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Enfermería: Cuidados Humanizados

Print version ISSN 1688-8375On-line version ISSN 2393-6606

Enfermería (Montevideo) vol.9 no.1 Montevideo  2020  Epub June 01, 2020 

Original Articles

Educate Nursing students for life and death: “from fear to love”

María Cinta Palomar Gallardo1

María Romero Palomar2

Esteban Pérez García3

María Isabel Romero Palomar4

1 Facultad de Enfermería, Universidad de Huelva. España

2 Hospital Juan Ramón Jiménez, Huelva. España

3 Hospital Infanta Elena, Huelva. España

4 Centro de Salud de Lepe, Huelva. España


This research is based on phenomenological observation both as a nurse caring for patients at the end of life and as a nursing teacher of the subject "Coping with death: an interdisciplinary intervention". The considerable deficiencies in training nurses for care at the end of life, death and grief led me to propose a teaching intervention "Coping with death: an interdisciplinary intervention", the general aim of which was to evaluate the impact of this subject on nursing students. Methodology: this research is framed by the interpretive or hermeneutical paradigm, with a qualitative approach. From a phenomenological point of view, a descriptive study was proposed, and the reflective journals written by students enrolled on the course were used as the research tool. Results: of the 36 journals gathered at the end of the course, 14 were selected randomly. Qualitative analysis enabled the students' discourse to be structured in 5 categories for analysis: reason for choosing the subject; personal development; what I have achieved in the learning process; how to apply the techniques learnt on the course to my professional activity; the students’ assessment of the subject. Conclusions: The impact of the educational intervention was high, according to the students, who acknowledged the positive effect on two important dimensions of their lives. On the one hand, it enhanced their academic skills as future nursing professionals, and, they acquired skills and positive attitudes towards coping with death, and how to live and love life

Keywords: education; death; grief; Nursing; Gestalt Therapy


Esta investigación surge de la observación fenomenológica como enfermera asistencial cuidando a pacientes al final de la vida y como docente de enfermería en la asignatura “Afrontamiento de la muerte: intervención interdisciplinar”. Existen grandes carencias sobre formación en los cuidados al final de la vida, la muerte y el duelo. Para cubrir esta necesidad de formación de los alumno/as realizo una propuesta de intervención docente en la asignatura “Afrontamiento de la muerte: intervención interdisciplinar”, cuyo objetivo es evaluar el impacto que la propuesta educativa de la asignatura tiene sobre los estudiantes de Enfermería. Metodología: Esta investigación está enmarcada en el paradigma interpretativo o hermenéutico, de enfoque cualitativo. Desde una mirada fenomenológica, se plantea un estudio descriptivo y como instrumento de investigación se tomarán los diarios reflexivos de los alumnos/as, matriculados en la asignatura que eligieron la opción de asistencia a clase. Resultados: El número de diarios fueron 36, pero se seleccionaron de forma aleatoria 14. El análisis cualitativo ha permitido estructurar el discurso del alumnado en 5 categorías de análisis: Motivo de elección de la asignatura; Crecimiento personal; Logros en el proceso de aprendizaje; Aplicación profesional de las técnicas desarrolladas en la asignatura; Valoración de la asignatura por parte del alumno. Conclusiones: La intervención educativa de la asignatura, ha tenido un alto impacto en los alumnos/as, en dos dimensiones importantes para sus vidas. Por un lado, aumentando sus competencias académicas como futuros profesionales, y por otro adquiriendo habilidades y actitudes positivas sobre la muerte, para vivir y amar la vida

