ATTITUDES IN FRONT OF DEATH: NURSES’ VIEWS IN THE HOSPITAL ENVIRONMENT

ACTITUDES FRENTE A LA MUERTE: PERSPECTIVAS DE LOS PROFESIONALES DE ENFERMERÍA EN EL ÁMBITO HOSPITALARIO

ABSTRACT

Objective:

to analyze the relationship between personal characteristics and the profile of attitudes towards death among nurses in a Portuguese hospital.

Method:

a cross-sectional, quantitative, exploratory and descriptive study, carried out in a hospital in the North of Portugal, with 981 nurses, who answered a questionnaire composed by the scale of evaluation of the Profile of Attitudes about Death. Data collection was carried out in February and March 2018 in the services, and the findings went through descriptive and analytical statistical analysis with the aid of the SPSS software.

Results:

the nurses revealed to have the attitudes of approach (36.29 points), fear (27.82 points), neutrality (27.25 points), avoidance (17.48 points) and escape (15.52 points) in the face of death, and these were associated with the different socio-occupational characteristics of these professionals, including gender, marital status, age, having children, type of employment relationship, professional category, specialty, time of service, and the practice or belief of some religion.

Conclusion:

the profile of the nurses' attitudes towards death is influenced by their socio-professional characteristics, which points to the importance of rethinking training strategies in the academic environment, in health organizations and in services, favoring the better reception of patients and family members, but also in relieving the suffering of the professionals in the face of finitude.

DESCRIPTORS:
Attitude towards death; Death; Nursing; Hospital care; Nursing care

RESUMEN

Objetivo:

analizar la relación entre las características personales y el perfil de las actitudes frente a la muerte entre profesionales de Enfermería de un hospital de Portugal.

Método:

estudio transversal y cuantitativo, del tipo exploratorio y descriptivo, realizado en un centro hospitalario de la región Norte de Portugal, con 981 profesionales de Enfermería, quienes respondieron un cuestionario compuesto por la escala de evaluación del Perfil de Actitudes Frente a la Muerte. La recolección de datos tuvo lugar en febrero y marzo de 2018 en los servicios, y los hallazgos fueron sometidos a análisis estadístico descriptivo y analítico con el auxilio del software SPSS.

Resultados:

los profesionales de Enfermería revelaron tener las siguientes actitudes: aproximación (36,29 puntos), miedo (27,82 puntos), neutralidad (27,25 puntos), evasión (17,48 puntos) y escape/fuga (15,52 puntos) frente a la muerte, y fueron asociadas a las diferentes características sociolaborales de estos profesionales, entre ellas: sexo, estado civil, edad, tener hijos, tipo de vínculo laboral, categoría profesional, especialidad, tiempo de servicio y la práctica o creencia en alguna religión.

Conclusión:

el perfil de las actitudes de los profesionales de Enfermería frente a la muerte se ven influenciado por sus características socioprofesionales, lo que señala la importancia de repensar estrategias de formación en el ámbito académico, en las organizaciones de salud y en los servicios, favoreciendo así una mejor recepción a los pacientes y familiares, como así también el alivio del sufrimiento de los profesionales frente a la muerte.

DESCRIPTORES:
Actitud frente a la muerte; Muerte; Enfermería; Asistencia hospitalaria; Cuidados de Enfermería

RESUMO

Objetivo:

analisar a relação entre as caraterísticas pessoais e o perfil de atitudes frente à morte entre enfermeiros de um hospital português.

Método:

estudo transversal, quantitativo, do tipo exploratório e descritivo, realizado em um centro hospitalar da região Norte de Portugal, com 981 enfermeiros, os quais responderam a um questionário composto pela escala de avaliação do Perfil de Atitudes Acerca da Morte. A coleta de dados foi realizada em fevereiro e março de 2018 nos serviços e os achados passaram por análise estatística descritiva e analítica com o auxílio de software SPSS.

Resultados:

os enfermeiros revelaram ter as atitudes de aproximação (36,29 pontos), medo (27,82 pontos), neutralidade (27,25 pontos), evitamento (17,48 pontos) e escape/fuga (15,52 pontos) frente à morte, e estas foram associadas às diferentes características sociolaborais destes profissionais, entre elas, sexo, estado civil, idade, possuir filhos, tipo de vínculo de trabalho, categoria profissional, especialidade, tempo de serviço e a prática ou crença de alguma religião.

