I. Introduction

Nursing is a professional discipline. The aim of nursing education is to develop practitioners who are competent, knowledgeable and able to respond to the changing needs in clinical practice. In university undergraduate programs the focus is on enabling students to develop clinical competencies. Therefore, clinical teaching has become a major component of baccalaureate nursing education. Thus clinical teachers in the hospital setting take prime responsibility for supervising students in the clinical setting. The clinical experience of nursing students has been changed from ‘doing’ to ‘understanding’ in order to integrate theoretical knowledge into clinical practice. Being an effective clinical teacher requires competency in both clinical practice and teaching Karuhije [23] As nursing education progresses in the 21st century, new directions in clinical teaching are required to maintain a high standard of nurses who are adequately prepared intellectually to perform required tasks. To be effective clinical teachers they should not only help students to develop their clinical competency, but also help to create an environment conducive to learning.

A. Purpose

The two purposes of this study were to explore clinical nurse educators’ personal experiences of death and dying, as well as to explore how they perceived this experience influenced the way they teach end of life care to nursing students.

B. Significance of the study

A literature search identified few studies about how clinical educators teach their students in this field of nursing and how it affects the students. The significance of the current study, apart from filling a research void, is that it provides new and specific insights for student and clinical educator learning as well as postgraduate nurses and health professionals. Common themes identified in the data may be useful in teaching undergraduate nursing students. The findings have the potential to highlight the need for nurse educators to share personal experiences with students, so that students can benefit in their own dealing with death and dying patients

Looking from clinical educators’ perspectives has allowed me to reflect on my own thoughts, feelings and understanding of the meaning of the importance of personal experiences in this area of nurse teaching. Looking at lived experiences in this field has the potential to enhance student learning and therefore make it a more comfortable area for the student to work in.

II. Literature review

A. Background

While preparing nurses for care of the dying is viewed as an important aspect of nursing education, the most effective approach to providing such education remains far from clear. In a longitudinal study by Burnard [6] a theoretical model was developed which looked at exposure to the dying. It also looked at the lack of education leading to death anxiety and negative attitudes which resulted in withdrawal from the care of the dying patient. Britten looked at educating student nurses and ways of dealing with dying patients. He believed having exposure to the care of the dying will lead to less death anxiety and more positive attitudes in the approach and behavior when caring for the dying.

B. End of Life

What is end of life and why is it so important for this study? There are many definitions of end of life. Matzo, Sherman, Penn, & Ferrell [31] state that ‘end of life is not confined only to Cancer or AIDS but rather it is essential across all life threatening illnesses and in cases of sudden death’ (p.267).

DeSpelder and Strickland [18] regard death as being ‘an inevitable component of our everyday lives’ (p.208). Although not everyone has experienced the huge sense of loss that often accompanies a death, DeSpelder and Strickland observed that everyone has experienced comparative losses with the transitions and changes in daily life. Mooney [49] refers to these losses as ‘little deaths’ such as leaving home, the loss of a job or a pet or losing a limb. In another article death is referred to as a ‘universal phenomenon, inevitable, permanent and yet not fully understood’ Evans [15] (p.73).

Mooney [26] defines death as ‘life as it was known is no more’ (p.125). Nurses have an obligation and responsibility to ensure that end of life care is tailored to beliefs, customs and practices held by patients. While these authors are expert in their fields, they are mainly from medical/nursing fields. It is possible they have not looked outside the opinions of their own discipline such as sociology or education.

Death itself is final and although losing a job may also be final at the time there is another phase to follow when some people commence another job. Therefore it can be argued that it is not analogous to the end of life. Denton,[10]. The literature reviewed has stressed the importance for students and clinical educators to understand the meaning of end of life so that the impact of caring for people who are in the end of life stage will not be such a traumatic experience for students to deal with Watts, [34]

C. End of Life Care

The significance of understanding the words ‘empathy’ and ‘caring’ is also emphasized in the end of life care literature reviewed. The literature emphasizes the importance of sharing with students what it means to show empathy and care for patients who are dying. Care is defined by Benner [5] as:

The alleviation of vulnerability; the promotion of growth and health; the facilitation of comfort, dignity, or a good and peaceful death; mutual realisation; and the preservation and extension of human possibilities in a person, a community, a family, a tradition (p.2).

