Enhancing the affective domain in order to reduce fear of death in first-year student nurses
Dr Kim Goode - Senior Lecturer, Adult Nursing, University of Hertfordshire
Attrition in undergraduate nurses is not only a logistic and financial problem, but also has ethical dimensions. Accepting a student onto the programme implies that the university believes that the student has the potential to succeed, and that the university will provide the resources necessary for that achievement. In a multicultural and diverse population, the resources needed can vary greatly. This research set out to demonstrate that supporting student nurses required holistic preparation for caring for dying people and their families, before they professionally meet with death for the first time. Teaching in the affective domain needed to be considered in terms of developing resilience through enhanced emotional and spiritual intelligence (EQ and SQ). Mixed methods were used with new student nurses in order to achieve the research aims. Findings showed that, as well as early preparation for death, students require strong home support and also that their specific demographic features need to be included and respected.
Background and study
Throughout the 1980’s I worked as a nurse in clinical practice. I really enjoyed caring for patients and also teaching and supporting students. I had become a specialist in nursing children and adults with major burns trauma and so there were pre-registration students and also those undergoing post-registration specialist preparation. Also, in those days, surgeons who had been practicing in general surgery dropped down a grade to learn to become plastic surgeons. When they entered ‘Burns and Plastics’ many had to learn the initial and long term care of these particularly traumatised people. It was an example of an environment where holistic care was imperative. There was little point providing new skin cover if the person hated their new body image and felt excluded from their marriage or their family. Psychological care was delivered through spending a lot of time with each patient and supporting the changes that they and their families needed to experience. Following a major fire, many patients felt grief for dead family or friends, as well as suffering from the pain of their wounds and the pain of loss of function, which often meant the end of their role or career. After this, I entered nurse education and was mindful that people need supporting in multidimensional ways when they are experiencing trauma.
As a nurse teacher, I have been concerned with the reasons why student nurses might leave the programme. Are we failing to support them in some way? Recruitment tutors have a challenging professional life, as the university is contracted to the local NHS Trusts to find and train their future staff nurses. At Hertfordshire the contracts are for around 450 student nurses per year. Approximately 70 of these enter in February, with the bulk arriving in October. Over half of the students are from BAME families and a significant minority are mature students (Student profile analysis, UH, 2014). The picture of a typical student is in her thirties, with children, and with English as her second language. These students often seem to have very high expectations of the programme and of themselves. They see nursing as a game changer, with the qualification providing entry to a ‘job for life’. If this is their expectation, then we collude with this by accepting them onto the programme. By doing this we invest hope and expectation that this person will graduate in three years time. She has shown the potential.
The UK Higher Education Statistics Agency (2015) defines attrition as “non-continuation following year of entry”. A significant number of student nurses do not complete the programme and this appears to be partly due to difficulties in clinical practice. Attrition is between 20-25% for student nurses in Hertfordshire (Say, 2016). The programme is far from ‘a walk in the park’. These students have a 37.5 hour week, every week. Their holiday time amounts to 7 weeks per year; far less than most students from different faculties. In effect, they are completing two parallel three year courses. They need to meet the expectations of the Nursing and Midwifery Council (NMC) for first level registered nurses, and also the level 6 requirements of the University for a BSc (Hons) degree. The programme is 50% each of theory and practice. Theory weeks can be intellectually challenging with group work and presentations to prepare, as well as assignments. When the students are in clinical practice they work a full week, sometimes including weekends and night shifts. Placements can be physically, mentally, emotionally and spiritually difficult.
Leaving the pre-registration programme can sometimes be the best thing for the student nurse and for the profession. A proportion of students will not meet the academic or clinical expectations (Pryjmachuk et al, 2009). Some students could realise that the role of the nurse is different from the one envisaged and that this is not the profession for them. However, the opposite can also be true. Students might feel confident to be continuing on the programme and then circumstances dictate that they must discontinue. This could be disappointing for the student, who might have invested financially and emotionally in their preparation to be a first level nurse and see this as a considerable loss. Currie et al. (2014) suggest other losses, in that attrition could imply mistakes in recruitment or lack of support for the individual, and that these might affect the HEI’s reputation. There will be a reduction in the number of the local Trust’s workforce projections and there will also be the cost of financial penalties to the HEI.