Conclusão:

o perfil de atitudes dos enfermeiros diante da morte sofre influências de suas características socioprofissionais, o que sinaliza para a importância de repensar estratégias de formação em meio acadêmico, nas organizações de saúde e nos serviços, favorecendo o melhor acolhimento dos pacientes e familiares, mas também no alívio do sofrimento dos profissionais frente à finitude.

DESCRITORES:
Atitude frente à morte; Morte; Enfermagem; Assistência hospitalar; Cuidados de enfermagem

INTRODUCTION

Among the challenges of the professionals working in hospital services, there is the daily coping with the death of users. Despite a natural and inevitable biological event among human beings, finitude is a phenomenon experienced in a unique way by each individual. Thus, the experience of death transcends the physical event and the family relationship and confronts beings with finitude, making the nurses' intervention at the end of life and at the moment of death dependent on multiple factors, including individual beliefs and values.1

The death-dying process permeates daily nursing practices; however, the theme is often diligent. Commonly, the death-dying process is limited to the training of Nursing professionals and, when the debate occurs, it tends to happen in a fragmented manner, with little progress towards expanding and integrating this process into the life cycle.2^,3^,4 A number of authors2^-5 highlighted the scarcity of research studies on the theme.

In addition, it is up to the nurse to develop skills in order to enhance the ability of these professionals to embrace the responsibility of caring for patients at all stages of life, including, inevitably, the moment of their death.6 However, advances and investments in the provision of specialized care to improve and prolong life, sometimes translate a departure from the acceptance of death, with a wide range of potential emotional communication and relational difficulties for patients, family members and health professionals.7^,8

A researcher9 reinforced the primacy that is given to the problem of death and dying in the context of Nursing correlated with the object and essence of the profession, which requires, on the one hand, care focused on both the patient and the disease. On the other hand, the author9 reiterated the exposure that the professionals are subjected to and that has a direct impact on their health and well-being.

The hospital culture, with a focus on clinic and medicalization, easily permeates Nursing, if it is not based on disciplinary bases for knowledge and practice,10 and this also permeates the way nurses perceive and conduct care for patients in the face of death. The author reinforced the confrontation between the unitary world view of Nursing and the curative view of approaching and understanding the health-disease process of people,10 which always requires resuming postulates that guide the practice of these professionals in different care contexts.

Thinking about the problem of finitude in a hospital environment transcends the relationship between nurses and patients and incorporates the social, cultural and religious environment of the latter and their families, but also the management of the conditions of organizations and professionals so that everything goes in the direction to avoid suffering for all involved in the final moments of life, in which it has been verified that the effectiveness of academic training has not shown to be sufficient for the professionals to deal with these moments.4

In this sense, this study started from the following question: What personal characteristics of nurses are related to their attitudes about death? Thus, the objective was to analyze the relationship between personal characteristics and the profile of attitudes towards death among nurses in a Portuguese hospital.

METHOD

A cross-sectional, quantitative, exploratory and descriptive study was performed in a hospital in the Northern region of Portugal, which has 1,105 beds and also works as a reference center in the North.

For the composition of the study sample, the following inclusion criteria were used: being a nurse and working in adult inpatient services. Professionals who were away during the data collection period for any reason and who worked with clients under the age of 18 years old were excluded, given that it was not intended to analyze other variables implicit in studies with children. In addition, for the definition of the sample, it was determined that this would be intentional non-probabilistic, inserting the entire population that, in the period of the investigation, totaled 1,345 professionals, but resorting only to professionals who reached a response rate of 73% of the instrument, thus totaling 981 nurses (corresponding to 72.9% of the nurses), with a confidence margin of over 95% and an error margin of 2%.

Data collection was carried out in February and March 2018 in the services, using a questionnaire composed of two parts as instrument. In the first part, questions were elaborated that allowed characterizing the sample and, in the second part, the Death Attitude Profile - Revised (DAP-R) scale was used, translated and validated for the Portuguese population9 with permission from the author. The Death Attitudes Profile (DAP-R) assessment scale consists of 32 items and is a scale presented in the form of a self-report, in the Likert format, from one (completely disagree) to seven (completely agree) points. The 32 items cover five dimensions, namely: fear (seven items: 1,2,7,18,20,21,32); avoidance (five items: 3,10,12,19,26); neutral acceptance/neutrality (five items: 6,14,17,24,30), acceptance as an approach (ten items: 4,8,13,15,16,22,25,27,28,31), and acceptance as an escape (five items: 5,9,11,23,29). The score can vary between 32 and 224.