Caring therefore implies a form of love, since it involves a giving of self. Caring for the dying is a particularly emotionally demanding area of nursing. In addition to its demand on the emotions, this type of nursing also requires specialist knowledge and skills. These include knowledge relating to symptom control and the use of effective communication skills. Nursing research and theory has focused primarily on looking at nurses’ attitudes to the care of the dying, the communication skills used and specific areas of symptom control (Benner & Wrubel, [4].

There are many concepts to consider in the end of life care of a patient; one that is essential in providing quality care for the patient is empathy. Hope-Stone & Mills[32] conducted a study of fourteen nurses examining their interpretation of empathy, the conditions they perceived influenced empathy and their beliefs about how empathy is established in nursing. Their findings showed that empathy was best achieved through a combination of personal and professional experiences. Their research suggests that empathy can be expressed through the care-giving acts of nurses and goes beyond the need for words. The findings of their study also suggest that some nurses believed empathy towards dying patients was a skill which could be taught and the remaining nurses felt it to be a skill that was associated with experience and intuition. This research further commented that student nurses dealing with dying patients cannot possibly know the ‘correct’ way of providing empathy if they are unaware of the meaning of empathy Stolick [32]

In the clinical setting dying patients, like other people, want nurses to respond to them in a ‘natural’ way. Death is inevitable; unfortunately caring for people who are dying or who have been told they are dying is something nurses often have to deal with. The understanding of the true definition of end of life or death and how nurses deal with it will make a difference to the care being delivered to patients in the dying process. Mallory [25] explained that caring and empathy are perhaps the most fundamental elements of palliative nursing or end of life care. If a nurse is not caring, then the other elements will not be a standard part of the quality of care. Studies conducted by Hudacek [20] and Searle and McInerney [30] also support this view [not substantive enough to be considered a theory]. They viewed comfort as the major instrument for care in the clinical setting

Mallory [25] stated that ‘there is no uniform definition of caring in the literature’ (p 298). However, the definition of caring proposed by Goldie [17] is considered most appropriate: “Caring is concerned with meeting needs, by nursing actions that bring relief, ease and transcendence” (p. 394). If this is the case, then unless students see true caring from the clinical educator, they are not going to see this as important. Caring for the dying involves personal emotion and most critically it involves accessing the emotions of others. Goldie [17], (p 395) says that:

To be effective in caring for a dying patient a nurse needs to understand and be able to explain the emotions of others; imagine the emotional experiences of others from the inside; put themselves in the patient’s shoes, be sympathetic and recognise another’s emotions; and have feelings of distress about them. Goldie, [ 17 ], p 395),

Clinical educators who are not caring or do not show they care cannot be good advocates for their students. This could have a lasting adverse impact on the students. However demonstrating the true meaning of caring for the dying patient will have a lasting effect on the students they are educating in this already difficult field.

Self-awareness in palliative care is one of the qualities that Burnard [7] considered necessary in effective counselling of the dying patient. Other necessary qualities were empathy, genuineness and unconditional acceptance of others. A climate of trust is created not only by what is said but also by gestures. These gestures, either verbal or non verbal, will demonstrate confidence in the nurses and their ability to use their own resources to help themselves. Nurses may be unable to express any negative feelings about people because they are dying. This may not be helpful, either for patients or their relatives. So are students being prepared for the worst case scenario, and are they able to cope with the negative impact this may have on them in their later nursing careers? The literature does not address this question. This gap in the literature has led the researcher to learn more about how personal experiences from the clinical educators’ perspective, may or may not be helpful to students Lugton, [24]

Bereaved people often feel that they can no longer acknowledge the faults and failings of the deceased. This in turn can give rise to feelings of guilt over their own attitudes and behaviour. The patient may feel unsafe with staff who are ‘too kind’, since they may feel unable to express their own negative emotions Lugton [43]

