Perceptions of Death Among Intensive Care Nurses: A Metaphor Study

ABSTRACT

Background

Intensive care nurses frequently encounter death as part of their clinical practice, which may evoke complex emotional and cognitive responses. Understanding how nurses perceive death is essential, as these perceptions can influence care delivery, decision‐making processes and the quality of end‐of‐life care. Although previous studies have explored nurses' experiences with death, research examining these perceptions through metaphors remains limited.

Aim

This study aimed to explore intensive care nurses' perceptions of death through the use of metaphors.

Study Design

This study was conducted using a qualitative design. Data were collected using a metaphor‐based approach and analysed using content analysis to identify common themes and categories.

Findings

Intensive care nurses expressed their perceptions of death using a variety of metaphors, which were grouped into five main categories: ‘End’, ‘Peace’, ‘Beginning’, ‘Uncertainty’ and ‘Unclassifiable’. The findings revealed that death was most commonly perceived as an ‘End’, often associated with inevitability and finality. However, some nurses described death as a peaceful transition or a new beginning, while others emphasized its uncertain and ambiguous nature.

Conclusions

The findings suggest that intensive care nurses hold multidimensional perceptions of death, shaped by both emotional and experiential factors. These perceptions reflect not only the finality of death but also its potential meaning as a transition or a source of peace.

Relevance to Clinical Practice

Understanding nurses' perceptions of death may contribute to improving end‐of‐life care practices, supporting their emotional coping strategies, and enhancing communication with patients and families in intensive care settings. Addressing these perceptions through education and supportive interventions may strengthen nurses' ability to provide holistic and compassionate care.

1. Introduction

The nursing profession provides holistic care to individuals throughout the life cycle, from birth to death. In all settings where care is delivered, nurses may encounter individuals approaching the end of life, as well as their families [1]. Intensive care units, in particular, are environments where critically ill patients receive comprehensive medical treatment and nursing care. Although the primary objective of intensive care units is to save lives, high mortality rates remain common [2, 3].

Death and issues related to death have been a constant part of human history and have continued to evoke a sense of mystery. As a universal phenomenon, the perception of death varies across cultures and even among individuals [4, 5, 6]. While death itself, evoking the unknown, remains a concept that is difficult for humans to fully comprehend, providing care to dying patients and witnessing a patient's death constitutes a stressful experience for nurses [7, 8]. Whether death is expected or unexpected, peaceful or painful, the emotions and experiences it evokes in nurses will vary [9]. Providing care to a dying individual has an emotional impact on nurses working in intensive care units and may indirectly influence their decision‐making and care processes. Therefore, the need for studies examining the emotions and thoughts experienced by nurses while caring for dying individuals has been emphasized in the literature [10].

A review of the literature indicates that both quantitative and qualitative studies have examined the emotions experienced by nurses while providing care to dying individuals [2, 7, 8, 10]. Although previous quantitative and qualitative studies have explored nurses' experiences of caring for dying patients, no study was found that investigated the concept of death through metaphors based on nurses' own self‐reports. In recent years, metaphors have been increasingly used to identify individuals' perceptions of the phenomena and events they encounter [11]. Metaphors provide insight into how individuals interpret their experiences and the events they face [12].

Understanding the perception of death, an inherently universal phenomenon frequently encountered by intensive care nurses, may contribute significantly to care delivery and decision‐making processes. In this context, metaphors provide a valuable opportunity to explore the emotions and thoughts that death evokes in nurses. Therefore, the aim of this study was to identify intensive care nurses' perceptions of death through the use of metaphors.

2. Method

2.1. Research Design

A metaphor analysis method, one of the qualitative descriptive research approaches, was used in this study. Metaphors are particularly useful for revealing subjective and implicit aspects of experiences that are often difficult to capture through conventional data collection methods [13]. The aim of this study is not to examine the lived experiences of nurses in caring for dying patients, as in a phenomenological design, but to reveal the perceptions, meanings and conceptualizations of death by nurses through the metaphors they produce. Therefore, metaphor analysis was preferred in this study to explore an abstract and emotionally complex concept such as death through symbolic expressions.

