Being confronted by others
Students during their participative observation in the wards experienced two distinctive behavioral pathways that challenged their beliefs and their theoretical education. These included nurses who behaved in an offensive and less caring way towards the patients and simultaneously deprived the students from acting upon such situations. The students experienced this behaviour as an underestimation of their abilities to interact with the patients and an exercise of power over them by the professional nurses. Students felt powerless in their practice and constrained in their duties. However, the students also identified nursing behaviors that included the necessary support to patients and their families. This group of nurses also acted as role models for the students, adopting this way a more responsible and mentorship-like approach.
Sub-theme: being challenged and powerless
M1: “We observed many times that the staff had behaved offensively towards patients, without respecting the unfavorable position in which they were. Unfortunately, many times, we, as students seek to approach the patient, but sometimes, the personnel looks at us curiously because they consider that communication with the patient is a loss of time. They simply do not have faith in our abilities to approach and effectively communicate with the patient in suffering, it is so disappointing”.
F6: “It is not only that they do not have faith in us…I get the impression that they rather are “afraid” of us, I don’t mean it in a real sense, but as intruders we invade their personal space their kingdom where they rule and feel challenged… they feel that they need to be protected against us and the easiest way to achieve this is by exercising their power over us…and this can take many forms”.
F5: “It is a dull and “cold” center; it almost gives me the creeps. The confrontation that we had from the staff was disappointing. Some of them made us feel as if we were a burden, an unnecessary but mandatory issue that they had to deal with during their work. They were moments that I felt so bad; I preferred to be anywhere else but here […]. Not trusting us meant that they did not trust our abilities and skills…they somewhat took for granted that we had nothing to offer”.
Sub-theme: being a self-actualized nurse
G7: “With her (i.e. professional nurse), I have learned much, the way one should work and treat each patient as a unique individual […] paying attention to (important) details. Everything is important and relevant to caring, nothing should be assumed. The nurse X was caring for the patients with love and affection. I would have wanted to be one nurse just like her, worthy, with self confidence, creative and very energetic. This is a nurse every patient wants be cared by”.
B1: “I was training in this ward for 2 days and I felt that what I had been taught in the classroom was in the best case not applicable in practice. My whole training was challenged and I found myself in uncomforting situations. Many times I had to rely on myself to cope with the situation; I had to drawn on good examples from my practice and avoid the bad ones”.
During their clinical practical nursing students evaluated their own abilities, behaviors and reactions towards the patients. Feelings of self fulfillment when accomplishing a task were reported by the majority of the student informants and this was generally observed when good communication with the patients was established. Not paying attention to details communicated by the patients made patients and nursing students feeling uncomfortable. The same problem occurred when nursing students were not in a position to accept their own fears and prejudices especially in relation to death and dying.
Sub-theme: being acknowledged
Β2: “Ηis mother told me: you have moved us, you are suitable to be a nurse. You will become a very good nurse.” Before I left, his father had shaken my hand and told me thank you for everything…it made me feel so good about my work, about the “good” I was offering to the patient…now I am sure that I made the right choice, I am in the right place to actually make a difference”.
B3: “I am not celebrating merely because I have done something good, it is simply my job, what I was trained to do best, I don’t expect congratulations from everybody, just acknowledgement for what I do…and the patients and their families are generous with that, I don’t know if I always deserve it…but it sure makes a difference when it comes”.
G6: “They [the patients] kept thanking us for insignificant things… That was particularly impressing for me… They showed particular interest about us. They wanted to know about our lives, where we came from, about our studies and many more. They demonstrated a genuine interest, and this was rewarding. They kept wishing us good follow up with our studies and be good practitioners because they relied on us to care for them”.
Sub-theme: being lost in translation
G4: “Today, while we were taking the medical history from a female patient, I wasn’t careful that she had a mutilated right leg and asked her if she could easily move. She said: How? I felt so bad and embarrassed; I wanted to vanish from the face of earth…why I wasn’t more careful? I learned the hard way that is important to be a good observer and listener and that our patients expect us to be as such”.
M1: “He was trying to say something to me…I didn’t figure it out until now…he didn’t feel comfortable having his family around when the doctor gave the news…I didn’t realize…I took some thing for granted and that was obviously wrong!”.
Sub-theme: being frightened and challenged by cancer
G6: […] “I knew that a patient would die and I was trembling on the idea that this might occur on my presence in the room, I felt fear and at the same time sorrow just by thinking of it. When leaving, I thought that I had to accept that death is part of our lives, part of our job and that those people had the need to be listened to and be supported by me. I believe that what made me feel horrified was what I would do if one of my loved ones was in a similar situation or what I would have done if I was dying of cancer…?. These thoughts circled my mind for weeks…At the end of the day I was trying to be in their shoes and this was draining away all of my strengths”.
