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INTRODUCTION ABSTRACT Death will give impact on people around the patient.

People use to have their death traditionally in their own house but nowadays, the death that occurs in the patient house is getting lesser and lesser (Tang, 2000). However the numbers of death occurs in hospital has increase (Chiu, 2006). According to Zgaga & Pahor (2004), this might be due to the social and family structure changes and the advancement of medical care. Thus, it is important for the health care provider to deliver the care for dying patient adequately. Care for dying patient can be stressful since it can potentially evoke emotional reaction (Huang et al., 2010). To deliver the best care for dying patient, the nurse need to be prepared, and the preparation starts at the student years. It is said that the experience in the student years will influence the registered nurse years when they are working soon especially in delivering the care for dying patient. This is because the care for dying patient involve with emotional and psychological influence. According to Kelly & Nisker (2007), the student that has not undergone this experience in the good ways will have emotional breakdown and also avoid the patient. According to Parry (2011), some might also have an emotional breakdown. Therefore, researcher wants to explore the IIUM nursing student nurse experience on facing death during clinical posting. This study aims to explore the experience of IIUMs nursing students experiences of their first encounter with clients death during clinical practice, to explore the student nurses feeling when facing the death of their client; before, while, after, to describe students emotional reaction towards the dying client; before, while, after, to describe how student nurses cope with the dying client; before, during, after and to check whether the tools given in the class is sufficient to prepare the student nurse to face death in clinical area This research is meant to explore the nursing student experience on death of the patient during clinical posting to see how the student cope with that experience and see ways to improve it since care for the dying patient is a stressful event (Parry, 2011). We also hope by enabling the student to have a successful coping, the care of the dying patient will be improved since the student without a successful coping then to neglect the patient due to the trauma that they have before (Kelly & Nisker, 2010) By doing this research, we also hope that the IIUM nursing student who will become a nurse in the future will be able to delivered a holistic care not only for the dying patient but also to the family. Thomson, Austin & McGrath (2010) stated that the future response to death is influence by the first exposure. RESEARCH METHODOLOGY The qualitative research method was used as it can refer to research about people live, lived experiences and behaviours, as well as feelings and emotion, cultural phenomena and interaction between nations (Strauss & Corbin, 1998). Qualitative approac h was used because it focuses on how people interpret and make sense of their experiences and the world they live in. So, using qualitative approach was a wise step to explore the experience of nursing student facing death in the clinical area because its investigate different views of human being and interpret their lived experiences in a natural context; which is hard to be achieved suing quantitative approach. The interview was conducted in IIUM Indera Mahkota Campus and Jalan Hospital Campus, Kuantan. The study population was the IIUMs Bachelor of Nursing student from fourth yea r. The participants are selected using purposive sample method. The participants that have the experience of the patient death was searched through the 4 th year nursing student by asking them personally if they had any experience facing their client or patient death. After that, those who experienced the death of the patient during the clinical posting were recruited as the participants and consent were asked from the participants. Before the interview the entire research plan was explained in details to the participant including the way the interview was take place which is recorded face to face interview, the transcript was made from the interview recording while the anonymity and privacy was maintained in the result. The entire participant gave their consent before the interview and if
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they want to withdraw from the interview they wish will be respected. As this topic can provoke emotional reaction, the participant can stop the interview at anytime they feel uncomfortable. The participant will be referred to the counsellor if they feel like they feel like they need any further help with their past experiences. 5 students were involved in this study. The interview was conducted using semi structured interview until the point in data collection when new data no longer bring additional insight to the research question. The data analysis was done using Colaizzis method (1978). The steps of Colaizzis method will be as follows: 1. Read all protocols , get a feeling for them 2. Extract significant statements 3. Spell out meaning of each significant statements 4. Organize formulated meanings into clusters of themes 5. Integrate results into exhaustive description of phenomenon 6. Formulate exhaustive description of phenomenon into unequalvocal statement of identification 7. Validate by asking participants about finding RESULT & DISCUSSION The conversations were transcribed into transcription in order to ease the analyzing process of data. The researcher was read and re-read the