Palabras Clave: educación; muerte; duelo; Enfermería; Terapia Gestalt


Esta pesquisa decorre da observação fenomenológica como enfermeira assistencial que cuida de pacientes no final da vida e professora de enfermagem na disciplina "Enfrentando a morte: intervenção interdisciplinar". Existem grandes deficiências no treinamento de cuidados no final da vida, morte e sofrimento. Para suprir essa necessidade de formação dos alunos, faço uma proposta de intervenção docente na disciplina "Lidando com a morte: intervenção interdisciplinar", cujo objetivo é avaliar o impacto que a proposta educacional da disciplina tem sobre os estudantes de enfermagem. Metodologia: Esta pesquisa está enquadrada no paradigma interpretativo ou hermenêutico, com abordagem qualitativa. Do ponto de vista fenomenológico, propõe-se um estudo descritivo e, como instrumento de pesquisa, serão realizados os diários reflexivos dos alunos, matriculados na disciplina que escolheram a opção de presença nas aulas. Resultados: o número de jornais foi 36, mas foram selecionados aleatoriamente 14. A análise qualitativa permitiu estruturar o discurso do aluno em 5 categorias de análise: Motivo da escolha do assunto; Crescimento pessoal; Realizações no processo de aprendizagem; Aplicação profissional das técnicas desenvolvidas no assunto; Avaliação do assunto pelo aluno. Conclusões: A intervenção educativa do sujeito teve um alto impacto sobre os alunos, em duas dimensões importantes para sua vida. Por um lado, aumentando suas habilidades acadêmicas como futuros profissionais e, por outro, adquirindo habilidades e atitudes positivas em relação à morte, para viver e amar a vida.

Palavras-chave: educação; morte; pesar; Enfermagem; Terapia Gestalt


This research is based on my extensive personal and professional experience. In 1990, I began working as a nurse in Internal Medicine hospital units, attending to patients with terminal pathologies (cancer, AIDS, pulmonary emphysema), and which included palliative care. Palliative care comprises full and active dedication to patients, their families and friends by an interdisciplinary team at a point in time when there is no longer any hope of a cure; its main objective is treatment, not for prolonging life but for ensuring the best possible quality of life for the patient and their family in their remaining days. Palliative care is dedication to the patient’s physical, emotional, social and spiritual needs, to enhance the dignity and autonomy of the patient and the family; it includes assistance in the period of grief. Actions are not designed to prolong life or to accelerate death, but to be with the patient and apply specialist knowledge to fulfil the patient’s needs 1,2,3,4). At the time, I was technically but not psychologically qualified to perform such care duties, and I had to confront the death of a patient and the grief felt by their family. This is what led me to seek support and the instruments that I needed as a nurse to accompany patients and their families at the end of life, at death and in grief.

In 2000, I joined the University of Huelva’s Faculty of Nursing as a professor. From my new position as teacher, and based on all my experiences shared with patients and their families in the Internal Medicine hospital units, I presented an educational proposal for training future nursing professionals in palliative care 4. In 2001, palliative care began to be taught as an optional subject in the faculty 5,6,7, and was later added to the nursing degree study plan as compulsory.

In 2011, the Faculty of Nursing accepted my new proposal, “Coping with death, an interdisciplinary intervention”. I believed it was necessary to increase the number of hours dedicated to instruction on end-of-life care, death and grief. This course gave me the opportunity to explore this topic more deeply with nursing students, so I chose this subject as a way to develop the research presented in this work.

  • As a teacher, my main concern has always been to ask myself:

  • How can I make nursing students more aware that palliative care and care for end-of-life patients and the families’ grief can contribute to their personal and professional development?

  • How can I transform their fear and rejection of these patients into an outlook based on love and respect towards them and their families?

  • How can I teach them that people who are going to die can teach us how to live?

  • How can I communicate to my students that awareness of death also means being aware of life? It means to live life and to love life.

Answers to all these questions came to me in workshops that I attended on psychotherapy techniques, and especially in systemic pedagogy 8,9 and the systems of psychology according to Bert Hellinger 10,11. On a personal and professional level, this education has provided me with a different way of thinking and enjoying the task of instructing students on end-of-life care, death and grief, based on gratitude and deep respect for life as it is, as I am, as are others and as my parents are 12.

Our attitudes and behavior towards death are culturally acquired. These customs have changed over time, as has the concept of death itself, from a natural and inevitable fact of life to becoming an enemy to be suppressed 3,14. When therapeutic resources have run their course, many nurses believe that “nothing more can be done for these patients”15. The problem I perceive in these professionals is that they do not know what to do or say in these circumstances, they lack the tools and training to face the process of death and grief (15,16,17.