Being “trapped” in the system
Having a different confrontation on patient’s situations was reported by the student nurses. Nurses’ burnout and not showing empathy towards the patients were among the important issues that students acknowledged during their clinical practice. They also stressed that there was a strong presence of prejudice that driven the actions of some people working in the hospital. Students acknowledged that prejudice also influenced their own practices.
Sub-theme: being driven by prejudice
G5: “Often in practice, we take for granted many things, especially health related information. However, knowledge and information seem that are not so well distributed among the staff working in hospitals. I remember, one child with herpes zoster kept ringing the bell for taking his milk and no one was responding. I was impressed when I entered the room facing the dishes that he ate the day before. This means that cleaners were not well informed by us or the nurses and the fear of transmission kept them from entering the room. It is neither acceptable nor fair to the patient having to pay the results of ill informing processes of the staff or the prejudices some people hold against certain illnesses”.
B1: “Having cancer is not a simple thing, it has never been in Cyprus, and we still come across and have to deal with examples of prejudice against cancer itself. The taboo remains strong even among us students sometimes but we have a duty to set things right, at least to the extent that our knowledge and power allows us to do”.
Sub-theme: being emotionally detached
G1: “During the nursing round, we came across a patient that was in a critical state. That moment a nurse that cared for him the day before said: He has not died yet? I thought that I will come today morning and I wouldn’t find him alive […] That moment I thought of replying to her…but I restrained myself from doing so […] I was so mad with myself for not saying nothing, after all she (i.e. the nurse) overruled everything that I have learned in theory and gave a bad impression of what she represents…the nursing itself. I am still wondering how a person can be so crude or insensitive to another person.”
M1: ‘Listen [a male nurse talking to a group of students]…this is not an easy ward to work in…it takes courage and strength to be able to handle the physical and emotional burden of caring…you cannot feel sorry and bereaved for every patient you care for…you have to be in a ‘safe’ distance…otherwise it is you that will eventually become the patient. At first I thought that this sounded perfectly logic, however, I soon had to reject this approach because I had realized that nursing is all about human contact and human interaction, what’s left if you take away these prominent principles?.’
Being caring towards the family
Cancer is a blow to every family and each person/significant other reacts to differently. Many feelings that are faced by patients are also faced by relatives. The stages of grief are a process that relatives go through in order to cope after the diagnosis and includes the following stages: a) denial, b) anger, c) bargaining, d) depression and e) acceptance. Everyone experiences them in a different way and sometime in a different order, than the one suggested by Kübler Ross . Reactions to illness, death and loss are as unique as the person experiencing them. Some of the relatives are trying to be cheerful in front of the patient acting as normal in order not to influence patient’s psychology and empower them. However, when being on their one their true emotions emerge, often leaving those crying and stranded in a prison like situation, relying only on themselves to cope. Anger is the second stage of the stages of grief. The individual recognizes that denial cannot continue and because of anger, the person is very difficult to care for due to misplaced feelings of rage and envy. There were relatives reporting that health professionals are not giving the appropriate attention to the psychological aspect of the disease and support alternative therapies. There were relatives reporting changes in their energy level, as signs of depression.
Sub-theme: being emotionally and psychologically supportive
B3: “Parents expressed certain complaints for health professionals in Cyprus that they tend to focus on the biological aspects of their children, while the psychological aspects are left untouched and often neglected. Even if health professionals are paying attention to it, this is to a minimal degree. Those parents were supporters of alternative treatments and medicines”.
Sub-theme: being let down
B5: “During the day I was upset with the words of a father that he stated that he was tired. At first, I felt disappointed but later on, I figured out that maybe due to the stress and worries for his child’s health he had reacted in this manner. Instead of being judgmental, I should have realized that this father and every father in his shoes is in need for my support now more than ever, being there when mostly needed […]”.
Sub-theme: βeing offensive towards the nurses
G4: “I went to take the vital signs of a lady that she was dying and she did not want to, I have explained to her why this was necessary and she finally agreed to it. A relative of her then told me in a very offensive manner: She is afraid of you and she does not accept anything from you. Holy Mary, I felt so bad, and of course I did not response to his remarks. . What does it mean that she was afraid of us? Because we may be doing something painful for her own good this does not mean that we care? But from those people that they say when she dies call us to take her what do you expect? I do not want to get in touch with those people and of course I don’t want them to have such an impression for me, and nurses in general”.