Participation was voluntary upon presentation of the study and previous invitation, and the questionnaires were delivered to all the nurses in the eligible services according to the study criteria, and were subsequently collected. For the analysis of the findings, descriptive and analytical statistics were used, and the quantitative variables were measured in median, mean and standard deviation, with a 95% confidence interval. The normality distribution of the variables was assessed using the Independent-Samples Kruskal-Wallis Test and the Mann-Whitney U Test. The qualitative variables of interest were the nurses' attitudes towards death in daily hospital work, which were tested using the chi-square test, with a significance level of 5% (p<0.05). These were also expressed as absolute frequencies. The tests were conducted with the aid of the Statistical Package for the Social Sciences (SPSS) program, version 21.0, for Windows. The scale obtained a Cronbach's Alpha of 0.872. In the original study and in the translation of the scale by Loureiro, only the Cronbach's Alpha per item was calculated and, thus, the data that can be analyzed in Table 1 were obtained.

Table 1 -
Comparison of the Cronbach's Alpha in the different studies. Porto, Portugal, 2019.

	Original Scale	Scale Translated and Adapted by Loureiro	This article
Fear of Death	0.86	0.84	0.833
Death Avoidance	0.65	0.87	0.899
Neutral Acceptance	0.88	0.64	0.619
Approach Acceptance	0.97	0.91	0.923
Escape Acceptance	0.84	0.82	0.804

The anonymity of the participating nurses was guaranteed and the study was carried out after a favorable opinion from the Institution's Ethics Committee, with anonymity and the right to participate in the study being preserved.

RESULTS

The profile of the participants was mostly female (75.7%), with a partner (55.7%), with a minimum age of 22 years old and a maximum of 63, mode of 35 years old and a mean of 37.6 (±8.24), with 54.8% having children.

From a professional point of view, only 37.3% (n=306) have a job contract in public functions, the length of service varies from one to 42 years, with the mode being 12 years and a mean of 12 years (±8.84). Among the participants, 24.9% (n=235) have a specialization in Nursing, the following being mentioned: Rehabilitation Nursing (10.29%); Medical-Surgical Nursing (8.15%); Community Health Nursing (2.65%); Mental Health and Psychiatric Nursing (2.24% nurses); Child and Pediatric Health Nursing (0.40%); Maternal and Obstetric Health Nursing (0.30% nurses). It was also identified that 2.75% (n=27) are head nurses or in the exercise of managerial functions.

Among the participants, 75.53% (n=738) reported practicing a religion. Of these, 72.68% (n=713) mentioned Christian religions and one nurse mentioned Buddhism (0.1%). The rest did not mention which practice or belief they follow.

It was evidenced that only 5.7% (n=55) of the sample reported having undergone some training in the area of Loss and Mourning. It was also identified that 71.4% (n=692) did not experience the loss of someone significant in the last year, but everyone lost significant people at some point in life.

Attitudes towards death among the participants

Firstly, seeking to analyze the relationship between the personal characteristics and the profile of attitudes towards death with the scales, the perceptions of the professionals regarding the phenomenon of death were explored, with the postures mentioned by more than 50% of the sample shown in Table 2.

Table 2 -
Scores of the nurses' attitudes towards death. Porto, Portugal, 2019. (n=981)

Attitude towards death	Agree*	(%)
1. Death is undoubtedly a cruel experience	636	64.83
2. The prospect of my own death causes me anxiety	539	54.94
3. Death must be seen as a natural, undeniable and inevitable event	883	90.01
4. Death is a natural aspect of life	936	95.20
5. I do not fear death, nor desire it	542	55.24
6. It scares me that death means the end of everything I know	490	49.94
7. Death is simply a part of the life process	889	90.62

• * Means.

The analysis of the attitudes towards death revealed that attitudes of approach (36.29 points) predominate, followed by fear (27.82 points), neutrality (27.25 points), avoidance (17.48 points) and escape/evasion (15.52 points). In Table 3, the significant profile variables for each type of attitude on the DAP-R evaluation scale were collected.