transcription to acquire sense of each transcript. Analyzing process was guided by open ended questions and the individual statements made by each participants. The coding has been made by extracting the significant state ments from each transcription. The coding was given to dialogue in the transcripts when it repeated many times. Analyzing process was continued with formulation the meanings and organizing the coding into clusters of the sub themes and main themes. It include the clustering the ideas, concepts, behaviors, incidents, terminology, and phrase used by the participants. All of the data has been organized into coherent categories which summarize and bring the meaning to the text. The themes identified as in stated in Table 4. The three major themes was formulated which are challenge in caring for the client , emotional reaction, care to the patient and relatives, student coping mechanism. Based on the interview with the participants, a few challenges were found. Patient death is an uncomfortable condition to deal with. This finding is supported in various study conducted whether the subject the nursing students, nurses or even for the doctors; all of them find patient death is uncomfortable (Parry, 2011; Zambrano & Barton, 2011; Liu er al., 2011;Thomson, Austin, McGrath, 2010; Hurtig & Stewin, 1989). In this research said that the experienced of dealing with the body was very uncomfortable for them especially dealing with the body. Shortage of knowledge as described by the participants also mentioned in other researches (Loftus, 1997; Shea, Grossman, Wallace & Lange, 2010). Due to this reason, the student cannot do as much as they wanted to the patient and relatives. The students need to be prepared with enough knowledge to be able to care for the dying patient successfully. They have to be assigned to the appropriate patient in accordance to her or his knowledge and experience (Mallory & Allen 2006). Mallory & Allen also suggested that during the first year of posting as a student, the clinical instructor need to be always by their side especially if they are caring for the critically patient. There is also a participant feels she is lack of confidence when dealing with the dying patient. Loftus (1997) & Shih et al. (2006) described that the student is aware that they are lacking in confidence to serve the patient and relatives. Mallory & Allen (2006) also found that the treatment that the student receive from the nurses and others influence the nursing student experience in caring for the dying patient and also patient in general. From the interview, we found that the nurses are yelling at the student during when they are doing resuscitation to the patient. The nurses should be friendly, be available when the student has a problem, showing interest to the student and also be aware of the student condition (Jackson & Mannix, 2001). Before the patients death, the participants feel scared, stress, shock, amazed, excited, and touched. The participants feel shocked due to the patient condition. This is also found in various
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researches and one of them was found in the research done by Parry (2011). The participants also feel stress when caring for the patient due to patient condition or relatives concern but either way, this made them keener on delivering care on dying patient. As mentioned by Mallory & Allen (2006) stress makes the nursing student deliver a better care towards dying patient. Mallory & Allen in their research also found that the student felt amazed, excited and touched by the patient and relatives. According to Wadsworth (2010), the nursing student is feeling excited because they want to apply what they learned in the class. During the event, the participants feel panicked, shocked, happy, and hopeful. The participants feel panicked because of the rapid patient changes. According to Thomson, Austin & McGrath (2010), the changes in the patient condition caused the novice nurse to be panicked and shocked. When the patient is dying, the participants did feel happy and hopeful. The participant feels hopeful when she performed the CPR. During that moment she really hopes that the patient survives but she didnt. According to Huang et al. (2010), they found that the student is feeling scared while performing CPR. They were afraid because that was their first encounter and they dont have any experience in CPR. So, if the participant was in her first year during that time, she might feel scared as well during the CPR. After the patient died, all of the participants did feel sad. Feeling sad after seeing patient death is a normal reaction (Kiger, 1994). Based on the interview, the level of sadness is different according to the attachment with the patient and relatives. All the participants agreed that when they become attached with patient, they will become sadder when the patient passed away. They are many literatures reporting the same finding (Loftus, 1998; Thompson, Austin, &McGrath, 2010;Kiger, 1994; Huang et al., 2010). In the interview, the participants also found to be having a self-doubt. The participants also did feel guilty (P1, P2, P3). According to Zambarno & Barton (2011), the sadness that they feel might come from the guilt whether they realize it or not while Loftus (1998) found that the guilt come from seeing the patient condition deteriorate. One of them felt the trauma because they way that the patient died was quite dramatic. Having trauma in the difficult condition like death is to be expected (McKenna & Rolls, 2011). The other one was traumatized by seeing the death body for the first time. Trauma means that the participants will try to avoid the encounter of