During this phase, the interpretation cycle is completed with the critical reflections on the researchers’ pre-understandings, the sense of the naive reading, the findings from the structural analyses, the research question, the context of the study, and the relevant literature in order to gain a deeper understanding. This deeper understanding is the decipher meaning of what the students narrated in their reflective diaries in relation to being caring for a patient suffering from cancer.
The theme “Being part of the center’s life” according to the interpretation has been related with the way informants reflected the feelings generated by their presence in the various clinical centers. Even though the informants considered themselves as being part of the organization, they often felt neglected and in a way “punished”. However, this did not negatively influence the development of strong relationships with the patients and their families. On this issue, the informants repeatedly expressed their concern on the ineffective or ill communication between the health care professionals and the patient and the family. The issue of communication was reported in the study of Sanford et al.  where the lack of communication between the patient and the healthcare professionals was conceived as lack of caring. This interpretation becomes more probable if we take into consideration the fact that the patients rely on the healthcare professionals and especially the nurses for information on their situation.
The next theme entitled “being sympathetic”, encapsulated the informants’ ambivalent feelings towards patients as well as feeling puzzled as to how helping the patients cope with the stages of grief. The inability of the nursing students to cope with the care of terminally ill patients lies on their inadequate clinical and theoretical preparation and is in line with the findings of the study of Cunningham et al. . According to the researchers, the informants reported less positive feelings about their confidence in practice and their preparation for the required nursing skills as well as the amount of theory provided about cancer care before their clinical placements. Further findings are in line with the study of Sanford et al.  as well as the study of Allchin  and Sadala and da Silva  where nursing students were feeling a tension between what they believed that should be done to help the patient and what they were able to do due to lack of preparation and inability to cope with their own feelings. Reflecting on the Cypriot clinical setting, the students are often found trapped in situations that can generate feelings of disappointment, distress, despair and anger due to the inability or the ill-preparedness of the student to handle such situations. This is perhaps the result of the lack or poor mentorship for 4th year students in the clinical oncology settings, as these students are considered able to work with the patient with minimal supervision or guidance.
“Being confronted by others” was conceived both as positive and as negative aspect in some of the centers. Students identified members of the staff that underestimated their clinical skills and further considered them as less supportive during their clinical practice. They assert that they often provided poor guidance to the students which let the student to unpleasant clinical experiences involving the inability to effectively respond to the patient’s or the family’s needs. Contrary, the staff that was identified as supportive by the informants, acted as role model and a key player for students’ learning whilst in clinical practice. They were perceived as “open”, “approachable” and “understanding” towards the students’ needs and concerns. The positive effect of supportive professionals was emphasized in the study of Cunningham et al.  where most of the nursing students reported the importance of support during their clinical practice. This aspect facilitated their clinical experiences and promoted their abilities to provide efficient care to the patients tackling difficult situations. On the contrary, in the studies of Huang et al.  and http://Saarikoski et al. , nursing students reported that during the period of caring for near-death patients, mentors and nurses were providing guidance and support in terms of preparing the students caring for terminally ill patients while little help was given during the dying process and the bereavement phase. The lack of support resulted in struggling to manage their feelings and ill-prepared them to offer support for the loved ones left behind.
Reflecting on their abilities and responses towards patients revealed that in their majority students expressed feelings of self-fulfillment when accomplishing a task. Informants emphasized the importance of good communication with the patients in clinical practice and acknowledged that managing to establish good communication could reflect their self actualization. Within the study of Sanford et al.  students commented that the interactions with the patients were rewarding to them. On the contrary, the poor or lack of communication was reported as a complication in the care of the patients. Cunningham et al.  in their study showed that lack of communication from the informants was expressed in the form of fear and inadequacies, a manifestation also recorder in this study. Similar finding are reported in the study of Sadala and da Silva  where the nursing students’ inexperience of dealing with stressful situations such as the care of terminally ill patients was conceived as a communication barrier that blocked the effective delivery of the care.
The issue of providing good or ill communication also prominent in the theme related to the student nurses’ evaluation of their interventions to the patients. The provision of inadequate communication and the inability of nursing students to deal with their own perceptions of cancer and thoughts of death were outlined in the study of Sanford et al. .