Nurses can behave as human beings with human emotions and not be concerned only with appearing clinically correct. The students will see and learn from what they see and what actions the clinical educators take; therefore it is imperative students learn from experience Lugton[24] If the information shared is going to play a significant part in dealing with a difficult situation then this information may be beneficial to the student and they will absorb all they see and hear. It is important for all health professionals and patients to monitor the development of skills in supporting the terminally ill and their relatives. Sometimes nurses are conscious of using these skills, for example, when they have successfully interpreted non-verbal cues as to how a patient is feeling. At other times, nurses can be equally conscious of having failed to understand or communicate with their patients’ sensitively Lugton [24]

For all nurses personal experiences can influence attitudes to work with dying people, witnessing a painful death, or having a difficult bereavement. Sometimes carers are not aware as to how much such an experience still affects them, until situations at work remind them of their own loss. The experiences of losing a close relative or friend can give staff added insights and sensitivity in working with dying and bereaved people, but it is easy to underestimate personal needs when trying to help others. Experienced nurses need to understand their own emotions to acknowledge them and to act on the advice often given to the bereaved, not to suppress feelings or pretend that they are always coping Lugton [43] These coping mechanisms such as sharing stories with students are a way of demonstrating to students that although they may have experienced death, they too are also human with feelings which can have an impact on their working with dying patients.

While getting close to patients is one of the most rewarding aspects of palliative care, nurses cannot mourn the death of each patient as they would that of a close relative or friend. Care should be taken in nursing practice that empathy is not confused with identification. Empathy enables the nurse to put themselves in another’s position and to recognise how that person may be feeling. Identification means the nurse becomes the other person to the extent of taking on his or her problems Lugton, [24]. The patient, with the help of the nurse, needs to work through their own anxieties and problems. Therefore, nurses must remain comfortable within themselves in order to be effective for patients and relatives, and also to ensure their own survival. Students need to be made aware of this, as they are very vulnerable and tend to become too involved, making it more difficult for them to deal with real life situations.

In an article by Payne, Seymour and Ingelton [28], it was established that there are risks and benefits associated with empathy for dying patients. It also highlighted that the requirements of being empathetic possibly resulted in increased stress and anxiety among nurses. As the nurses who took part in the study were not identified as being or having a particular level of experience, it could be believed that all nurses have a chance of increased stress and anxiety when dealing with death and dying patients.

D. Teaching end of life care

It is important that nurse educators have credibility in relation to what they are teaching; this in turn allows students to feel that they are being given the best information available to deal with this already difficult area of end of life care. Some studies have focused on assessing nursing students’ end of life knowledge, skills and/or attitudes Arber, [2]; Mallory, [25]..

Few studies have actually addressed the readiness and ability of educators to teach end of life care, and how this impacts on student learning about end of life care in the hospital setting; hence the reason for the current study. The addition of teaching end of life care to all nursing curricula is essential, because it addresses a reality that most nurses will face. If nurse educators can increase student knowledge, understanding and acceptance of caring for dying persons and their families, then student comfort with the situation, confidence and skills in end of life care will improve (Allchin, [1]. It is assumed by students that nurse educators will have the knowledge required to teach end of life care, when in reality they may not feel adequately prepared to teach these specific competencies and may require additional education (Sherman Matzo, Coyne, Ferrel & Penn, [31].

Nurse educators recognise the need to prepare undergraduate nursing students to acquire the relevant attitudes, knowledge and skills in various aspects of end of life care, such as effective pain and symptom management, supportive care interventions, ethical frameworks and the use of therapeutic communication skills (Sherman, et al, [31]. If educators are not prepared themselves for the end of life care process it may have a negative impact on the students, patients and families.

Beck [3] found that nursing students have ‘feelings of personal inadequacy and limited clinical experience caring for the dying patients’ (p. 408), which often results in death anxiety for students. Beck’s recommendations included an increase in death and dying content in nursing curricula, consistent with the recommendations of other authors Allchin, [1].

The student responses were again highlighted as being those of initial hesitancy and discomfort. One student responded by saying ‘I kind of felt at a loss because, you know, I didn’t really know what I should be doing or what my place was with the family’. This was repeated by another student who said ‘I’m a student so it’s not like I really know how to act or not to act or what to say. I wanted to say something but I didn’t know what’ Allchin,[1].

