The first theme, knowledge, emphasises that for a person to perform an activity effectively and efficiently, she must be knowledgeable on what to do and how to do it. Without knowledge in performance of activity will yield negative results. It is important for those that are knowledgeable to impact such knowledge to those that lack knowledge [1]. Education and training must constitute of senior health care professionals engaging in planning and coordination of teaching activities, development of clinical training on the job, and supervision, until one is competent to perform a job alone. Senior professionals such as lecturers, facilitators, clinical professionals in the wards had to provide students with knowledge of dealing with death of patients, because knowledge is key in safe provision of care [14]. However, it is evident that student nurses of the study did not have knowledge and did not receive guidance. A conclusion drawn is that students were not adequately prepared to deal with death of a patient. Often, student nurses are placed in the wards with limited training and inadequate knowledge of dealing with deaths, and this compromises their well-being and the quality of care [27], and this poses a serious challenge to students. Beside negative sub-themes related to knowledge, one sub-theme, empowerment emerged, which supports the notion that experiencing something unknown can teach a person to become a better being, because through experience, one develops knowledge, skills and understanding of how to react in a certain situation, and how to deal with problems [15].
The second theme, psychological trauma, outline the overwhelming impact of dealing with death of a patient, hence the sub-themes terrified, stressed and insomnia arose. Results of dealing with death of a patient can be compassion, sadness, and helplessness [12]. Due to unpreparedness, these results were more severe on student nurse. The reason why student nurses become more affected than senior professionals is because they encounter death of a patient more often, and at the early stage of training, at the time when they have just joined the profession and are still unsure of how to handle patients. As opposed to senior professionals, they would have had constant contact with the patient, which gives them the greater advantages of dealing with death better [24]. It is for this reason why it is important for students to undergo extensive training before dealing with death of patients.
The third theme, low self-esteem, explains loss of self-value or self-worthy, hence sub-themes feeling worthless, feeling of not belonging, and loss of confidence. Student nurses, due to inability to adequately manage death of a patient, had low self-esteem. People with low self-esteem have extreme self-criticism, think badly about themselves, become extremely critical of themselves, downplay their positive qualities, and judge themselves as inferior [29]. Student nurses felt useless when a patient dies whilst in their care and had a sense of not belonging to the nursing profession, even though the main cause was inadequate knowledge and expertise, which were supposed to be provided to them prior placement in health care facilities.
The last theme, nutritional disorder, emphasises the negative impact of dealing with death of a patient on student nurses. They could not eat, had weight loss and nutritional deficiencies. There is a correlation between appetite and exposure to death. People who encountered death have lower level of appetite, and are at risk of significant weight loss, and might even need medical treatment to cure such disorder [28]. It is therefore understandable why student nurses of this study presented with nutritional disorder.
Limitations of the study were that the study was confined to a one nursing college in the province; therefore, the findings could not be extrapolated to other provinces of the country or globally. Furthermore, the research was conducted in a government nursing college. Private nursing colleges and nursing schools were excluded. Therefore, there is no certainty that should such study be conducted in both private colleges and nursing schools, the results will be similar.
The following recommendations are made, under the headings recommendations to nursing practice, nursing education and nursing research.
Nursing practice
Clinical professionals should endeavour to adopt an enthusiastic attitude of mentoring student nurses, especially vulnerable first year student nurses. This will assist them to be competent in delivery of quality patients, to booste their self-esteem and morale, thus enabling them to enjoy nursing profession. There is, furthermore, a need for regular in-service trainings pertaining to effective dealing with death. In addition, it is recommended that the Department of Health employs more psychologists and counselors to provide counseling, de-briefing, and emotional support to counter the traumatising effects experienced by student nurses post dealing with death of a patient.
Nursing education
Clinical outcomes envisaged for first-year student nurses need to be revised with a view to ensuring that procedures such as dealing with deaths deferred until students have gained more knowledge, skills, and experiences in dealing with death. Furthermore, clinical facilities need to be equipped with full time clinical preceptors and mentors who will guide and support students throughout.
Nursing research
Future studies that will be conducted in other nursing colleges of the province, private nursing colleges and nursing schools are recommended. These studies will assist in determining if experiences are similar, whether there are different strategies used to empower students in dealing with death, as well as to broaden the research under review.