such event until they recover. Feeling insaf means that a person fully understands a situation until they have the awareness about that matter. Insaf is a Malay word which is influenced by the Islamic influence. In this case, what the participant means from the word insaf is fully understand about the dying process which brings them closer to the God. Death brings discomfort to the living. When, human are in a condition where they feel overwhelmed, they will find something to rely on and in this case God (Kelly & Chan, 2012). Other emotional reactions after the patient death found in this resear ch are feeling regret, hopeless, scared, stress, nervous, disappointed, indifferent, and shock. All of these finding are similar with the other finding in other researches. According to Peterson et al., even a nurse still fell nervous and stress when dealing with death. In this research, the participants feel nervous because of the last office procedure where they have to prepare the death body to be sent home and also feeling nervous to approach the patient. There is also research found that the student nurse wanting to go back to the past and give a better care to the patient (Shih et al., 2006). In this research similar finding was found. The participants are regretting what they had done to the patient and feels like doing it again. After being hopeful when trying to save the patient, the student did feel hopeless after the patient dead. Loftus (1998) also found that the nursing student feel hopeless and disappointed after the patient died. Besides all of these emotional reaction, there is one participant said that she feels indifferent. Kiger (1994) found out that there is small group of student feel nothing when the patient died. They dont feel anything because they cant find anything to relate themselves with the patient and some just dont feel anything. According to Loftus (1998), the student feeling is influenced by the attachment formed with the patient. When the patient is experiencing death, spiritual support is very important to them Kelly and Chan (2012). As for a nurse, it is important for us to provide the patient and relatives emotional and
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spiritual support. In the interviews, we had the entire participant experienced in giving spiritual and emotional support to the patient. Other than emotional need and spiritual needs, the student nurse also gave advice to the patient and provides them with the thing that they need. As a nurse, we need to allow the relatives to practice their religious practice when the patient is dying as this can reduce the patient fear of death (Ross, 2001). In this research, the student did allow the relatives or see the nurses allow the relatives to read yassin, quran, or any other religious book since it can make the patient calmer (P1, P3, P4, P5). As the patient still breathing, the care to patient goes on as a normal patient does (Huang et al. 2010). In caring for the dying patient, they most important things is to provide them with comfort and also minimizing their pain (Shea et al., 2010). Before the patient died, the most important thing for them is being with relatives (Shea et al., 2010). As in the research we found that the students were respecting and understands the needs of patient to be with the relatives. The nursing student also did have the opportunity to do the LO and the found that in some cases the procedure was not properly done (Shih et al. 2006). There were also students that did the LO in a very compassionate ways. However, in this research, we found that they are on student unable to perform the LO because she was too a ttached with the patient. This finding is also supported by Thompson, Austin & McGrath (2010) and Peterson et al. (2010). The first and most used coping mechanism by the student is coping mechanism. The participants told friends and relatives of what had happened. This finding is congruent with the research done by Peterson et al. (2010) and Liu et al. (2011). The participants also go to the lectures for support. This finding is congruent with the research done by Mallany & Allen (2006). The other coping mechanism found is being closer with god. This is supported by the research done by Kelly and Chan, 2012). Acceptance of death is the participant own way of coping from the inside. This finding is supported by Zambarno & Barton (2011) and Peterson et al. (2010). The participants feel like the patient death is the best for them and also every living soul will be death. They are also a few old folk tips that the participants did like not staring at the dead body for too long. However, there is no scientific explanation for the rituals and old folk tips practiced by the participants. There are also a participant reported that after encountering the patient death, she could not eat. There is research done saying that there are certain people cope by doing negative thing (Zambarno & Barton, 2011). In this research they found that some people cope by doing negative thing like increase the amount of alcohol drank. CONCLUSION AND RECOMMENDATION As conclusion, nursing student experiences facing death during clinical posting is inevitable. The experience is very challenging. So, as a student, we have to be prepared to face the clients death and family. Learning on how to adapt with the client death not only will minimize the trauma inflicted to the family, but help student nurses deal with their feeling as well. Having the experience of facing death during clinical posting is quite useful they can use the experiences that they gain during the clinical posting when they are working in the future. There are also researches done