The reported emotional exhaustion of the students that emerged as a finding of the current study stresses the necessity of high-quality preparation and support to both professional nurses and nursing students in relation to the care of terminally ill patients [9, 12, 13]. The emotional depletion seemed to be experienced by the students as a situation that they could not escape from. This assumption was based on the described occasions where the challenging experiences of the students influenced their family and social interactions. Caring deeply, as these students did, about a person who suffers from cancer was experienced as a limit situation in life, sometimes an unbearable situation that was difficult to be resolved. This findings emphasizes the role of the broad meaning of providing effective or ineffective cancer care which can also be related to patient satisfaction as well as to nursing student’s satisfaction of being able to implement in clinical practice their knowledge and skills .
“Being frightened and challenged by cancer” is a hidden aspect of being a student nurse or professional nurse working in Cyprus. The aspect that seems to generate the fear is a possible confrontation with a patient suffering from cancer that in a way relates to them through family or social connections. Assuming the role of the caregiver in these situations can be burdensome and often can lead to excess stress, disempowerment and lack of effectiveness in their role [25, 26]. The cultural aspect of cancer as a taboo should also be considered in these situations since largely cancer is connected to death and dying . Being diagnosed with cancer brings up many emotions both for the patient and his/her family. The possibility of dying brings up more intense and overwhelming feelings. Student nurses reported that cancer for some patients was synonymous to death and this was expressed in everyday life by the majority of the patients. However, other patients chose to suffer in silence, but their depression and sadness was graphically expressed on their faces. Fear of dying, distress and insecurity after being diagnosed with cancer or living with cancer are topics often students and nurses are called to act upon. Many patients cannot even pronounce the word cancer due to their intense worries of death and dying. Some fears are solely based on rumors, outdated information and sociocultural norms. In Cyprus few people can say that they or a member of their family has been diagnosed with cancer or has died from cancer. The fear of not being able to take care of their own family often drives the patients to deny informing their relatives about their disease in order to ‘protect’ them from the possibility of setting aside their own lives to care for the patient. Sadness and depression are also reported as a normal response to any life-threatening disease including cancer. However despite the obvious stereotypes, students and nurses can act as catalysts to facilitate the patients and their families to better deal with the changes and the new realitied imposed by a life-threatening disease. For many of the students, cancer is considered a terminally ill disease and therefore death and cancer have somewhat became synonymous with many negative cannotations deriving as a result. This generates the feelings and fear of death not only among students but also among professional nurses . As cancer is considered a taboo topic openly communicating about cancer is often avoided . The patients belonging to the same cultural community demonstrated a similar response. Therefore, in the journals the students narrated situations where they exorcized the disease with expressions such as the “damned disease” (katarameni astheneia) or the “evil” or the “that thing”. This being a negative prejudice towards the disease itself, it can also be transferred toward the patient and its’ care strengthening this way their inability to cope and promoting “avoidance” as a defensive mechanism especially in those cases where the patient is a person socially close to them.
Being caring for the family was a theme identified in the current study that was strongly related with the stages of grief that relatives go through, in order to cope after the diagnosis that includes the stages suggested and identified by Kubler Ross . The theme emphasized the fact that cancer remains a “social disease” that does not affect only the patient but the family as a whole. This stresses the need for a holistic approach involving the family in the care and not just the patient in all aspects of the disease trajectory. The fact that health professionals were giving inadequate attention to the emotional and social problems generated by cancer was a fact stressed in the study of Sanford et al. . The researchers found that the nursing students reported that due to limitation of time and the need for further training of health professionals little attention was given to the psychosocial care of the patients and their families. This finding links to health professional’s reported low self esteem which is attributed to the lack of skills and knowledge when providing care for cancer patients as well as their prejudice towards cancer which can be manifested as avoidance .
Within the theme “Being better for clinical practice” the student informants stressed the need for emotional and psychological support for both the patient and the family. They also commented on the need for the adoption of a policy that focuses on the patient as the center of the care. The students have repeatedly acknowledged in their daily reflections, the importance of patient-centered care in clinical practice. As a prominent example of this need, the students commented on the need for patient-centered communication between the healthcare professional and the patient. The topic of patient-centered care has received extensive attention in the literature not only by the students’ perspective , but also by the perspective of the professional nurse [28, 29] and the clinicians [30, 31]. In relation to the suggestion made by the student informants, these were focused in relation to the nurses’ uniforms and the provision of more creative activities to teenage patients. The study by Meyer  explored children’s’ perceptions of nurse caregivers based on uniform color and style. The children that participated in this study preferred the nurse wearing a colorful smock top, and most feared the nurse wearing a white dress uniform. This conclusion coincides with some of the expressed perspectives of the students that argued in favor of a more colorful uniform instead of a white one. Similar studies have explored this issue in adult patient with contradicting however results [33, 34].