Table 3 -
Scores of the nurses' attitudes towards death. Porto, Portugal, 2019. (n=981)

Variable	n	Mean	Standard deviation	p-value*
Acceptance attitudes as an approach
Gender				0.019
Female	743	36.92	12.56
Male	238	34.68	12.85
Marital status				0.039
Single	383	35.83	11.92
Married/Stable union	546	37.09	11.47
Divorced	46	33.85	15.49
Widow/Widower	04	27	13.95
Practice or belief in a religion				0.000
Yes	747	39.11	10.44
No	228	27.53	12.14
Fear attitudes
Marital status				0.000
Single	383	27.41	8.58
Married/Stable union	546	28.59	8.33
Divorced	46	23.80	8.37
Widow/Widower	04	22.25	6.75
Specialty				0.0009
Medical-Surgical Nursing	80	27.54	9.12
Child Health Nursing	04	28.25	12.09
Community Nursing	26	31.54	7.67
Rehabilitation Nursing	105	26.99	8.34
Mental Health Nursing	22	23.59	7.54
Maternal Health Nursing	03	31.67	8.14
Practice or belief in a religion				0.000
Yes	747	28.57	8.32
No	228	25.56	8.76
Acceptance/Neutrality attitudes
Marital status	0.011
Single	383	27.22	3.87
Married/Stable union	546	27.10	3.90
Divorced	46	29.04	3.81
Widow/Widower	04	29.00	4.08
Position held ‡				0.017
Nurse	704	27.05	3.87
Nurse with specialization	244	27.54	3.90
Head Nurse	20	28.90	4.88
Registered nurse in duties of	8	30.13	3.64	0.041
Age
Under 25 years old	35	27.66	3.09
26-35 years old	445	26.81	3.85
36-45 years old	335	27.52	3.88
46-55 years old	126	27.90	3.84
Over 55 years old	40	27.23	5.21
Service time				0.016
Up to 10 years	358	26.87	3.80
11-20 years	398	27.24	3.87
21-30 years	178	27.72	3.88
31-40 years	46	28.28	4.90
Over 40 years	1	26	-
Avoidance attitudes
Practice or belief in a religion				0.002
Yes	747	17.96	7.15
No	228	16	7.05
Acceptance attitudes as an escape
Type of employment relationship †				0.000
Public service employment contract	366	16.60	16.43
Permanent employment contract	511	15.10	6.13
Individual fixed-term or uncertain employment contract	99	14.10	5.57
Age				0.0001
Under 25 years old	35	14.46	5.94
26-35 years	445	14.84	5.94
36-45 years	335	15.79	6.23
46-55 years	126	16.83	6.80
Over 55 years	40	18.15	6.67
Service time				0.009
Up to 10 years	358	14.96	5.80
11-20 years	398	15.41	6.27
21-30 years	178	16.40	6.76
31-40 years	46	17.93	6.34
Over 40 years	1	8	-
With children
Yes	538	15.80	6.34	0.046
No	432	15.14	6.12

• * Independent-Samples Kruskal-Wallis Test; † In the fixed or uncertain term employment contract, there is an employment contract deadline: it is a temporary replacement contract. The open-ended contract has no limit on the employment relationship and can be definitive; ‡ In Portugal, there are specific functions for nurses with specialties and nurses in charge of leadership. The head nurse acts in a management position for an indefinite period of years and the nurse in management functions is appointed for a period of three years.

A significant association was evidenced, with statistical resource to the Mann-Whitney U Test, between gender and the approach attitude (p=0.19), that attitude being most prevalent among women, as illustrated in Figure 1.

Figure 1 -
Distribution between gender and the approach attitude in face of the perceptions of death among nurses. Porto, Portugal, 2019. (n=981)

The practice or belief in any religion, using the Kruskal-Wallis statistical test, was associated with the attitude of fear of death (p=0.000), avoidance (p=0.002) and the approach attitude (p=0.000), being that all prevailed more among those who answered affirmatively. The following Figure 2 illustrates these findings.

Figure 2 -
Distribution between the practice or belief in a religion and the attitudes of fear of death, avoidance and approach among nurses. Porto, Portugal, 2019. (n=981)

The age and length of professional practice variables were also associated with attitudes towards death, both of which are significant for neutrality and escape.

DISCUSSION

The studies2^,3 on death and dying among health professionals and students pondered on understanding/interpreting finitude as part of the human life cycle, as a phenomenon linked to life inherent to vital processes, issues that converge with the findings of this study regarding the nurses’ attitudes towards death in the hospital under study.

However, death and dying are seen as situations laden with negativity and sometimes revolt,4 which can help to understand the fearful attitude. This attitude was associated with the participants’ marital status, the type of specialty of the nurses, and the practice or belief in some religion.