III. Method

A. Methodology

The methodology chosen for this study incorporated phenomenology using a Gadamerian hermeneutic philosophical approach, Rogers’ theory of learning and Patricia Benner’s ‘novice to expert’ model. The phenomenological method offers a theoretical framework to guide nurses through the process of research, thus helping nurses to develop knowledge associated with the ‘how’ and ‘art’ of nursing. This method has been adapted by writers such as Pascoe [27], and Evans & Hallet [15]. The theoretical framework of phenomenology used in this study aims to translate and understand the lived experiences of the clinical nurse educator into a recognisable meaning that can then be used as a knowledge base in nursing practice Gadamer, [16].

While phenomenology has many different forms, the focus of phenomenology is on people’s lived experiences. It is a tradition that seeks to understand the social actor’s frame of reference. Each individual’s uniqueness and experience as a self-interpreting person is valued Wiseman, [68]. Wiseman also refers to each individual’s uniqueness as a lived experience; the kind of knowing which occurs when a person is involved in a specific situation, as a clinical educator involved with a dying patient or a death experience shared with students. Heidegger [18] for example, saw people as self-interpreting individuals with shared meanings. It is the kind of understanding that comes from such shared meanings which infuses each new experienced situation.

Phenomenology generally follows two schools of thought: Husserlian and Heideggarian hermeneutic. Crotty [9]. Husserl’s approach is more descriptive in nature compared to Heideggarian hermeneutic phenomenology, which is interpretive in terms of what the interviewee is saying on one hand. Husserl believes the person who is conducting the research needs to bracket their own experience and become disengaged. On the other hand, Heidegger believes that the researcher should reflect not only on their own situation within the research, but also on notions of neutrality and knowing Pascoe[27]

Phenomenology aims to purely describe the phenomena, unlike grounded theory, which aim is to develop a theory about what is already known. The goal of a phenomenological study is to understand what it is like to ‘walk in another person’s shoes’ or to see the world through their eyes. Phenomenology researchers describe people’s worldviews, that is: What their experiences are and the meaning they give to these experiences in terms of thoughts, feelings, understandings or interpretations. For example what happens to a dean, a professor and a student in the course of one day at university is completely different, and their thoughts about a lecture are likely to be completely different as well. Similarly, an operation is likely to have quite different implications for a surgeon, a nurse, a patient and the patient’s relatives and friends, and each is likely to have quite different outlooks on the experience. Wiseman,[35]

The role of the interpretive researcher in the unending conversation is to listen to many narratives- the contemporary embodied experiences of clinicians in nursing education to hear the familiar and the common. In selecting a narrative that embraces the familiar, the researcher does not attempt to show the correct interpretation among many interpretations. That is, the researcher does not seek to clarify and evaluate already known interpretations. Rather the researcher seeks to reveal hidden interpretations and bring them to light. The researcher does not stop at what the participants say, but goes behind the text and asks what the participants could or did not say Dielermann [13].

Referring back to Heidegger ‘seeing it through others’ eyes’ increases the clarity of being open to students and sharing personal experiences from the clinical educators’ perspectives. This phenomenological methodology is useful when a topic has previously been studied, but when a fresh perspective is needed. Phenomenology seeks to understand another’s experience, so is ideally suited to the research of nursing and nursing care. The meanings the clinical educators attribute to their experiences help create or clarify the needs of the students and how these needs can best be met Cohen [8].

While clinical educators need to understand the anxiety that individual students hold, understanding themes that researchers learn through phenomenological research provides a useful guide to all nurses as they seek to understand the individual perspective Cohen [8]. Understanding these common themes may be a useful beginning for assessment with students as they start to learn.

Hermeneutic phenomenologists study how people interpret their lives and make meaning of what they experience; therefore interpretation should be the object of the research Gadamar [16] Research undertaken and guided by Gadamar’s philosophy asserts that the researchers’ preunderstanding and prejudices form part of the research data and are not bracketed out. Gadamar [16] contests that elimination of prejudices is not impossible and is also unnecessary. He supports this argument by stating that its absence can interfere with the interpretation process.

Using phenomenology as a research method in the current study has allowed the clinical educators to describe their thoughts and ideas about their teaching style and the impact it has had on their students, while at the same time explaining the value of their style through their stories. What is significant and what is of value to the students in their telling of these stories may thus be uncovered.