This research is based on phenomenological observation in the experiences of a nursing professional involved in caring for these patients, and as a teacher working with nursing students. Both aspects have considerable deficiencies in terms of training in end-of-life care, death and grief 18. To fill this gap in nursing students’ training, I proposed a teaching intervention: “Coping with death: an interdisciplinary intervention”.

- General Aim:

To assess the impact of the educational proposal, “Coping with death: an interdisciplinary intervention” on nursing students.

- Specific Aims:

  • To provide students with knowledge of end-of-life care, death and grief.

  • To raise students’ awareness of the importance of end-of-life care, death and grief for their personal and professional development.

  • To change students’ attitudes of rejection towards the process of death and grief in order to foster quality care.

  • To help students overcome their fear of death.

  • To encourage students to accept death as part of life, and foster a sense of gratitude for everything learnt throughout the process of the patient’s death and grief.

  • To encourage students to integrate into their life philosophy the idea that “helping a patient to die means learning to live” and that “awareness of death is to be more aware of life”.

Future nursing professionals need to be able to overcome their fear of death, and be aware that the process of death forms part of life; they need to know how to be present, at the patient’s side, looking them in the eyes fearlessly, with love and a deep sense of gratitude towards the patient, the patient’s family and to life itself for all that this person has given and taught us during this process. Our understanding of palliative, systemic and Gestalt philosophy enables us to transform that perspective of fear of the patient dying to one of love and acceptance of the patient’s process, and of acquiescence in that moment in time when the nurse is the patient’s carer and companion, sharing with them that moment with respect and humility.


This research is framed by the interpretive or hermeneutic paradigm. The qualitative approach based on this paradigm provides us with a holistic perspective 24,25 that fits with traditionally accepted values in nursing 26,27,28.

The tool for the development of this qualitative approach was the reflective journals kept by the nursing students on the course. The study population was all the students attending the optional course “Coping with death: an interdisciplinary intervention”, in academic year 2014-2015, at the University of Huelva’s Faculty of Nursing. A total of 36 students chose to attend the classes. The teaching intervention was explained to the students, whose consent was requested for the researchers to gather information from their personal journals.

The methodology used in the teaching of this subject consisted of a series of didactic activities and strategies. The conceptual basis of these activities was in humanistic psychology, specifically Gestalt and systemic psychotherapy. The tools for the workshops included systemic movements, drawing, the family genogram, music therapy, bioenergetics, dramatization and personal experiences. At the end of each session, the students would have 20 minutes to write up their journals, on their experiences and the class activities of that day. The aim of the reflective journal was for students to think about the teaching-learning experience and write freely about their perceptions of the experience, their feelings, emotions, thoughts, ideas, reactions and confrontations they may have encountered. This type of journal allows the student to achieve a degree of contemplation that facilitates transformative learning 29,30.

Phenomenology was the reference framework given that the theory and practice workshops focused on each student’s individual experience. That is, the personal experience of those in the sample (students and teacher) was the common thread running through this qualitative research work whose aim was to assess the impact that the educational proposal had on the nursing students, in order to obtain results and draw conclusions.


The number of reflective journals consulted was 36, 14 of which were selected at random for data saturation. The qualitative analysis enabled the students’ discourse to be structured as 5 categories for analysis. The first category was “reason for choosing the subject”; the second, “personal development”, recorded the evolution in the students’ attitude towards the process of life and death; the third, “what I have achieved in the learning process”, describes and examines the knowledge and skills acquired during the intervention; the fourth category was “how to apply the techniques learnt on the course to my professional activity”, and the fifth, “the students’ assessment of the course”, presented opinions on the subject imparted and a self-assessment.

Category 1. Reason for choosing the subject

In this category, students described their interest in increasing their knowledge of the process of dying, and as a form of personal development.

“...this is a second chance for me to take part in such interesting and stimulating classes that deal with coping with death, where we learn to live with it rather than just get through it” (d14p3).