The proportion of student nurses leaving programmes in the UK early due to personal issues appears to be approximately half of those who discontinue (Waters, 2010). It is difficult, however, to disentangle what this term ‘personal issues’ means. Glossop (2002) suggests that these include difficulties related to home and family life. Yorke (2000) mentions changes in personal circumstances being important and Waters (2006) includes difficulties with childcare arrangements. These authors accept that concerns regarding fear of clinical practice affect these difficulties. Thus, the fear of caring for people who are dying could be seen as part of a set of feelings that come under the category of ‘personal issues’ (Eick et al, 2012). It appears that many students may have had clinical experiences that contributed to their decision to prematurely leave the programme. Anxiety in the clinical placement can also lead to further fears of that anxiety causing the student not to perform well and to perhaps harm patients (Marcial et al. 2013).
From a review of the research on the relationship between attrition and placement experiences, it can be concluded that the clinical experiences of the student are a significant influence on whether she stays or leaves the programme. Therefore, clinical experiences are important factors for nurse educators to consider (Eick et al. 2012). Students are involved in a range of affective experiences when they enter the programme. Harris et al. (2014) found that the feelings evoked by these experiences reflect the student’s age, gender, culture and previous experiences and that these demographic factors will influence their decision to continue.
Research findings from Crombie et al. (2013) and Harris et al. (2014) illustrate the importance of support mechanisms, both in clinical placements and externally. My research indicated that there are effective strategies for strengthening the affective domain of the student, enhancing resilience. Although this is only one factor in attrition, this could contribute to the reduction of fear felt in clinical practice and empower some students to stay.
My EdD research sought to investigate fear of death in first-year student nurses. It considered how this might be ameliorated through teaching and learning interventions that involve addressing emotional and spiritual intelligence within the affective domain. Fear of death, for this study, was defined as fear of death and of caring for dying people and their families. The aims of this research were to:
- Gain an understanding of the fear of death in a group of first-semester student nurses.
- Evaluate two strategies designed to reduce fear of death in first-year student nurses by strengthening aspects of the affective domain.
- Explore the relationship between students’ fear of death and gender, age, prior experience, ethnicity and spiritual affiliation.
- Gain an understanding of factors that affect the feelings of students who are caring for people who are dying and their families in clinical practice.
- Identify teaching and learning strategies that help to reduce fear of death.
A pragmatic paradigm and a mixed method approach were used to explore the feelings and experiences of newly recruited student nurses in relation to fear of death and the care of the dying person and their families. Quantitative and qualitative methods were used to examine the impact of two different interventions intended to reduce the fear of death.
Several questionnaires were examined, in order to find the one that would be most appropriate to measure aspects of fear of death in new student nurses. The Multidimensional Fear of Death Scale (MFODS; Hoelter, 1979) was chosen because this tool appeared to be the best in terms of a professional, rather than a personal stance, and the questionnaire had been previously tested with nurses. It has 42 questions that are rated on a 5-point Likert scale. There are eight categories that cover variations on the fear of death and dying, the unknown, and issues to do with bodies. Table 1 shows these eight categories.
Fear of death categories.
Fear of the dying process.
Fear of being dead.
Fear of being destroyed.
Fear for significant others.
Fear of the unknown.
Fear of conscious death.
Fear for the body after death.
Fear of premature death.
The scoring system for the 42 questions is complex, with several scores being reversed in order to ‘check’ responses. The adult field students (n=75) were then randomly allocated to three equal groups. Group 1 was the control group, and the members of group 2 experienced a psychological self-help programme called ‘Do Something Different’, (DSD, Fletcher and Pine, 2009). Students in group 3 attended a weekly group meeting that explored relationships through the use of strategies based on Family Constellation theory (Hellinger, 2006).