2.2. Population and Sample

The study population consisted of nurses working in the intensive care units of training and research hospitals in Türkiye during the study period. A convenience sampling method was used. Initially, 63 nurses who agreed to participate in the study were recruited. The study was conducted in Level II and Level III intensive care units, where nurses had experience providing care to dying patients. During data analysis, eight forms were excluded because they were either incomplete or did not adequately explain the concept of death. Consequently, the final sample comprised 55 intensive care nurses.

2.3. Data Collection Tools

2.3.1. Nurse Information Form

This form consists of questions related to the nurses' demographic characteristics (such as age, gender and educational status) and professional characteristics (including total years of experience in the profession and duration of employment in intensive care units).

2.3.2. Metaphor Form

The metaphor form used in this study was developed by the researchers based on a review of previous studies that employed the metaphor method and in line with the aim of the study [14, 15]. The researchers reached consensus on the most appropriate prompt to elicit nurses' perceptions of death. Participants were asked to complete the statement, ‘Death is like … because …’. To facilitate the generation of metaphors, an example metaphor was also provided in the form. The metaphor form was prepared and administered separately from the sociodemographic information form.

2.4. Data Collection

The study data were collected between January and June 2025 from nurses working in the intensive care units of a training and research hospital. After the researchers administered the Nurse Information Form, the participants were asked to complete the metaphor form based on self‐report. At the beginning of the metaphor form, an example of a metaphor on a topic unrelated to the study was provided to familiarize participants with the task. Based on this example, the nurses were asked to generate their own metaphors describing death. The researchers did not intervene or provide guidance during this process. Upon completion, the metaphor forms were collected by the researchers.

2.5. Data Analysis

Data were analysed using content analysis, a systematic procedure for describing, organizing and interpreting qualitative data in a clear and concise manner [16]. The primary purpose of content analysis is to organize similar data into themes and concepts and to interpret them systematically [17]. For this study, the analysis process was conducted in four stages: naming, classification, categorization, ensuring validity and reliability and quantification of the data.

In the first stage, all completed data collection forms were independently reviewed by two researchers. The researchers examined whether the metaphors generated by the nurses adequately described the concept of death. Forms that were left incomplete or failed to explain the concept of death were excluded from the analysis (n = 8). All metaphors related to death were then coded (e.g., final, birth), and a preliminary list of metaphors arranged in alphabetical order was created.

In the second stage, all metaphors were examined and evaluated according to their common characteristics. A representative metaphorical expression was selected for each metaphor, and an exemplar metaphor list was developed.

In the third stage, the metaphors were analysed based on their shared characteristics. Each metaphorical image was associated with a theme according to its common attributes related to death and subsequently classified into different conceptual categories. Based on the metaphor list and the classification process, the data were ultimately organized into five conceptual categories.

In the fourth stage, strategies were employed to ensure methodological rigour by establishing validity and reliability. In qualitative research, validity requires a detailed description of the research process. Therefore, the data analysis procedure was described comprehensively. To enhance the transparency of the analysis, a representative metaphor was presented in the findings section together with direct quotations from the participants. To ensure reliability, the data were analysed independently by the two authors, and any disagreements during the analysis were resolved through discussion until consensus was reached. Inter‐rater reliability was calculated using the formula proposed by Miles and Huberman [18], yielding a reliability coefficient of 98%. In addition, the identified metaphors and conceptual categories were reviewed by three experts in the field of nursing to establish the validity and reliability of the findings.

2.6. Ethical Considerations

The study was conducted in accordance with the World Medical Association's Declaration of Helsinki. Prior to the study, ethical approval was obtained from the Bandırma Onyedi Eylül University Health Sciences Non‐Interventional Research Ethics Committee (date: December 27, 2024; No: 2024‐11) and institutional permission was obtained. On the first page of the data collection form, participants were informed about the purpose and duration of the study as well as how the data would be used. Data collection proceeded only after obtaining both written and verbal informed consent from the participants.

3. Findings

As shown in Table 1, the mean age of the intensive care nurses was 35.63 ± 7.05 years. The mean duration of professional experience was 13.03 ± 8.05 years, and the mean duration of intensive care experience was 7.80 ± 5.59 years. Of the participants, 69.1% (n = 38) were male, and 78.2% held a bachelor's degree.

TABLE 1.

Demographic and professional characteristics of nurses (N = 55).