Discussing the narrative power of phenomenological texts, Wiseman, [35] explains that phenomenological description tends to have a strong emotional appeal which the author and the reader recognise as being part of their engagement with the world. In line with this phenomenological way of thinking, the aim of this current study was to understand in greater depth the lived experiences of the clinical educator and how these experiences impacted on their teaching of undergraduate nursing students.

B. Sample

1) Selection of participants

The purpose of opportunistic sampling in the current research was to select the most appropriate group for the phenomenon being explored Pascoe [27]. In this case it was looking at clinical educators with experience of teaching students in the clinical setting. The only prerequisite for the clinical educators chosen was they at some time had taught nursing students in a clinical setting. Patton goes on to suggest that the rationale behind purposefully selecting participants is to provide information-rich cases for study in depth. It is not desirable in qualitative research to attempt to fully understand the extent of the phenomenon of interest before the study begins. Indeed, if researchers fully understood the phenomenon it is arguable that there would be no need for the research study in the first place Pascoe [27].

In this study of clinical educators’ personal experiences of death and dying, it became opportunistic to use clinical educators who taught in the clinical setting and who may have had some experience with students from different levels in the undergraduate nursing program. Although this was not a prerequisite for participants to take part, it became apparent that educators who responded and were chosen were all considered appropriate because of their experience of teaching undergraduate nursing students in the hospital setting.

2) Recruitment of Participants

Prospective participants were chosen by a mail out system inviting them to take part in the study. The mailing list was generated through the Federation University School of Nursing via administration. This method of recruitment prevented the risk of collusion or coercion on the researcher’s part and allowed the participants to be invited to take part completely voluntarily.

Four clinical nurse educators responded via email to the researcher expressing their interest in the study. The participants were then asked to take part in a one on one interview, which was conducted in a mutually convenient and safe location. The interviews were audio- taped, then transcribed to elicit common themes and threads arising from the interviews.]

C. Data Collection

A safe and mutually convenient interview location was organised. The interviews took approximately 20 to 30 minutes each. They were all audio-taped, then transcribed. The researcher also listened intensively to each interview to elicit commonalities from the four interviews. The interviewees were typically a little awkward at first when told their interview would be recorded, but once the interview started and questions were asked, they felt comfortable answering in their own time.

Although the educators interviewed all knew the researcher and were aware of how sharing their knowledge contributed to the openness experienced in the interviews, many emotions were expressed including tears and laughter.

The researcher’s clinical experience and ‘insider’ knowledge provided a good foundation from which to conduct interviews. However acknowledgement of pre-conceived assumptions was essential, as they may have influenced the interviewing process Johnson [22]. For example, it was difficult not to assume that all participants shared personal experiences with their students as the researcher did. The acknowledgement of the researcher’s familiarity with the teaching environment and its practices was made evident by participants’ asides such as, ‘you know what I mean’. Extensive shared knowledge between the clinical educators, of the teaching environment with student nurses, facilitated other questions and added further depth and meaning during interviews and analysis.

Due to the level of experience they all had with the phenomena under study it was quite interesting to see that this topic was one of great interest to all of them and they all felt passionate about what they did. As this was a phenomenological approach, the researcher felt there was no need to have any more than four participants involved.

All the questions were semi structured allowing any answer to be given. At no time were any uncomfortable questions or answers given. The researcher met with each participant and allowed them to ask any pre interview questions and talked freely about what the research was hoping to uncover. This allowed all of the interviewees to feel relaxed and talk about their experiences in the clinical field with students and also with the dying patients. The researcher explained to them that there were no right or wrong answers, so this made them feel more relaxed. The interviews were semi-structured but very informal, with a “chatty” approach and usually over a “cuppa”, which lessened the barrier between the participant and the researcher.

The questions that loosely guided the interviews were:

  1. 1.

    A student comes to you and says they do not know what to say or do in an end of life situation. How do you respond to this?

  2. 2.

    Have you had personal experiences with death and dying?

  3. 3.

    Do you think this experience influences the way you teach your nursing students?

  4. 4.

    Is death and dying something that can be taught, or do you think that nursing students learn from experience?

D. Limitations

The limitations to the study were that the participants all worked in a regional hospital. Although the small sample size limited the findings, as this was a phenomenological study, it did not really affect the results..