Category 2. Personal development

The information from the journals on personal development was structured in four sub-categories: self-esteem, identity, raising awareness and relations between participants.

- Self-Esteem. This sub-category gathered opinions expressed by the students on their sense of self-worth.

“Listening to my course colleagues gave me a lot of strength, happiness, a sense of lust for life, to enjoy life, to enjoy being with the ones I love; it was an experience with a lot of beautiful sensations” (d2p3).

- Identity. This sub-category related to the students’ values, traditions, behaviors and beliefs, both as individuals and as a group.

“Some of the words I picked up were well-being, fun, peace, roots, happiness, freedom, love, hope, harmony, serenity, humility, all things which are part of me and which make me feel alive” (d14p9).

- Raising awareness. Content development and particular activities such as “life cycle” helped to raise students’ awareness and develop personal skills.

“In each activity, we were asked to imagine what had happened to us, or what would happen to us in the future, throughout our lives, so it was a productive activity that generated a lot of strong sensations” (d30p6).

This activity also generated a sense of humility among the students. A journey through the different stages of their lives enabled them to understand the grandeur of life.

“...on emerging into life, I realized that I had to get my head down and not fight against life but go with the flow of it” (d29p2).

This act of humanity towards life was reinforced on many occasions during the course, such as in awareness of their roots. There were several highly emotive expressions, such as “Mother Earth”, “the place where we were born”, “where we live”, “it’s something that is immense”. These expressions of love, connection and a deep respect for their roots were heard during the “Mother Earth” workshop. The opinions reflect that many of the participants were not from the city of Huelva but felt welcome and accepted in the city, even though they missed the place they came from, their roots and the sustenance it gave them.

“…it is such a big thing, we are immersed in it day after day. Mother Earth, where we born, and where we live, is so immense that we are all submerged in it, our loved ones, all those who surround us” (d30p4).

It was also observed how students were effectively facing up to life and death. In the former, students clearly and concisely manifested the idea that it lies within all of us to be successful in life.

“I have it clear that we are all unique, 100%, and that we have within us all that we need to be successful in life” (d6p4).

On acceptance of death as a natural part of life, students expressed some very moving opinions:

“Now, the only thing that concerns me is to live life because death, as we know, forms part of life, and it comes to you when it’s your time, but one thing I know is that when I arrive at that moment, I will have lived life, breathed and felt it, and I will know that I have lived life to the fullest in each moment” (d16p5).

In terms of raising awareness of the family system, there are three aspects that require explanation. Firstly, there were expressions of fear regarding the family system, “not being in control”, “something might change”, “worries” which, until they receded, the students were not fully aware of.

“When I finished, I had become conscious of everything written on the card. Fear of change, of the changes in those around me, fear of not being in control of time, situations in constant change” (d6p11-12).

The second aspect is becoming aware of a problem in their relationships with their mothers in their family system: “Not listening to their mothers”, situations resolved by talking with their Mums, “both of us felt better for it”.

“…talking with my mother, she got a lot of things off her chest with me… we talked about the things we have in common…I just hadn’t realized because I didn’t listen to her; after that, we both felt a lot better” (d30p2).

The third aspect relates to how students felt “disconnected from the family circle”. These aspects became apparent in the course work on “fears and the family system”.

“While my brothers and sisters are all close to my mother and support her, I have to do the same at a distance because I’m studying away from home, and this makes me feel a bit remote from the family circle” (d14.p6).

There was also growing awareness of their parents as other than just their mothers or fathers, that they were part of the student’s family system, but also members of other systems. “It made me realize that our parents are not just my mother and father but other people’s brothers and sisters, friends, children and grandchildren” (d18p6).

The students also expressed wonder at seeing the “look of innocence” in their parents in photos of them as children.

“I felt quite emotional. I had never thought they had once been children too, and I could see how young and innocent they were” (d14p7).

These expressions were gathered from the class in which students presented photos of their parents as children.

- Relations between participants. The evidence from the journals shows how the students were gratified to hear positive words from their colleagues. Three students expressed satisfaction at comments from their co-participants, which were gratefully received: “I’ll carry these feelings with me for the rest of my life”. These feelings of happiness and gratitude to colleagues for their kind words manifested in the “My House” activity, designed to promote good relations between participants.