Variable		Min‐Max	Mean ± SD
Age		25–51	35.63 ± 7.05
Professional experience (year)		2–32	13.03 ± 8.05
Intensive care experience (year)		1–24	7.80 ± 5.59
		n	%
Gender	Female	17	30.9
	Male	38	69.1
Educational status	High school	3	5.5
	Associate degree	7	12.7
	Bachelor's degree	43	78.2
	Postgraduate	2	3.6

Abbreviations: Min–Max, minimum and maximum values; SD, standard deviation.

Within the scope of this study, intensive care nurses' perceptions of death were evaluated through metaphors, and the identified metaphors were classified under five categories: ‘End’, ‘Peace’, ‘Beginning’, ‘Uncertainty’ and ‘Unclassifiable’ (Table 2).

TABLE 2.

Classification of nurses' metaphors related to death.

Category	Metaphors
End (n = 25)	Candle (P3), Extinguishing of a candle (P45), A candle going out (P16)
	Sunset (P5)
	Closing curtain (P6)
	An empty bed (P7)
	A finished journey (P8)
	Withering of a flower (P10)
	The end of a beginning (P11)
	Waking up from a dream (P13)
	Inevitable end (P14, P47)
	Era change (P29)
	End (P30, P48)
	End of a war (P33)
	The final sentence of a finished story (P37)
	Final (P40, P44)
	A nursery rhyme at the beginning of a tale (P12)
	Separation of the soul from the body (P46)
	A spool slipping from one's hand (P4)
	An unwilling journey (P52)
	Wind (P26)
	Time (P36)
Peace (n = 9)	Liberation (P1, P2, P24)
	Blessing (P19)
	Detergent (P20)
	Peace (P32)
	End of the feeling of being a burden (P18)
	Eternal sleep (P25)
	Sleep, rest, separation (P17)
Uncertainty (n = 8)	A Door (P21)
	Eternity (P22)
	An unknown room behind a door (P34)
	Pitch darkness (P38)
	Endless sleep (P39)
	Uncertainty (P50)
	Black hole (P54)
	Passing through a door into uncertainty (P55)
Beginning (n = 7)	Continuing life (P9)
	Rebirth (P23, P43)
	Birth (P31)
	Beginning (P35)
	Transformation into energy (P42)
	Crossing the finish line (P53)
Unclassifiable (n = 6)	A uniform you wear every morning (P15)
	Knife (P27)
	An ordinary event that is an inevitable reality (P28)
	Pavement stone (P41)
	Reality of life (P49)
	Being subjected to injustice (P51)

Note: Refers to participant number (e.g., P1 = Participant 1).

Analysis of the distribution of metaphors showed that the majority of nurses perceived death as an ‘End’ (n = 25). Within this category, the most frequently generated metaphors were ‘Candle’, ‘Inevitable End’ and ‘Final’. This was followed by the categories of ‘Peace’ (n = 9), ‘Uncertainty’ (n = 8), ‘Beginning’ (n = 7) and ‘Unclassifiable’ (n = 6), respectively. Some participants also approached the concept of death from a realistic perspective.

Death is like an inevitable end. Everyone dies, yet no one knows what comes afterward. (P47)

Death is like an inevitable end. Every living being will taste death. (P14)

Death is like a final. It is the end of life in this world. (P40)

Death is like the wind. It comes without warning, takes you away, and disappears.’ (P26)

The metaphors suggested that nurses perceived human life as a story that ultimately ends with death, and they believed that whether one has gained or lost in life holds no significance in the end.

Death is like the end of a war. Whether you win or lose, there is an end. (P33)

Death is like the final sentence of a finished story. Every life is a story, and once that final sentence is written, the pen is put down. (P37)

Death is like a final. It is life's final breath and final heartbeat in this world. (P44)

One of the concepts used by nurses to describe death was the ‘candle’. Nurses described death as a candle going out, symbolising the beginning of darkness and the end of life.

Death is like a candle. The light it gives is limited and temporary. (P3)

Death is like a candle going out. The flame suddenly goes out, leaving only darkness and silence. (P16)

Death is like a candle going out. It is the loss of the light that once illuminated everything around it. (P45)

When the metaphors generated by the nurses were examined, another category that emerged was ‘Peace’. Within this category, the most frequently used metaphor was ‘Liberation’. The metaphors indicated that nurses perceived death as a means of attaining peace by being freed from patients' suffering and the hardships of this world.