The relationship between the above characteristics and the attitude profile of the Nursing professionals indicates the impact on the care provided by these professionals in patient care in the death and dying process and in welcoming the family. Because Nursing is at the center of care, it also reflects the other components of the health team. Certainly, fear limits the wide possibility of dialog and exchange of information needed in the process of finitude.

Death raises numerous questions and explanations for which Philosophy, Theology, Mythology and other fields of knowledge have tried to find meaning, associating different views and values to it. Death confronts man with his body, no longer a body for life, but a body subject to deterioration and to the impossibility of remaining functional and able to live.11

Often, death can be interpreted as contradictory to life, referring to feelings such as loss, fear, pain, and suffering, among others. A broader and multi-factorial approach to the theme, based on bio-psycho-socio-cultural aspects, can better influence these emotions and actions.12

Fear of death was also associated with the type of specialty of the nurses, with specialists in Maternal Health Nursing, Community Nursing and nurses specialized in Child Health expressing this attitude the most. It is recalled that only adult services took part in the study; however, there were nurses of all specialties in these services, and studies with nurses working in services for minors were identified.13 Care in the context of a child's finitude, in any age group, tends to be permeated by non-acceptance, painful feelings, with guilt, a feeling of failure among the professionals, potentially among the members of the Nursing team.13^,14^,15 Another study16 performed using the same attitudes profile scalewith undergraduate students in the health field, found the attitude of neutrality with greater expression, and the avoidance and fear of death attitudes obtained higher means in Collective Health undergraduates. In the case of the nurses, the highest mean of responses was also obtained in the neutrality attitude.

The approach attitude was associated with the gender and marital status of the nurses, being more prevalent among women and widows. Potentially, women are culturally the main caregivers in the context of families.17^-18 A number of authors8 recalled that the proximity of death refers to the appreciation of life.

The escape attitude, on the other hand, was associated with the having children variable, with those who do not have being the ones that most have this attitude towards death, as well as the type of employment relationship, with nurses with an individual open-ended employment contract avoiding death more.

In the face of escape/evasion attitudes towards death, it is worth rescuing the writing of an important Nursing theorist, who recently considered the impact of several aspects, such as economics, science, technologies, practices and policies, which is potentially driven to deviate from its disciplinary bases. In this context, Nursing tends to focus on the development of techno-industrial hospital practices, the process of care centered on illness, limiting its responsibilities in caring for individuals, human groups and community experiences.10

Sometimes, escape can be better understood in view of the nurse's difficulties in dealing with their feelings related to death even before the patient's death.19^,20 When faced with imminent death, these professionals avoid verbal contact with the patient and adopt distancing behaviors.20

The neutrality attitude was significant in relation to the professional categories existing in the institution, with the head nurse being the one who most stated it. They have their work process permeated by concerns about developing key conditions in the implementation of care.5 The neutrality attitude can be associated with the understanding that patients have the right to participate in decisions that influence their lives and may accept or reject care, especially since the goals of the professionals and caregivers may not be congruent,21 which is an aspect that should be considered.5 However, neutrality can give a posture similar to escape in which patients and family members do not feel welcomed in the process of dying and mourning.

A number of studies4^,22 considered that the issue of death and dying has been neglected in the training institutions, which has repercussions on tensions that affect the professional practice. The lack of training in the continuing education format also strengthens this situation. The formative limits culminate in stress and difficulties experienced by Nursing, which often resort to solitary solutions in facing the limitations.8^,19^,22^-23

Death and the death-dying process must be interpreted as complex, uncertain and singular phenomena. In this context, the training of nurses requires opportunities for praxis in environments that favor the expansion of understanding about these phenomena, potentially giving new meaning to the life and death among the Nursing students, including the theme in the curricula in a more substantial and better worked on manner by the educators.2^,3^,4^,19^,22^-23

In this direction, care needs to be developed and taught based on references that potentially integrate and contextualize the different and complex events of human life, including the death-dying process.2

The practice or belief in some religion was also statistically associated with attitudes of fear, avoidance and approach, all of which prevailed among those who answered affirmatively. Religious belief has been mentioned in the literature as a resource that helps nurses, especially, to assume acceptance in the face of the death of patients, which is considered a spiritual transition, that is, something that is not permanent.19 Spirituality offers preparation to face death naturally, that is, from the cultivation of this value, it is understood that the end of life is only associated with the physical death of an individual, and there is something far beyond human life.8 However, the factors that facilitate coping with death are subjective, requiring conceptual analyses about spirituality that are not evidenced in the literature.19

It was clear that, with advancing age and professional practice, the professionals adopt attitudes of neutrality and escape.