E. Ethical Considerations

Ethical approval was granted through the Federation University. All participants were sent a Plain Language Statement explaining the study and outlining what the requirements were for their participation. Confidentiality was assured through the use of pseudonyms and by interviewing in a private location of mutual convenience. Participants were able to withdraw from the study at any time. Processes were in place to direct participants to professional debriefing help and to offer referrals in the event of undue stress.

Issues of confidentiality were emphasised given the focus of the study where there was greater chance of future work with health professionals of the same status, and the fact the participants all worked within the same regional hospital. Assurance was given that no information would be discussed amongst the other clinical educators.

Interviews with participants comprised the raw data but transcriptions were necessary in order to describe the experiences, allowing familiarity and identification of common themes. Due to time constraints, the researcher employed a transcriber for all four transcripts. This in turn led to the researcher listening again to gain full insight into what the interviewees were trying to say. The researcher highlighted what the common themes were throughout Evans [15]. Reading and rereading allowed for richness of data and reflection of the participant’s responses, both verbal and nonverbal. This served as another part of data analysis Evans [15]. Listening to the narration allowed thorough immersion and familiarity in the dialogue.

Death experiences and dying patients being a fairly emotional topic meant that the researcher picked up on visual and emotional aspects along with body language and voice tone from the interviews. This was used in the documentation of the transcripts from each participant. The personal interaction also enriched the text and helped to more fully represent the data. Significant statements and phrases pertaining to clinical educators’ views on student teaching particular with end of life care patients were then identified. Interview transcriptions were read several times whilst listening to the tape recordings. This primary analysis promoted an early understanding of the descriptions as a whole through voice tone and broad meaning analysis. Listening intently is an essential element of successful analysis of tape-recorded data Too [65].

In accordance with the standard practice in the descriptive school of phenomenology, the researcher continually returned to the interview transcripts to validate findings at each stage. Colaizzi’s seven-stage framework in Crotty[9] facilitated a robust analysis of the data.

F. Data Analysis

Data analysis began and continued during the data collection. This integration was considered an essential feature of an inductive and interpretive qualitative method such as interpretive description Evans [15]. The aim of the analysis was to develop a coherent understanding and explanation of the data Due to the small size of the study, the researcher was the investigator behind the interpretation. The researcher’s consciousness was influential in the construction of the findings Too [65] A thematic analysis was applied to separate the transcribed narratives.

Data analysis involved adhering to the seven-stage process described by Crotty [9] highlighted that many empirical phenomenological researchers who use Colaizzi’s method recognise that hermeneutic activity is an intrinsic part of the research activity.

G. Soundness

Soundness of the research was ensured by the use of an appropriate methodology to the research question and the researcher’s ongoing responsibility for coherent findings and conclusions Cohen [7] Interpretations of the participant dialogues were reflected back to them during the interview to ensure the credibility of the meanings and minimize misunderstandings of data Britten [5] Verification was obtained by reading the transcripts while listening to the tapes; this also facilitated a broader interpretation of the dialogue

On of the themes that emerged as central to nurses’ lived experience of using personal experience to integrate into their teaching of student nurses in the field of death and dying was humanizing stories All four participants spoke of their experiences of sharing stories with their students and how it affected their teaching. They also emphasized the fact that nurses need to remain professional when they teach, but at the same time show their students they are also human. The experience of teaching undergraduate nursing students at different levels of experiences was apparent in the narratives.

The researcher sensed from these four participants that it really mattered how and what they told the students. How they thought individually and how this impacted on them as individuals when they were working as clinical educators was important. Humanising the personal experiences did not have to have a negative impact on the students, as Amy put it:

I don’t want to tell the students personal stuff to scare them but, I actually used [my personal experience] for the good and there is nothing wrong with being upset as I was. Nursing is a tough job emotionally, and it’s OK to be upset, providing that you don’t let it rule you. You don’t let it get too heavy. You have to make sure you know where to draw the line and be comfortable sharing but not overstepping the mark for your own benefit too.

H. Theme Two: Humanising teaching

The second theme which emerged from the transcripts was the importance of showing human emotions in teaching. The participants were all asked to share their personal experiences of death or dying and how they felt this influenced their teaching style. This was elicited in the interviews by asking the question “Do you think personal experience impacts on your teaching to student nurses?” There were several different responses to this question

Anna’s story was informed by a personal experience of being a clinical educator and a clinician at the same time.