Death is like liberation. It is the end of pain and worries, a transition into peace. (P1)

Death is like liberation. The world is a cruel and unjust place; perhaps what comes after death is a ray of hope. (P2)

Death is like liberation. While everyone is exposed to the evils of this world, that person has now been freed from them. (P24)

Among the metaphors generated within this category, the most striking was the ‘detergent’ metaphor. The nurse who developed this metaphor expressed that, with death, a long‐term bedridden patient is cleansed or purified, and that both the nurse and the patient attain a sense of peace.

Death is like a detergent. For patients who have been bedridden for a long time and for whom no solution can be found, it represents a form of cleansing. In a sense, both the patient and the nurse find peace. (P20)

When the metaphors generated by the nurses were examined, another category was ‘Uncertainty’. Although the metaphors within this category varied in content, they commonly focused on the unknown aspects of what happens after death.

Death is like a door. No one can fully know what lies beyond it, but everyone will pass through it one day. (P21)

Death is like an endless sleep. There is nothing tangible or visible about what comes after. (P39)

Death is like a black hole. Its end is uncertain, and no one truly knows what it is. (P54)

Another category derived from the metaphors generated by nurses regarding death was identified as ‘Beginning’. Within this category, nurses perceived death as a rebirth, a new life and a transformation. The most frequently recurring concept in this category was ‘rebirth’.

Death is like being reborn. When our loved ones die, they do not completely disappear from our lives; they simply take on another form and continue to live with us. In a way, they are reborn in a different form. (P23)

Death is like being reborn. Every end has a beginning. (P43)

Death is like transforming into energy. The soul that leaves this body will somehow continue to exist. (P42)

Some of the metaphors used by nurses to express their perceptions of death did not demonstrate thematic coherence with the identified categories; therefore, six metaphors were evaluated under the ‘Unclassifiable’ category. Among these, the most striking metaphors were ‘a uniform you wear again every morning’, ‘a knife’ and ‘being subjected to injustice’.

Death is like the uniform you wear every morning. You have to learn to live with it. (P15)

Death is like being subjected to injustice. It comes at different times and under different circumstances for everyone. (P51)

Death is like a knife. You do not feel it until it cuts you. (P27)

4. Discussion

In this study, which aimed to examine intensive care nurses' perceptions of death through metaphors, the metaphors generated by the nurses were evaluated under the categories of ‘End’, ‘Peace’, ‘Uncertainty’ and ‘Beginning’. Additionally, some metaphors that did not demonstrate semantic coherence emerged as ‘Unclassifiable’ metaphors. Based on our review of the literature, this is one of the first studies to explore intensive care nurses' perceptions of death using metaphor analysis. While previous studies have examined attitudes towards death or experiences of end‐of‐life care, this study provides novel insights into how nurses conceptualise and make meaning of death through metaphorical expressions.

In this study, the clustering of the metaphors produced by intensive care nurses regarding death under the themes of ‘End’, ‘Peace’, ‘Uncertainty’ and ‘Beginning’ closely aligns with the findings of the study conducted by Teskereci et al. [19] with nursing students. The study categorized students' death metaphors as ‘Beginning’, ‘End’, ‘Eternity’ and ‘Mystery’ and emphasized that death was perceived as a state situated between an end and a beginning. The presence of both ‘End’ and ‘Beginning’ categories in both studies suggests that death is interpreted within a dual framework, as both a biological closure and a form of transformation. In the study by Teskereci et al. [19], the fact that the majority of participants were first‐year students may explain why death was interpreted primarily along the dimensions of ‘Beginning’, ‘Eternity’ and ‘Mystery’. In contrast, in the present study, the more frequent use of metaphors such as ‘a candle going out’, ‘final’ and ‘inevitable end’ by intensive care nurses suggests that, with increasing clinical experience, death is perceived as a more concrete, irreversible and biological reality. This difference indicates that perceptions of death may evolve with professional experience and more frequent encounters with patient deaths.