“This dynamic helped me to hear the kind words of my colleagues about me, especially as in the day-to-day routine we find little time to say such nice things, and I felt that these four years with them was all worth it, and I’ll carry these feelings with me for the rest of my life” (d18p8).

There was also an expression of the sense of union among the group, with words of affection, sympathy and support:

“The satisfaction of saying what I could never express before, reinforcing the idea that ‘Yes I Can’…”…“I’ve said things I have been trying to say for a long time but never found the right moment” (d4p8).

These expressions arose from the “My House” activity, which was aimed at strengthening ties within the group. It is a basic strategy to promote group cohesion and is essential for preparing students to tackle more delicate and serious content.

The activity called “Healing Relationships” allowed students to put their relationships with others in order, yet contradictory sentiments were often expressed. On the one hand there was relief at mending fences:

“Thanks to this work, I feel I have got something off my chest, and was able to fix a problem which, because it was never discussed, got worse and worse” (d16p6).

On the other hand, feelings of liberation for having expressed pent up feelings were set alongside “indifference”, and of a problem left unresolved:

“…in the activity in which we put ourselves in the situation of others and try to see things from their point of view, I said things to my father, who I don’t get on well with, but I noted that he didn’t seem to care and felt uncomfortable with it all” (d14p8).

This activity also showed how some students could successfully resolve their problems by facial gestures, body language, looks, and how others could not do so through such actions.

In the systemic approach, it is important in relationships that a balance between giving and receiving can be found in “the tunnel of affection”.

Here the comments were contradictory. Some felt “brilliant” after receiving affection and hugs of gratitude from their colleagues:

“It felt great when my colleagues showed me their affection when I passed through the tunnel” (d16p3).

However, others found it difficult to receive hugs and affection from their colleagues:

It’s difficult for me when they enter my vital space.” “Like in life in general, I didn’t feel comfortable with this. I am only affectionate with a few people and cold towards the rest, and I find it uncomfortable when someone steps into my space.” (d6p12).

These contrasting feelings appeared frequently in the development of this activity; there was resistance on the part of some students to accept the affection of their colleagues. This awkwardness has a systemic background, and touches on the loyalties to our system.

Category 3. What I have achieved in the learning process.

Here, the sub-categories were: systemic knowledge; knowledge of life and death; skills; knowledge of grief; attitude; knowledge of mind-body therapy.

- Systemic knowledge. Here the students discussed and reflected on their knowledge of the systemic approach and the Commandments of Love:

“All this made us stop and think about whether our environment really is a system and if it functions like a system or not. It is surprising what we discover and understand after this…” (d14p8).

“The importance of balance between giving and receiving so that a relationship can be healthy” (d29p1).

It is clear that the students acknowledge the importance of their place in their own system, and the balance between giving and receiving. This knowledge was acquired in the class on the theory of “Systemic Pedagogy” that developed this knowledge in a range of activities.

The students also expressed their understanding of the “Commandments of Care”.

They reflected that each person has their own strength to face the different processes of life and by taking on the role of the other person in this process, we end up weakening them.

“... I have to work on this since if I take my father’s place, for example, I diminish him, as if he was incapable of doing that role himself, and you end up creating a dependence” (d16p4).

- Knowledge of life and death. Students’ opinions on this subject were clear on how to face life without prejudging:

“The class made us think, we become aware of the reality that surrounds us and how, once again, we see that death forms part of life, and that is how we must deal with it” (d30p12).

Then there is the students’ awareness of the difference between pain and suffering, themes that were treated in the theory classes.

“Pain exists in the present, since we are protagonists of the present, the moment we live in, recalling the past and worrying about an uncertain future; we have no pain, only suffering, which is nothing other than toxic pain” (d6p6).

Two important aspects emerged in this sub-category on the treatment of the patient as a person, an adult, giving them the chance to close affairs they have pending.