It’s very interesting being on the clinician side… Being an educator as well as a clinician, you have to take more of an objective role and be a little more distant from that actual situation. I actually find…dealing with death and dying a little bit easier because I have found I am not close to the patient when I am [a] clinical educator. As far as dealing and trying to help the students through a death situation, I actually don’t know at the [end of life], I think I am just a reference and a person that [the student] can focus student connection with or go somewhere else to get help.

Anna’s response indicated that as a clinical educator, she was not completely comfortable discussing her personal experience with students. She felt it was more beneficial allowing someone with experience in the field of death and dying to discuss with students and herself as an educator.

Sharon told another story of her personal experience and how it influenced her teaching:

Obviously personal experience does impact largely [on teaching]; I think you have compassion towards the family if you’ve actually had some personal experience of near death or dying, like a close relative, and certainly if you have had any experience[ of ] being in hospital as compared to how you are feeling when nursing patients. Students want answers so they can give answers to the patients or the relatives. This makes it difficult for us as educators, because sometimes there are no right answers, and we don’t want to give the patients false hopes.

In essence Sharon clarifies that you need to share personal experiences but the personal experiences don’t always give the answers that the student want to hear.

Jackie told a distinct but relevant story:

I truly believe personal experience plays a huge part whether it is personal or personal -professional like looking after someone who is dying. I had an experience of caring for my husband’s father dying with cancer. I don’t necessarily use that as my starting point with to students, but if it is about breathing or something like that I will relate [the concept of breathing] to my personal experience with my husband’s father and talk about that. Students will [then] ask me as a nurse what [could] you do and say but as the daughter-in-law how did the [dying situation] affect you? [Sharing information about death] has to be helpful to the students because they know you are supposed to have the theoretical background, this is what the research suggests [but] that you have that personal experience and that the personal understanding of death enables you to share your first-hand knowledge you aren’t just there as the knowledgeable nurse and that [you] actually [have] feelings and such things.

Although this was quite a long story it is relevant to cite in full. This allowed for the participant to share why her personal experience could impact the students she taught.

Amy described sharing her personal experiences with students as ‘horror stories’:

Students have really enjoyed listening to my experiences it is like the horror stories, they love hearing horror stories, Not that these are true horror stories; I have got some horrible stories of people dying. One in particular I always share with the students was a guy who arrested and I ended up laying him out and I bawled through the whole thing. Thank God I had five days off because I wasn’t going back, because he shouldn’t have died.

It was pleasant to hear all the participants take such a solid view on sharing of stories with their students.

IV. Discussion

Phenomenology is the study of experience, When people teach and learn from a phenomenological perspective, they view course content not in terms of an additive curriculum, but as opportunities for teaching and learning that have not been revealed yet Diekelmann & Smythe [13] In phenomenologic-humanistic models, teachers are facilitators of learning, not knowledge disseminators. Goldie, [17] Engaging students with clinical educators’ first hand experiences of death and dying can help students learn about the multiplicity of views on experience, help them focus on the patient as an individual, and heed the Institute of Medicine’s (IOM) call for patient –centred care. Experience can be gained in a variety of ways.

The results from the research have shown that for the clinical educators interviewed, death and dying is always personal on either part of the work context or as part of life experience. While all death education incorporates theoretical models drawn from philosophy, sociology, psychology and cultural studies, these are all subject to individual interpretation that gives rise to meanings linked to personal and contextual understanding Watts,[66]. Whilst the narratives were individual and personal, similar themes emerged much like the analogy of wearing the same hat with different interpretations. However consistent with a phenomenological analysis there is no clear end-point to the interpretation Roch-Fahy & Dowling [29].

DeSpelder and Strickland [12] developed and applied their concept of ‘teachable moments’ to the student - curriculum interface and the student - teacher relationship. These ‘moments’, it could be argued are linked to what Denzin [11] terms ‘the narrative turn’ that captures the particular and the personal from the individual storytelling. This narrative turn is highlighted in the findings of the current study, drawn from the stories told by the clinical educators and the observations that they believe influenced their teaching to nursing students.