The two interventions had been chosen in terms of their ability to influence emotional or spiritual intelligence. The DSD journal had developed from many UH based research studies, starting with the FIT programme (‘Framework for Internal Transformation’, Fletcher 2003:560). Essentially a personal development tool, FIT considers the qualities that determine success and wellbeing. Fletcher and Stead (2000) wanted to identify which behavioural dimensions would result in a person having a behavioural richness that underpinned a broad personality. The DSD strategy offered a development of the ‘Constancies’, which are Awareness; Fearlessness; Self-responsibility; Morality/Ethics and Balance (Fletcher, 2003).
Fearlessness was particularly relevant here, but the other Constancies, if strengthened, could also offer the student increased resilience in challenging situations, helping them to be more aware of the experience, and to feel more in control. This might ultimately lead to a deepened appreciation of their new experiences. By the time I came to consider the strategies, a journal type book: Do Something Different – The Journal, had also been produced. This made the suggestions for brief, daily, behavioural changes accessible for the individual (Fletcher and Pine, 2009).
It seemed that having a focus on developing the emotional aspect of the student’s emotional intelligence (EQ) was one route to strengthening the affective domain and developing the flexibility that could help her to deal with stressors in any environment, at any time during the programme. Because nursing is such distinctive work, the nature of this tool allowed real flexibility, with the student choosing how and when the DSD would be implemented.
The second intervention group met with me on a weekly basis for an hour to explore issues of resilience through spiritual intelligence (SQ). A technique called Family Constellations was used. This is a four dimensional experience where a family or personal problem is explored through members of the group representing aspects of the problem. There are boundaries, but no barriers to what can be represented, so death and other archetypes can be experienced in this way. I had been previously trained to facilitate the work and the group seemed to enjoy these sessions. Some students did not want to give the time, and others were not comfortable with the spirituality of this work, but most of the 25 attended several sessions. There was a core of ten students with seven attending every session. It could be argued that every family constellation is a small heuristic inquiry, as the phases of engagement, immersion, incubation and illumination (Kenny, 2012) are reflected in the constellation process. To fully understand this strategy it must be experienced. It is learnt through participating in the work.
Following a period of time in clinical practice, the questionnaire was administered again and the results analysed and interpreted. By this time the number in the cohort had dropped considerably and 55 students completed the second questionnaire. Firstly, the relationship between the students’ fear of death and their age, previous experiences, ethnicity and spiritual beliefs was explored. Secondly, a more in-depth analysis of the change in fear of death was undertaken.
After analysis using SPSS (2012), there was a small decrease in fear of death between two of the groups (group 1, control and group 3, constellation). However, the DSD group (group 2) showed a marked decrease in fear of death. In this group, F2 (fear of the dead) and F7 (body after death) showed a statistically significant change. The quantitative findings are consistent with the proposition that the DSD programme was effective in ameliorating fear of death. These results support the theory that DSD increases behavioural flexibility. Fear of death was reduced in all eight FOD categories for DSD students, indicating an increase in acceptance and flexibility in these areas. There was also a substantial decrease in fear of death in the constellation group, more so than the control group, although not statistically significant. However, the qualitative findings provided rich data on the value of the constellation work on developing spiritual intelligence.
The qualitative part of the study involved semi-structured interviews with fifteen of the students who had completed both questionnaires. Interviews were carried out in private rooms within the student’s clinical practice setting. The students’ experiences of preparation for caring for dying people and of being in an intervention group were discussed. Tapes were transcribed and loaded into Nvivo 9 (Nvivo, 2010). The interviews were analysed using interpretive phenomenological analysis (IPA, Smith 2007). This enabled the transcripts to be examined for themes and super-ordinate themes (Table 2). Influencing factors from home, such as cultural issues, and from within the clinical context, such as mentorship, were identified.
Superordinate Themes (SOTs)
Death and dying
Death and dying.
Culture and ethnicity
Hospice versus hospital
Care at the end of life
Liverpool Care Pathway
Care after death
Interventions (DSD or Constellations)
The student and her nurse education.