“The need for a person who is dying to be treated as a person, with all their feelings and emotions. It’s important to know how to listen and understand what they are going through, that they should not be treated with fear and they should be allowed to tie up loose ends, as well as helping them to remember all the good things of the past” (d9p6).

It is important that the family is able to bid farewell to the patient with love, with an acceptance that the end of life has arrived.

“Letting go of their loved ones, with beautiful memories, out of love. So, it is out of love that they should be able to let their loved ones go when their moment has come, and understand that their lives must now draw to a close” (d18p10).

This sub-category also touched on knowledge of how we, as professionals, can approach the patient’s individual spiritual needs, accompanying them and respecting the decisions they take at all times.

“…it has opened my eyes, and it is possible to be close to the patients in their spiritual needs; they would like us to be close to them in the final days of their lives” (d18p10).

The students also expressed their belief that each death is unique, and patients should be treated as such.

“Each person is unique in the way they pass away” (d4p2).

As a result of the knowledge acquired in this section, the students manifested the desire to live life from the perspective of living life to the full, with gratitude, with the realization that when their time comes, they will have lived life as they wanted to live it.

“We must live life to the full so that when we reach the end of life we can look back and feel at peace with ourselves, giving thanks for the life we have had” (d14p10).

Students’ awareness of the importance of motivation in life, to give life meaning and to reach their goals manifested in various comments:

“The motivation to keep on making life meaningful, and to continue pursuing our goals in life” (d2p5).

Here, we see how the intervention has led to the evolution or change of perspective in the students in terms of their lives. In most of the classes given, reflection on the phrase “to understand death is to understand life” had a profound effect.

- Skills. The students’ comments reflected their satisfaction with the “Looking at the other person and knowing their feelings” activity.

“It was surprising to see how in 90% of cases we correctly guessed the feelings of a colleague. In my case, I could feel how this one student, who stood out as one of the best, displayed feelings of fear” (d14p7).

- Knowledge of grief. The students described the knowledge they acquired on the subject of grief.

“We had a set of objectives that will help us deal with grief in the best way possible” (d30p14).

Other comments revealed how the students learnt to measure whether grief was ongoing or had been assimilated and resolved.

“The comforting recollection is a feeling that helps us recover, and overcome our sense of guilt. It is the sign that our grief is resolved” (d30p14-15).

Students also recorded how a loss is not only related to the death of a loved one but manifests in other forms that also lead to suffering a feeling of grief.

There are several types of loss” ... “We observed that not all loss centers on the death of a person. Grief can appear as something affective, physical, social and evolving” (p30p14).

The work with students on the subject of grief also related to the process of grief in its various stages.

One student expressed joy and support for a colleague who was involved in this dynamic.

“My colleague was grieving for her grandfather, and talked about all the things she would say to him if she could see him one more time, and afterwards she felt how much her grandfather loved her and how proud he was of her. It was emotional to see how my colleague was really overcome by all this; she really lived the process and threw herself into the dynamic; it was emotionally very strong” (d18p12).

These actions fit with the theory of grief and the “working with grief” activity.

Other students expressed gratitude, and feelings of stronger self-esteem, of learning “to love yourself”.

I’m grateful for all that I have learnt. It has made me stronger and has shown me how beautiful life is…the most important thing is to love yourself more than you have ever loved yourself before. Because to catch the rainbow, first you need to get through the rain” (d29p4).

Other references to grief and personal development appear in students’ writings on the importance of working on grief on a professional level, and acknowledging how this learning affects their personal lives.

“It is important both professionally and personally to work on loss, since throughout our lives we can suffer a series of losses. And we need to come out of this stronger, and learn from loss to make us stronger” (d16p6).

Another aspect is how a person matures on accepting that a relationship with a person is concluded on death, but recalling all the good times lived with them.

“..this dynamic helped me because it was a relationship with one of my closest friends that I lost…a part of my life was lost but I remember only the good times we had together” (d18p8).

- Attitude. In this sub-category, the students described feelings of profound gratitude towards their loved ones who had died, and great respect for all those who pass away. The most-widely expressed feeling is one of love, pride and thankfulness for everything they received from them in life. These feelings were expressed in the “All Souls Day” activity.

