black, a shadow of terror originating from the death of patients gradually crept up on me. Alas! I suspect that ‘I am too terrified to do this work’.” (Participant 6)

Category 4. “Various interpretations on death”

A peaceful death: Although the participants saw patients dying in the same place during the internship, their interpretation of death varied depending on each person’s religion, values and beliefs.

“The patient looked very peaceful. That’s how it is with death. The patient has gone to the realm of God, thus being able to rest in peace. I don’t think the family members need to be so sad. However, for the family members, it seems to be very sad not to see the patient right now.” (Participant 2)

Looking back upon life: The nursing students in the early 20s regarded death as distant from themselves, and therefore, it was difficult for them to define any association between life and death. However, the death of patients served as a momentum for them to consider that life and death are in the same line and to think about their future death. Also, the death of the patients gave an opportunity to the nurses to look back at their past and reflect upon their past actions and think about their future life.

“While watching people lose their life, I thought everything was over and I may die tomorrow, and therefore, I have to live life to the full day by day. Additionally, I looked back on my life, wondering to myself ‘Did I do a bad thing?’ Moreover, I made myself a promise that I will live a life without regrets.” (Participant 4)

Category 5. “Limitations of nursing practice”

Evasion of acceptance of death: The participants who had a dichotomous way of thinking that the recovery of heath is a success, but death is a failure, had a hard time accepting the death of patients and avoided the reality of death, indicating that they were unwilling to acknowledge the failure.

“We should have revitalized the patient but the patient was dead. It means that we provided poor caring. I believe the death of a patient I’m in charge of could lead to a bad evaluation result. I am much more worried about what I should take responsibility for later.” (Participant 3)

Bitter ending: Even though responsible nurses faced the reality of death, they were doing their best in emergencies. Although they faced hard situations, no one could comfort them over the difficulties they struggled to handle. Accordingly, the participants were concerned about their future as nurses and they tried to support a positive image of the nursing profession in their mind.

“A doctor called at the time of the patient’s death, and at the station, the doctor yelled at the nurse, saying that the nurse did not handle the situation promptly and left the place. Furthermore, another nurse in the next shift created stress due to a delayed shift change and the nurse who experienced the failure of death at the moment of death and after the death looked very stressed.” (Participant 5)

Category 6. “Resentment of lack of nurses”

Whose death?: The participating nursing students were picturing themselves in future from the nurses who struggled to deal with the death of patients. The participants considered that the person actually dying is not the patient, but the nurse who is busy cleaning up every mess by herself, and consequently, was sapped of all energy due to the shortage of manpower. The students also expressed their feelings about the fact the hospital does not supply enough nurses, as described below.

“It was in the evening. There were only two nurses, and at that time, a patient was on the eve of death. One nurse at the desk and the other in the patient’s room were running here and there and working non-stop. However, the basic work was in a state of paralysis and I thought that not the patient, but the nurses would die! (Omitting) Anyway, no one from the medical office or nursing department came to help them.” (Participant 2)

“I have learned that the hospital should be fully ready for any emergency but I could not find any support for the emergency situation. No matter how difficult it is to handle the situation, it’s only up to the relevant ward!…….” (Participant 3)

Category 7. “A longing for knowledge about death”

Terminal care: The participating nursing students realized it is necessary to organize a terminal care program for the nursing science curriculum. They made efforts to understand what proper terminal nursing care is through the experience of patients’ death and to enlighten themselves about terminal care.

“A patient was dying… Come to think of it, I joined the practice without being ready for it. I am wondering why the school didn’t teach terminal caring skills…….” (Participant 7)

Knowledge of death: While experiencing the death of patients, the nursing students participating in the study seemed to gradually accept the psychology of death. The students were reading books about death, taking interest in the afterlife and examining deeply the role of the medical staff in considering the dead patients and their families.

“I have a lot on my mind. What’s death like? Does death mean the end of everything? I searched for books and saw movies…. (Omitting) One of my friends asked, ‘Are you dying? You look so strange.’ However, I desired to know more about death and was just gaining ideas about death.” (Participant 2)

Category 8. “A motivation for self growth”

Terminal care as a duty of the nurse: The participants included the concept of death care into the future work plan of nurses, and in particular, showed increasing enthusiasm for learning jobs related to terminal care.

“This practice gave me a chance to realize that unexpected death is the duty of a nurse.” (Participant 5)

“I was worried about whether or not I could provide the terminal nursing service as well as a regular nurse but as I thought I should be able to do better, I decided to learn more about emergency nursing care skills.” (Participant 1)

Rediscovery of nursing care: The nursing students participating in the study were found to be willing to accept a wider range of concepts of nursing, which were expanded from symptom management-centered care to include death.

“I have come to the realization that death is not the failure of nursing, but just a series of jobs. I saw the strong presence of hospice nurses.” (Participant 3)

“Previously, I thought the recovery of heath was the best nursing care. But, now I have come to the realization that terminal care is just as significant a job as the recovery of health.” (Participant 4)

This study was intended to investigate the essential perception and meaning of the eight nursing students’ experiences of first encountering the death of patients during their internship. To that end, in-depth interviews with each student were made to collect data, and after that, Colaizzi’s (13) phenomenological method was employed in this study to generate 15 clusters of themes and derive 8 categories. As a result of this study, the first experience of the nursing students facing the death of patients was a reality they wanted to avoid and triggered a sense of powerlessness. In addition, unlike their expectations of being able to apply what they had learned theoretically to the clinical practice, they felt terrified by the death of patients. The participants with beliefs or religious views had interpreted death through them and had a chance to look back on life. Also, it seemed that they wanted to avoid the acceptance of death and felt they were failures when the patients died. The nursing students pictured themselves in the future as terminal care nurses and expressed resentment toward the hospital authority. They said that the hospital could not support the current number of nurses, and as a result, the nurses caring for the dying patients had to go through a lot of difficulties. In response to the absence of terminal care or death educational programs in the curriculum of their schools, they learned about death by themselves, and at the same time, regarded terminal care as a noble job, including terminal nursing service, as a realm of a nurses’ work.