Most metaphors related to death were classified under the ‘End’ category. Death is a universal and inevitable part of life and marks the end of life for all living beings [20, 21]. Within the ‘End’ category, metaphors such as ‘a candle going out’, ‘final’ and ‘inevitable end’ were the most frequently used. Death is an unavoidable end in human life, and nurses, particularly those working in intensive care units, are among the professional groups who most frequently witness this endpoint [22]. These findings suggest that intensive care nurses, who both witness death and provide end‐of‐life care, tend to perceive death as an end from a realistic perspective. These metaphors further indicate that nurses often experience patients' deaths in intensive care units as a passive, irreversible and uncontrollable process. Temelli and Cerit [23], in their study conducted to determine perceptions of death and palliative care among palliative care nurses, reported that nurses perceive death as the end of life and a natural process. A study by Hov et al. [24], which examined healthcare professionals' records related to patients' deaths, found that death notes were most frequently categorized under the loss of bodily function. Although the term ‘end’ was not explicitly used in the records, there were notes indicating the cessation of vital functions such as respiration and circulation. Similarly, Maraşlıoğlu and Kartopu [25] studied earthquake survivors and observed that the majority of the metaphors developed by participants regarding death were grouped under the ‘End’ category. Based on these findings, it can be suggested that individuals who have frequently witnessed death tend to perceive it from a realistic perspective as the end of life. Similarly, in the study conducted by Tomoi [26], which examined the attitudes of middle‐aged and older individuals towards death, it was found that participants frequently described their perceptions of death as the ‘final moments’. Taken together, these findings suggest that one of the most fundamental ways of perceiving death, whether among healthcare workers or the general public, is as ‘the end’. This perception is likely rooted in the fact that all vital functions and activities cease with death. The present study extends the existing literature by demonstrating that intensive care nurses most frequently conceptualize death as ‘the end’ through concrete metaphors such as ‘a candle going out’, ‘the final’ and ‘the inevitable end’. Unlike previous studies that primarily identified death as a natural end of life, the metaphors generated in this study illustrate how repeated exposure to dying patients may contribute to shaping nurses' perceptions into concrete and irreversible images of death.

The second predominant category, the theme of ‘Peace’, indicates that nurses interpret death not only as a biological end but also as a release from suffering and a form of relief. The frequent use of the ‘Liberation’ metaphor suggests that, particularly for patients undergoing long‐term treatment and experiencing a diminished quality of life, death may be perceived as relief from pain and suffering. Similarly, Temelli and Cerit [23], in their study examining perceptions of death and palliative care among palliative care nurses, reported that nurses perceive death as the end of suffering. A study conducted by Keleş et al. [27] with nursing students reported that students had difficulty witnessing impending death and believed that, at a point when they themselves struggle to sustain life, they might develop requests related to death. In the study conducted by Teskereci et al. [19] with nursing students, the frequent use of the ‘liberation’ metaphor also parallels the prominent ‘Peace’ theme identified in the present study. In the study by Hov et al. [24], which examined healthcare professionals' records regarding patient deaths, some death‐related records described patients dying in a peaceful and calm environment. Similarly, in a qualitative study conducted with paediatric oncology nurses, death was described as ‘the end of the child's suffering’ [28]. In a phenomenological study conducted by Stuart [29], which aimed to explore how hospital nurses utilize knowledge in end‐of‐life and palliative care, nurses reported that they were able to guide patients ‘from the storm to calm’ through the effective use of knowledge. Across many studies examining perceptions and attitudes towards death, healthcare professionals' tendency to describe death in terms of peace may be associated with the relief that accompanies the cessation of prolonged suffering and pain in patients. The present study also provides a more nuanced understanding of why death is perceived as peaceful. Rather than referring only to a peaceful death, participants associated peace with the relief of patients' suffering, pain and prolonged illness. The metaphors generated by intensive care nurses suggest that frequent exposure to end‐of‐life care may contribute to this perception.