“We give thanks to our loved ones who have departed, with words of praise and feelings of pride for all they gave us in life…there is a place in our hearts for all those who have passed away” (d18p5).

- Knowledge of body-mind therapy. This section deals with knowledge of bioenergy (mind-body therapy). Students understood the importance of this to release tension and to learn to listen to their bodies. It also made them aware of energy blockages, and recognition that there are times when “something needs to be done”.

Releasing tension and emotions, and listening to our bodies for a while…I could see my blockages that prevented me from expressing myself better, and it made me think about what I need to do” (d14p3).

These comments refer to work performed in the bioenergy workshops. Another important aspect of mind-body therapy is the well-being that comes from a bioenergy massage.

“It was amazing to feel the warmth of hands on my back. It releases all the pressure” (d29p1).

Category 4. How to apply the techniques learnt on the course to my professional activity

The information corresponding to this category is structured in four sub-categories.

- Nurse’s attitude towards death. Here we observe how students express themselves deeply and in heartfelt terms during the theoretical classes on the “four tasks for life and death”. Their comments come from the heart, not from rationale or the intellect, and express their personal satisfaction on feeling competent to be by the patient’s side in their final days, both as people and professionals providing care.

“ has taught me to know what these beings of light want in the final days of their lives; and as a nurse how I propose to look them in the eyes and see them as strong, and look at them with love” (d29p4).

- The systemic approach in nursing care. This sub-category deals with knowledge transfer in the systemic approach to nursing care, which acknowledges that behind the patient there is a family system and history to take into account. This section also examines the systemic approach, the commandments of love; the third order of love is to be in the place you are supposed to be.

“….to appreciate it as it is forms part of their system, and we should know where we need to be at all times. Each adult has their own life story…a terminally ill patient” (d6p21).

- The value of empathy in nursing care. The students expressed their understanding and appreciation of empathy as a fundamental value in nursing care, which was evident throughout the course.

“Empathy is value that each health care professional, and especially nurses, must acquire from the beginning because it is a vital skill to have in our development as good professionals and as people” (d30p10).

In their writing, the students showed an attitude of respect and support for, and recognition of, the patient.

“As nurses, we must be at the patient’s side, respect their decisions, support them, listen to them as they express their fears, the important things they want to say, and their pain, without judging them” (d18p10).

These reflections seem to point to the theory of dying people’s needs, and “putting our relationships in order”, because this activity concluded with a debate on the idea that a person is not complete until they accept both their good and bad parts.

- The health care professional, taking care of ourselves in order to care for others. The students’ journals reflect the work each one developed on personal growth in this particular area. One phrase that resonated in the class was “taking care of ourselves first before taking care of others”, an idea that was reinforced in the bioenergy sessions. This technique emphasizes “getting rid of the bad while holding on to the good”, and instructs students to appreciate the good things that life has given them that day, and get rid of what they do not like.

“... expel all those bad things that have invaded us, and keep hold of the good and the productive things in our day-to-day lives and in life in general; this helps us to encourage each other and gives us the strength to become better professionals in our work with our patients, in the hard times and not so hard times” (d30p3).

Category 5. The students’ assessment of the course

Here, the students expressed their satisfaction with the subject imparted. They recognized that the course provided them with knowledge and skills to become better people and nursing professionals. This awareness of their own value is the result of a process of growth and maturity during the intervention. They see they have acquired competences as nurses that will help them to confront the process of death and of their own lives.

“Dealing with death is a feature of our profession, and is a definitive part of life. To be able to face up to it in the best way possible as a person and a professional, we need a set of essential competences that this teaching has given us. I have lived through this process and gone through hard times with it. This subject interests me a lot, and I want to continue working on it, not just to be a good nurse for the living, but a good nurse for the dying too” (d14p15).

“I think that this is such a beautiful subject, and so real. I am grateful that you showed us what you see as the need for us to know ourselves and our fears, and how we can be with people in the final days of their lives” (d29p5).