Regarding the experience of first encountering the death of patients during their clinical practice, for the participants, it was a reality they did not want to avoid and those participants expressed negative emotions toward death and seemed to be unwilling to accept death. According to a study by Jo et al. (16) which was aimed at university students, as the number of patients who died in the hospital increased, those students were forced to see an increasing number of patients on the verge of death, therefore, not liking to go to the internship. Yet they acknowledged that they could not refuse clinical practice. Like the previous study results, the nursing students participating in this study appeared to want to evade the death of patients.

During their clinical practice, they studied the pleasure of patients or nurses and accustomed themselves to the new environment of the hospital, which in turn made them stressed, and moreover, the experience of encountering the death of patients contributed to increasing their stress further (17). The nursing profession, which aims at finite life, is always related to death, and accordingly, it is believed to be necessary to make the nursing students recognize death as one of the paradigms in nursing science. Additionally, if death and terminal care are included in the nursing curriculum, the stress the nursing students experience will be reduced and their adaptability will be enhanced. Thus, clinical practice will be more effective.

When the participants could not give any help in front of their dying patients, they regarded themselves as an insignificant existence, picturing themselves as an ‘invisible person’ and even as an impediment. While going through the practice, the nursing students found themselves powerless in their actual work, although they studied nursing science at school for four years; it shed new light on themselves and decreased their self-esteem.

The period of university study is a time to establish their own identity with an aim to arrive at the development stage where they get free from the control of parents, internalize their own morality, and select jobs (18,16). Also, this period is a time when they feel interested in and also terrified by death, and consequently, experience the terror of losing the newly built identity and being separated from life if they encounter death (19). If we fail to take the situation of death in a reasonable manner, fail to take the pain and sorrow of the family members of dead patients in a refined manner and fail to deliver nursing care with the individual’s own value of death, the profession will experience confusion in its identity (5,20). In addition, as this is the task for nursing students it is believed that they should be educated to correctly understand the experience of death of patients and bereavement, and accordingly, help the bereaved families to get over their sorrow.

Regarding death, people think of it negatively, such as terror, fear, perplexity, and as people cannot directly experience death, they take it as an inevitable process of life. In this study, the participants had a terrible dream of death, were shocked by the first death they encountered, or felt insecure emotionally and physiologically, which is in line with that of research conducted by Jo (20). Like this, negative prejudice prevents people from taking effective measures against realistic problems, and therefore, it is concluded that it is necessary to increase the flexibility of emotions by obtaining an indirect experience through death education (3,19).

In a phenomenological study aimed at medical students, Wear (21) stated that there were three themes based on which the students took death as a failure, included uncertainty about the end of life, absence of a role model and guidance of managing terminally ill patients, and the shortage of a considerate and integrated curriculum in the education courses. The dichotomous way of thinking that the recovery of health is a success while death is a failure triggered people to take an aversive attitude toward death and to interpret the remaining party as a failure, which was in line with the result of this study. This result is caused by the fact that medical science or the nursing science field does not include death into the understanding of human beings who are the subjects of both sciences. Hence, it seems to be necessary to organize a philosophy class based on an extensive understanding of man in the curriculum of nursing science.

According to research by Noh et al. (22), as nurses were experiencing stress and using up their strength when caring for terminally ill patients, they tended to avoid the death of patients, instead of sharing the emotion toward the death, deny the feeling, and disguise their sorrow and anxiety. This stressful experience also made them exhausted physically and mentally. As the nursing students faced a similar situation in their internship, they were found to be emotionally disturbed and experienced a lot of stress due to the death of the patients.

As the saying specified by I Ching (Book of Changes), that “there is always a way out,” ignoring death can cause anxiety and stress. In other words, it is necessary that people should realize their ignorance and have a correct understanding and knowledge of death. The necessity of creating the right value of death or the lack of experience of death initiated the demand by nursing students for death-related education.

According to the research by Kim et al. (23) on the types of nursing students’ perception toward clinical practice, it was concluded that the nursing students perceived their future nursing job through the current nurses. This conclusion was in agreement with the results of this study. The research by Park and Ha (17) about the clinical practice experiences of nursing students disclosed that the students pictured and considered their future as nurses through internship, which was in line with the result of this study. These experiences served as a momentum for the nursing students to ruminate over the importance of communication and response to the death of patients, as well as the sorrow of the bereaved families when caring for terminally ill patients and the noble meaning of heartfelt caring. This gives a chance for those students to rediscover the work of nursing.

This study showed that as the concept of death varies depending on the social and cultural background, religion, philosophy, and life experience (9,20) when encountering the death of patients, each nursing student had a different response.

Lee and Chun (24) emphasized the acceptance of self and identity as desirable elements of life that university students contemplated. They added that in order to have these elements, they were required to have a wider range of understanding on life and death, look back on their life, lead their lives all the more sincerely and respect the lives of others. The effort to accept death “peacefully” and look back on their past life proved that the nursing students’ experience of the death of patients had a positive effect on them to lead their lives in a more desirable direction. In this study, the nursing students expressed what experiences they had when first encountering the death of patients during their clinical practice, and accordingly, were given a chance to consider death, life and the nursing job seriously.

Based on the above conclusion, we would like to suggest the following ideas: To develop and include programs based on the understanding of death and a core practical terminal case in the curriculum of the College of Nursing. This will ensure that the nursing students can consider life and death seriously and establish a proper view of death and vocational identity.