The lack of preparation of the newly graduated nurses in relation to dying and death can lead to anxiety, to stress, and to the Burnout Syndrome,3 the supervision capable of filling the gap between theory and practice in Nursing during the void from novice to specialist being unique for these professionals. Better knowledge about palliative care during Nursing education and Nursing leadership committed to preparing for coping with finitude also stand out.3 So as to contribute to the development of skills and competences for assistance beyond technical, more human and collective, the creation of groups and seminars also emerges, among other strategies that propel the debate on death and dying.4

It is also worth considering, as limitations of the study, considering the exclusively quantitative approach, since the qualitative modality can contribute to the deepening of several aspects addressed in the study, suggesting new research studies, potentially, investigations with mixed method.

In view of the systematized results and also from the findings of this research, the magnitude is perceived of more and continuous investigations on the theme with results that can bring proposals, models, interventions and/or actions to qualify the training process, restructure the curricula and continuing education in the services, influencing the qualifications of professionals, students, teachers and managers.22 The findings demonstrate, as in other recent studies,24 that the Nursing professionals have different attitudes towards the patient's death/dying process, with influences on care. However, this research analyzes the different attitudes towards the characteristics of these workers, indicating the importance of monitoring the profile of the professionals, especially in settings with a high incidence of mortality.

The relationship between the characteristics of the worker's profile can contribute to better understand how they tend to act in the face of the death and dying process, contributing to the organization of in-service qualification and to the orientation of training strategies adjusted to the profiles, as well as to enhance the necessary investments for the acquisition of necessary competences in the human and integral assistance to individuals facing death.16 A number of researchers identified that nurses who had training in this theme changed their attitudes towards death, making them more positive, which reinforces the need to include the theme of death in the curricula, since the beginning of training, which can help prepare future nurses to better care for the patient in the process of dying.16

However, it is important to consider that the Nursing professionals also suffer in this whole process, not least because talking about death and the process of dying requires cognitive and emotional effort, as well as a language that was not instilled during training.25

It is considered that the study brings unique contributions due to the scarcity of research studies on the theme, especially those that analyze the characteristics of the profile of the Nursing professionals and their conduct towards the care of the patient/family in the death and dying process; and the findings impact on the potential concern in better equipping and supporting the Nursing professionals in the daily confrontation of finitude and the care it requires.

CONCLUSION

The profile of the nurses' attitudes towards death is influenced by their socio-professional characteristics, showing that the nurses in the hospital under study adopt attitudes of approach, fear, neutrality, avoidance and escape in the face of the death-dying process. The marital status, having children, type of employment relationship, professional category, specialty and practice or belief in some religion variables were significant for the attitude of the nurses in this context, and provide subsidies to better understand their influences on the attitudes of the professionals in the care provided to patients and family members facing physical terminality.

The study, in the theme of nurses, can provide a reflection on Nursing attitudes towards the death-dying process, with the potential to sustain the qualification of their practices and make local hospitals more humanized in the care of individuals in the face of finitude and farewell. However, it is worth considering that, as a cultural trait, the attitudes towards death and dying cannot always be transformed individually, suffering the influence of several socially, historically and culturally constructed aspects.

In addition, the dialog of the findings with the literature emphasizes the importance of qualifying the preparation in graduation and in the services about the theme, with the emergence of suggestions that can contribute to this process, especially, based on dialog strategies and on a verbalization space about the theme and the personal and professional experiences for their subjective coping.

ACKNOWLEDGMENT

To the nursing professionals of the Hospital Center for their availability and collaboration.

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NOTES

• ORIGIN OF THE ARTICLE

  Extracted from the dissertation - Living Death: challenges of the Nursing profession, presented to the PhD Program in Nursing Sciences of the Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, in 2019

• APPROVAL OF ETHICS COMMITTEE IN RESEARCH

  Approved by the Ethics Committee in Research with Human Beings Centro Hospitalar do Hospital São João under opinion No. 102/2017, approved by the Board of Directors on March 30^th, 2017

Publication Dates

• Publication in this collection
  07 Dec 2020
• Date of issue
  2020

History

• Received
  23 Aug 2019
• Accepted
  01 Apr 2020