Phenomenology, as used in IPA, is based upon the tension between reality, seen as subjective, and the value of interpretation. Critics such as Giorgi (2011) have asked for clarification regarding the difference between IPA and standard phenomenological inquiry, but it has been shown that IPA offers a roadmap for a more particular depth of inquiry through the use of an idiographic focus (Sydor, 2010). Ideography seeks to explore the understanding and meaning of an experience in a particular context. This focus considers the details within the interview. Each small element is identified and analysed in order to create meaningful conclusions about the participant, as well as the phenomena under scrutiny (Mcleod, 2007). This was complemented by the use of a heuristic approach and also by adopting the double hermeneutic of the student’s experience being described and then being re-described through the lens of the researcher.
Having been a nurse and looked after many dying people and their families, the exploration of difficult feelings and the effects of this exploration was a phenomenon that I understood. I wanted to explore how others experienced the context of death. Etherington (2004:99) stated, “In a heuristic inquiry the researcher is required to have some personal connection with the topic through which they filter their participants’ experiences”. Being aware of this approach was important for my study because the researcher and the participants all belonged to the culture of nursing, with its shared values, language and regulations.
The interviews provided data that confirmed how students can find clinical placements emotionally difficult. Several examples were given of frightening experiences, along with a lack of efficient mentoring. Students seemed to stay on the programme because they had strong supportive relationships at home and within their peer group. Those that had been part of the constellation group reported a rapport that sustained them in challenging times. Good mentors were highly appreciated and were seen as role models. Some were inspirational. Specific data from students from Black, Asian and Minority Ethnic (BAME) groups highlighted that teachers and mentors need to be sensitive to a variety of cultural backgrounds and beliefs about death and dead bodies.
Analysis of the datum led to the following conclusions.
- Mentors need to be aware that students may have particular fears around death and that they may need particular sensitivities to support students when delivering palliative care.
- Cultural aspects of death can be important to students and can affect their orientation to caring for dying people.
- Peer and family support is invaluable when students are feeling vulnerable and can keep the students on the programme.
Results demonstrate that there is value in using strategies to help the student to develop emotional and spiritual intelligence in order to prepare for aspects of dying, before they experience the death of a patient. This preparation enhances the quality of the therapeutic relationship between student and patient. Another outcome is that students need a particular quality of support, at home and in clinical practice and that there are particular implications for BAME students. Mentors of students need to be trained to be sensitive to the students’ needs when caring for people who are dying. Greater attention to preparation for death and care of the dying is likely to enhance the provision of end of life care and may also reduce attrition in first-year student nurses.
The research contributes to nursing education and practice by showing that early preparation for caring for dying people can be effective in reducing fear of death. The undergraduate programme at UH now includes a consideration of how students are prepared emotionally and spiritually to care for dying people and their families. A range of strategies are used, including discussions and experiential sessions. Dissemination of these findings through conference presentations and publication is now underway. Holistic care is regarded as essential to nursing and has been explicated as ‘the 6 C’s’. These are Care, Compassion, Competence, Communication, Courage and Commitment (UK DoH, 2012). I hope that developing these qualities in student nurses will be achieved through further research into exploring teaching and learning in the affective domain.
- Crombie, A., Brindley, J., Harris, D., Marks-Maran, D., & Thompson, T. (2013) ‘Factors that enhance rates of completion: What makes students stay’? Nurse Education Today.33 (11) pp.1282-1287.
- Currie, K., McCallum, J., Murray, J., Scott, J., Strachan, E., Yates, L., & Wright, M. (2014). ‘Developing a national computerised absence monitoring and management system to reduce nursing student attrition: Evaluation of staff and student perspectives’. Nurse education today, 34 (5) pp. 738-743.
- Eick, S., Williamson, G. & Heath, V. (2012) ‘A systematic review of placement-related attrition in nurse education’. International journal of nursing studies. 49 (10) pp. 1299-1309.
- Etherington, K. (2004) Becoming a reflexive researcher. London: Jessica Kingsley Publishers.