Interpretations are always open to reinterpretations. The aim of the current study was to illuminate four clinical nurse educators’ personal experiences of death. These experiences shared with the author informed the second aim, by demonstrating how personal experiences of death influenced teaching of undergraduate nursing students. The four participants spoke freely and without hesitation, all shared similar views about how their experiences influenced their teaching styles. What follows is a discussion of aspects of one of the three themes derived from the four participant narratives.

A. Theme Two: Humanising Teaching

1) Being human

Theme two identified the need for clinical educators to show they are human as well as teachers. Sometimes the sharing of stories can trigger a conscious choice to behave or react differently. The clinical educators interviewed have identified this sharing of stories as being a healthy learning tool for students. Being human should not be harmful to the student as long as they do not use emotion for the wrong reasons. Being human needs to balance with the first theme of remaining professional at all times, but being honest and able to show empathy to the patients the students will look after is very important for learning. Being human is linked in the literature review to the attributes of caring and empathy. As discussed by Goldie [29], a nurse must be able to understand the needs of others. A student being guided by the nurse educator must first look at themselves and knowing how to express their own feelings, will in turn be able to show empathy to their patients.

2) Showing empathy

Empathy is a skill that is crucial to the helping relationship. Many authors discuss the methods of teaching empathy most effectively Burnard, [6] suggests that before nurses can understand and explore a patient’s perspective, they must explore their own perspectives. Self- awareness, therefore, is a prerequisite to empathy. Burnard identifies other skills necessary for empathy including the ability to listen, to offer free attention and to suspend judgment. These are all skills that can be demonstrated by the clinical nurse educator when sharing stories with the students. The sharing of stories with students prevents negative thoughts when dealing with a dying patient, when their own fears have been acknowledged. As Stolick [32] indicates, fear of death can motivate health professionals to avoid discussion with patients about dying. To authentically engage with dying patients, self-examination is paramount. One must have considered death for oneself Stolick [32].

Working with patients who are living and dying with advanced illness can evoke strong emotions and be stressful for professional caregivers. Strong emotions, unchecked and unexamined, can have a negative impact on the quality of patient care and the well-being of the health professional. This is seen amongst a lot of health professionals.’ If student nurses are not aware of these emotions themselves then it can impact on patient care. However by the sharing of stories from the clinical educators’ perspectives, this in turn can have a positive impact on the students, who will be better able to manage nursing the dying patient Searle&McInerney [30] Strong reactions in response to patient situations can lead to nurse under involvement or over involvement

In conclusion, it is apparent that personal experiences shared by the clinical educators can have a positive effect on their teaching to undergraduate nursing students in a constructive way for both the student and other clinical educators.

This phenomenological study explored the lived experiences of clinical educators, providing an opportunity for a small number of individuals to reveal their innermost thoughts and feelings regarding teaching students about death and dying. All the participants as unique individuals shared ideas and gave of themselves in different ways and were pleased at the opportunity to share their stories with the researcher.

This study has highlighted many aspects which linked to the importance of sharing personal experiences with students in the clinical setting. As only one small group of nurses was interviewed the findings cannot be applied directly to all nurses in other settings. However, with the support of the literature and knowing what is important in dealing with the dying patient in the end of life situation, it becomes apparent that all students should be exposed to death and dying at some stage during their undergraduate training. By sharing personal experiences with students it has also highlighted the significance of sharing personal experiences for the health professional as well. Dealing with one’s own thoughts and emotions and sharing with others helps to seal the theory and practice gap in this already difficult area of nursing. In relation to the research question, clinical educators have a special responsibility to engage with students’ individual perspectives and experiences that, primarily, take the form of storytelling when sharing personal experiences. It is important to remember, however that in teaching emotionally charged material it is still the student who has to make sense of what is being learned; in this case making sense of how to handle difficult scenarios in end of life nursing. This is something that teaching can support but not replace.

The findings of this study may provide directions for future evaluations in the teaching of death and dying in the undergraduate program for nursing students. If nursing faculty members believe all nurses and consumers of health care deserve these benefits, they will provide curriculum revisions to include a required course, which includes the use of sharing personal experiences to enhance student learning in the clinical setting.