Some of the metaphors generated by the nurses were grouped under the theme of ‘Uncertainty’. In the present study, nurses emphasized the uncertainty surrounding what happens after death. Death is a multidimensional phenomenon, and one of its most fundamental dimensions is uncertainty [30]. Although previous studies have generally addressed uncertainty in relation to emotional distress and psychological ambiguity associated with death, the present study differed by highlighting uncertainty surrounding what happens after death. Abbasi et al. [28] reported that nurses experienced profound uncertainty and emotional turmoil when confronted with the death of a child. Similarly, Teskereci et al. [19] found that nursing students associated death with the themes of uncertainty and mystery. The students' metaphors, such as ‘a dark room’ and ‘an unknown ocean’, together with those identified in the present study, including ‘a black hole’ and ‘behind a door,’ suggest that although death is understood as a physiological event, its existential meaning remains beyond human comprehension.

The metaphors in the ‘Beginning’ category suggest that death can be perceived not only as an end or a finality but also as a process of transformation and new life. Expressions such as ‘being reborn’ and ‘transforming into energy’ suggest that nurses' belief systems and cultural backgrounds play a significant role in shaping their perceptions of death. This is consistent with the view in Turkish culture and Islamic belief, where death is regarded not as an end but as a transition [23, 25, 31]. Similarly, Temelli and Cerit [23], in their study examining perceptions of death and palliative care among palliative care nurses, reported that nurses perceive death as the beginning of the afterlife and a transition to eternity or spirituality. In a metaphor study conducted by Teskereci et al. [19] with nursing students, a considerable proportion of participants defined death using images such as ‘a new beginning’, ‘new existence’, ‘birth’ and ‘a new life’ and conceptualized death as a state positioned between an end and a beginning. Unlike the perception of death solely as an end, the metaphors in this category suggest that some intensive care nurses simultaneously conceptualize death as a transition or transformation. These findings highlight that nurses' perceptions of death are not uniform and may also be influenced by cultural and spiritual beliefs.

4.1. Limitations of the Study

As metaphors are based on participants' momentary linguistic expressions, they may not fully reflect the entirety of their perceptions. Additionally, the use of a single‐centre sample limits the generalizability of the findings.

5. Conclusion

This study examined intensive care nurses' perceptions of death through the metaphors they generated. The findings showed that nurses most frequently perceived death as ‘the end’, while also describing it as ‘peace’, ‘uncertainty’ and ‘a new beginning’. These findings indicate that nurses' perceptions of death are multidimensional and encompass biological, existential, emotional and spiritual meanings. In addition, some metaphors could not be classified under a common conceptual category, suggesting that perceptions of death may also reflect individual and unique experiences.

The findings contribute to a better understanding of how intensive care nurses conceptualize death, an experience they encounter frequently in clinical practice. Understanding these perceptions may contribute to the planning of educational programmes focusing on death, end‐of‐life care and the care of dying patients. Future studies involving larger and more diverse samples are recommended to further explore nurses' perceptions of death in different clinical settings.

Author Contributions

Berna Köktürk Dalcalı: conceptualization. Berna Köktürk Dalcalı, Seçil Erden Melikoğlu and Aleyna Semiz Büyükaltay: study design. Berna Köktürk Dalcalı and Yılda Arzu Aba: supervision. Aleyna Semiz Büyükaltay and Güzin Eşme: resource provision/materials. Aleyna Semiz Büyükaltay and Güzin Eşme: data collection and data management. Berna Köktürk Dalcalı, Seçil Erden Melikoğlu, Aleyna Semiz Büyükaltay and Yılda Arzu Aba: data analysis. Berna Köktürk Dalcalı, Aleyna Semiz Büyükaltay and Yılda Arzu Aba: interpretation and reporting of findings. Berna Köktürk Dalcalı, Seçil Erden Melikoğlu and Yılda Arzu Aba: critical revision of the manuscript. Berna Köktürk Dalcalı and Aleyna Semiz Büyükaltay: manuscript preparation and publication process. All authors read and approved the final version of the manuscript.

Funding

The authors have nothing to report.

Ethics Statement

Ethical approval for this study was obtained from the Bandırma Onyedi Eylül University Health Sciences Non‐Interventional Research Ethics Committee (date: 27 December 2024; no: 2024‐11). Before participating in the study, all nurses were informed about the purpose, scope and procedures of the research. Participation was voluntary, and written informed consent was obtained from all participants. The study was conducted in accordance with the principles of the Declaration of Helsinki.

Consent

All participants were informed that the anonymized findings of the study would be used for scientific publication purposes.

Conflicts of Interest

The authors declare no conflicts of interest.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.