Journal of Nursing Education

Syllabus Selections: Innovative Learning Activities Free

A Guided Reflection Activity on Sudden Death

Mary Jane Jobes, MA, RN; Kathleen Duncan, PhD, RN

Sudden patient deaths occur in the critical care setting, but nursing students have few opportunities to experience this type of situation. Positive strategies exist for helping students process a patient's death (Dzubak, 2018). In order to expose students to the emotional aspects of sudden patient death, a specific non-graded guided reflection activity was developed for senior baccalaureate nursing students in a required advanced medical–surgical critical care course. A published scenario provided a death experience in the classroom, and instructors guided students through personal emotional responses. More than 200 students have participated in this activity.

The scenario used is the article “The Pause,” written by Jonathan Bartels (2014). The author is an emergency department nurse and the article describes his emotional reaction to experiencing multiple sudden deaths as the basis for an action termed as “the pause.” The pause occurs when staff remain in a patient's room after a death and offer a few minutes of silent respect for the loss of the patient's life while also recognizing the staff's efforts as honorable.


During class, the students read “The Pause” and respond to three questions adapted from the article. To provide privacy and to reflect the seriousness of the topic, the assignment is completed individually and silently. Student responses are compiled, sorted into themes, and shared with students via e-mail.

In the future, during clinical post-conferences, students will discuss their emotional reactions to this assignment. In addition, students will brainstorm challenges to implementing the pause and talk about how this intervention can promote resilience in nurses.

The first question asks students to identify why nurses may not express emotions following sudden death situations. The major theme of responses to this question indicates that students feel that nurses may avoid showing emotions due to being uncomfortable with losing emotional control. Students who have observed a sudden death situation note they felt emotions and released them by crying after they left the clinical area.

The second question asks whether students have ever observed a nurse advocating for a dying patient or have done so themselves. Students report having observed nurses advocating by performing a pause, speaking up to a physician who is belittling a patient, and by supporting families. Students also reported they have advocated for dying patients by speaking up when unkind and unprofessional comments have been made by staff and by comforting a family when the nurse did not. A common theme for students is recognition that advocating for the patient is difficult and takes courage and that students often feel powerless and unable to act.

The final question asks students to describe their response to participating in a pause. Students note that pausing demonstrates honor, respect, and compassion for the patient and helps the staff share in the family's grief. Pausing is perceived as giving the team time to regroup, increasing trust among each other, and helping to bring closure and peace. The majority of students note that if involved in a pause, they would feel overwhelmed at first, but then humbled and sad. For students who have participated in a pause in the past, the majority noted that they felt comforted.

This experience indicates that the pause assignment provides an opportunity to reflect on an occurrence that is part of nursing but rarely experienced by students. Students felt emotionally drawn into the scenario that Bartels (2014) described. Their responses were heartfelt and showed that many had experienced personal and professional losses. This assignment helps students to realize the importance of taking few minutes to demonstrate compassion for the patient, as well as to provide support to the staff following a sudden patient death.

Mary Jane Jobes, MA, RN

Kathleen Duncan, PhD, RN
University of Nebraska Medical Center
College of Nursing


  • Bartels, J. (2014). The pause. Critical Care Nurse, 34, 74–75. doi:10.4037/ccn2014962 [CrossRef]
  • Dzubak, J. (2018). Nurses cry, too: What happens when we can't fix everyone. American Nurse Today, 13(6), 50–51.

The authors have disclosed no potential conflicts of interest, financial or otherwise.


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