- Fletcher, B. (C.) (2003) ‘A fit approach to work stress and health’. In M. Schabracq, M., Winnubst, J. & Cooper, C. (eds.), The Handbook of Work and Health Psychology. Chichester: John Wiley and Sons. pp. 549-568
- Fletcher, B. (C). & Pine, K (2009) ‘Do Something Different – The Journal’. St Albans: b-flex publishing.
- Fletcher, B. (C). & Stead, B. (2000) (Inner) FITness and the FIT corporation. London: Thompson Learning.
- Giorgi, A. (2011) ‘IPA and science: A response to Jonathan Smith’. Journal of Phenomenological Psychology, 42(2) pp.195-216.
- Glossop, C. (2001) ‘Student nurse attrition from pre-registration courses: investigating methodological issues’. Nurse Education Today. 21 (3) pp. 170-180.
- Harris, R., Rosenberg, L., & O’Rourke, M. (2014) ‘Addressing the Challenges of Nursing Student Attrition’. Journal of Nursing Education. 53 (1) pp.31.
- Hellinger, B. (2006) No waves without the ocean. Zutphen: Carl-Auer.
- Hoelter, J. (1979) ‘Multidimensional treatment of fear of death’. Journal of Consulting and clinical Psychology. 47(5) pp. 996-999
- Kenny, G. (2012) ‘An introduction to Moustakas’s heuristic method’. Nurse researcher. 19(3) pp. 6-11.
- Marcial, L., Brazina, M., Diaz, A., Jaramillo, C., Marentes, G., & Mazmanian, N. (2013) ‘A Brief Article: Is This the Cost of Caring? A Student Perspective on Compassion Fatigue’. Dimensions of Critical Care Nursing. 32 (1) pp.18–21.
- McLeod, S. (2007) Nomothetic Idiographic Debate. Available at: http://www.simplypsychology.org/nomothetic-idiographic.html [Accessed: 2 January 2015].
- NVivo qualitative data analysis software; QSR International Pty Ltd. Version 9, 2010.
- Pryjmachuk, S. Easton, K & Littlewood, A. (2009) ‘Nurse education: factors associated with attrition’. Journal of Advanced Nursing, 65 (1) pp.149-160.
- Say, J. (2016) Personal communication with programme leader. May 2016.
- Smith, J. & Osborn, M. (2007) Interpretive phenomenological analysis in J. Smith (Ed.), Qualitative Psychology. 2nd edn. (pp. 53-80) London: Sage Publications
- SPSS. (2012) IBM SPSS Statistics for Windows, Version 21.0. Armonk, NY: IBM Corp.
- Sydor, A. (2010) The lived experiences of young men addressing their sexual health and negotiating their masculinities. Thesis (PhD): University of Glamorgan.
- U.K. Department of Health (2012) Compassion in Practice. Available at: https://www.england.nhs.uk/wp-content/uploads/2012/12/compassion-in-practice.pdf. [Accessed: 18October 2015].
- U.K. Higher Education Statistics Agency (2015). UKPIs: Non-continuation rates (including projected outcomes) (tables T3, T4, T5).Available at: https://www.hesa.ac.uk/pis/09/10/noncon [Accessed: 5 July 2015]
- University of Hertfordshire (2014) University of Hertfordshire Student Profile Analysis January 2014. Available at: http://www.herts.ac.uk/__data/assets/pdf_file/0003/39288/Student-Data-Analysis-2010-11.pdf. [Accessed: 20 February 2015]
- Waters, A. (2006) ‘What a waste: Nursing Standard’s investigation into attrition rates from pre-registration courses produced some startling findings’. Nursing Standard. 20 (23) pp.14–18.
- Waters, A. (2010) ‘The question for Universities: How can they win the war on attrition?’ Nursing Standard. 24 (24) 12-15.
- Yorke, M. (2000) ‘Smoothing the transition into higher education: what can be learned from student non-completion?’ Journal of Institutional Research 9 (1) pp.35–47.
LINK 2017, vol. 3, issue 1 / Copyright 2017 University of Hertfordshire