stating that the more experience of student dealing with the death, they will become more adapting towards them. They also will know how to take care of the patient and client when they are working in the future. To prepare them to be good nurse, we could use various method of teaching for example role play. By applying role play, the student could practice what to say to the patient (Mallony & Allen, 2006). This method has also be proven to be used and practiced in training (Liu et al. 2011). Other than role play, sharing moment could also make the student gain an experience on how to take care of and face the dying patient (Leavy, Vanderhoff & Ravert, 2011). Other than that, the student might also improve their care for the dying patient by attending workshop on life and death issues. According to Liu et al. (2011), nursing student benefited from the workshop on life and death which they attended. After attending such courses, student able to understand themselves better, practice reflective thinking, and express their self better. Last but not least, the counselling service usage should as well be promoted to the students (Peterson et all, 2011).
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References Huang, X.-Y., Chang, J.-Y., Sun, F.-K., & Ma, W.-F. (2010). Nursing students' experiences of their first encounter with death during clinical practice in Taiwan. Journal of Clinical Nursing , 2280-2290. Hurtig, W. A., & Stewin, L. (1990). The effect of death education and experinece on nursing student's attitude towards death. Journal of Advance Nursing , 29-34. Kelly, E., & Nisker, J. (2010). Medical students' first experiences of death. Blackwell Publishing, Ltd, Medical Education , 421-428. Kelly, M. M., & Chan, K. T. (2012). Assessing the Role of Attachment to God, Meaning, and Religious Coping as Mediators in the Grief Experience. Routledge Taylor & Francis Group , 199-227. Kiger, A. M. (1994). Student nurses' involvement with death: the image and the experience. Journal of Advance Nursing , 679-688. Leavy, J. D., Vanderhoff, C. J., & Ravert, P. K. (2011). Code Stimulation and Death: Processessing of Emotional Distress. International Journal of Nursing Education Scholarship , 1-13. Liu, Y.-C., Su, P.-Y., Chen, C.-H., Chiang, H.-H., Wang, K.-Y., & Tzeng, W.-C. (2011). Facing death, facing self: nursing students' emotional reaction during an experiental workshop on life-and-death issues. Journal of Clinical Nursing , 856-863. Loftus, L. A. (1998). Student nurses' lived experience of sudden death of their pat ients. Journal of Advance Nursing , 641-648. Mallroy, J. L., & Allen, C. L. (2006). Care of the dying: A positive nursing student experience. MEDSURG Nursing , 217-222. McKenna, L., & Rolls, C. (2011). Undergraduated midwifery student's first experiences with stillbirth and neonatal death . Contemporary Nurse , 76-83. Peterson, J., Johnson, M., Halvorsen, B., Apmann, L., Chang, P.-C., Kershek, S., et al. (2010). Where do nurses go for help? A qualitative study of coping with death and dying. International Journal of Palliative Nursing , 432-438. Polit, D.F., Beck C.T. (2008).Nursing research,8th Edition. Lippincott, Williams & Wilkins, London. Ross, H. M. (2001). Islamic tradition at the end of life. MEDSURG Nursing , 83-87. Shea, J., Grossman, S., Wallace, M., & Lange, J. (2010). Assessment of Advance Practice Palliative Care Nursing Competencies in Nurse Practitioner Students: Implication for the Integration of ELNEC Curricular Modules. Journal of Nursing Education , 183-188. Shih, F.-J., Gau, M.-L., Lin, Y.-S., Pong, S.-J., & Lin, H.-R. (2006). Death and help expected from nurses when dying. Nursing Ethics , 360-375. Strauss, A. L., & Corbin, J. M. (1998). Basic of Qualitative Research: Procedures and Techniques for Generating Grounded Theory . CA: Sage Publications. Tang, S.T. (2000) Meanings of dying at home for Chinese patients in Taiwan with terminal cancer: a literature review. Cancer Nursing 23, 367 370. Thompson, G., Austin, W., & McGrath, J. P. (2010). Novice nurses' first death in critical care. Canadian Association of Critical Care Nurses , 26-36. Valentine, C. (2009). Negotiating a loved ones dying in contemporary Japanese society. Routledge Taylor & Francis Group , 34-52. Wadsworth, D. (2010). Baccalaureate nursing students' tacit experiences with transition from the classroom setting to their first clinical rotation. University of Hartford . Zambrano, S. C., & Barton, C. A. (2011). On the Journey with the Dying: How General Practitioner Experience of Death of Their Patients. Routledge Taylor & Francis Group , 824-851. Zgaga, A. & Pahor, M. (2004) How nursing students perceive dying. Obzornik Zdravstvene Nege 38, 325331.

Table 4 : Cluster of the themes Themes Subthemes Challenge in caring for the client Dealing with uncomfortable condition (C1) Physically incapable (C2) Shortage of knowledge (C2) Lack of confident in the student (C3) Treatment receive in the hospital (C4)

Emotional reaction

Before the event (C5) During the event (C6) After the event (C7)

Care to the patient and relatives

Islamic practice is essential (C8) Caring for the patient (C9) Emotional Support (C10) Spiritual Support (C11) Performing life saving measures (C12) Performing LO (C13) Giving information to the relatives (C14) Respecting the family last moment with patient (C15) Providing relative with what they need (C16) Giving emotional support to the relatives (C17) Giving advice to the relatives (C18) Need support (C19) Getting support from parents and friends (C20) Need the Instructor help (C21) Acceptance of death (C22) Be closer to God (C23) Doing negative things (C24) Adapt with old folk tips (C25) Rituals (C26)

Student coping mechanism