This research is both novel and original, and we have found no references in the literature to enable us to compare our results with other similar studies. To summarize the findings based on the students’ feelings as expressed in their journals, we can say that the course, “Coping with death; an interdisciplinary intervention”, was positively received, and the participants acknowledge that it gave them greater self-confidence as people and professionals, and that they now possessed competences as nurses to be able to deal with the process of death and of their own lives. The students expressed the notion of wanting to live their lives because they were now more fully aware of life itself. They discovered that, as nurses, they now felt able to attend to the spiritual needs of the patients, and understood the personal change and evolution that they had undergone during the course, as well as the strength it had given them to assume their responsibilities, and to respect their place within their own family system, to feel liberated and free.

Future research proposals. It is essential that more research is done on the use of the systemic and Gestalt approach in training for nursing students on end of life, death and grief:

  • Training of nursing students should incorporate humanistic psychology, in particular Gestalt and systemic psychotherapy.

  • Nursing students and professionals should be trained in a systematic approach that includes the Commandments of Love and the Commandments of Care in their daily nursing care work.


This section deals with fulfilment of the specific aims of the teaching intervention and the general aim.

Specific aims:

  • -To make a theoretical and conceptual link between the philosophical principles of palliative care and the systemic approach.

  • The students were instructed on the two disciplines in the teaching-learning process.

  • -To impart knowledge of the systemic approach so that students can improve their nursing care skills to deal with end of life, death and grief.

  • The knowledge and skills acquired by the students during the intervention, which includes the systemic approach, helped them improve their nursing care skills for end of life, death and grief.

  • -To develop a positive change in attitude in the students towards the process of dying and grief.

  • The intervention generated a positive change in students’ attitude towards the process of dying and grief, and a more positive outlook on life.

  • -To train students in humanistic psychotherapy techniques to help them deal effectively with the process of dying and grief.

  • All the humanistic psychotherapy techniques used in the intervention to help students cope effectively with the process of dying and grief were essential to enabling them to reach this objective.

  • -To stimulate students’ interest in the process of death and grief, and encourage their involvement in the systemic approach.

  • The intervention increased students’ interest in the subject by developing the systemic approach in the teaching-learning process.

  • -To make students aware of the importance of how the process of terminal illness, death and grief is experienced, to enhance their personal and professional development.

  • During the intervention, the students became aware of the importance of accompanying the patient and experiencing this process with them, both for their personal and professional development.

  • -To show the students that it is important to learn the values of gratitude and admiration.

  • On the course, the students understood how gratitude and admiration were key nursing values to be acquired.

  • -To show students the importance of assimilating the Commandments of Care into their daily nursing activities.

  • Students were instructed on the content of the Commandments of Care and how they are applied to nursing.

  • -To encourage good relations between the students through belonging to the system.

  • The students reflected positively on this aspect of the course.

  • -To show students the importance of the Commandments of Love for their own family system, and their part in that system.

  • The students wrote positively about this aspect of the course.

  • The general aim of this research was to assess the impact of the educational proposal “Coping with Death: an interdisciplinary intervention” on the nursing students who participated.

The teaching intervention had considerable impact on the students in two important dimensions of their lives. On the one hand, it enhanced their academic competences as future nursing professionals, and, they acquired skills and positive attitudes towards the process of end of life, death and grief, integrating the life philosophy that “helping someone to die is learning to live”, replacing attitudes of rejection and fear of death with an acceptance of life as it is.


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How to cite: Palomar Gallardo M.C., Romero Palomar M., Pérez García E., Romero Palomar M.I. Educate Nursing students for life and death: “from fear to love” Enfermería: Cuidados Humanizados. 2020; 9(1): 65-81. Doi:

Contribution of the authors: a) Study conception and design, b) Data acquisition, c) Data analysis and interpretation, d) Writing of the manuscript, e) Critical review of the manuscript. MCPG has contributed in a,b,c,d; MRP in c; EPG in e; MIRP in d.

Correspondence: María Cinta Palomar Gallardo, e-mail:

Managing scientific editor: Dra. Natalie Figueredo

Received: April 18, 2018; Accepted: March 31, 2020

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