Attitude towards euthanasia and its relationship with spiritual wellbeing among nursing students in Qazvin, Iran

Background: Euthanasia and its related factors are addressed as an important ethical issue in end-of-life care nursing. It's an illegal issue in Iran. This study aimed to examine the attitude towards euthanasia in nursing students, and its relationship with their personal beliefs’ level. Methods: The current cross-sectional study was conducted in Qazvin during the education year of 2017-2018. The samples of this study consisted of 121 nursing students who were studying at the Qazvin University of Medical Sciences for more than two semesters. The Euthanasia Attitude Scale and Palutzian and Ellison Spiritual Wellbeing Scale were used for the data collection. Results: The response rate was 73.3% (121 of 165 nursing students). All of nursing students in the present study were Muslim. The mean overall scores of attitudes towards euthanasia and spiritual wellbeing were 60.24±9.82 and 75.73±7.48, respectively. No significant relationship was found between attitude towards euthanasia and personal beliefs among them (p=0.204). Conclusion: Iranian nursing students reported a relatively neutral attitude towards euthanasia which is mainly related to its legal issue in Iran. Also, no significant relationship was observed between attitude towards euthanasia and personal beliefs among the participants. Further studies are needed in this regard.


Introduction
With increasing human lifespan and the advancements in medical facilities and equipments, the number of patients who need end-of-life care is increasing worldwide (1). One of the challenges related to the care and treatment of this group of patients is the debate on "euthanasia" or "mercy killing" (1,2). Euthanasia referred to "A physician (or another person) intentionally ends the life of a person by the administration of drugs, at that person's voluntary and competent request" (3).
Euthanasia and its related debates have greatly been interesting for Iranian researchers in recent years (1,4,5,6,7). Islam, as the main religion Attitudes towards euthanasia among nursing students www.ijehs.com 2020, Vol. 1, No. 5: e05 2 of Iranians, refers the euthanasia as a non-acceptable issue (8). In fact, based on Islam's perspective, the phenomenon of "death" and "life" is beyond the scope of human authority and it is not allowed to interfere on it (6). However, many members of healthcare teams, especially nursing teams, are confronting with this issue in Iranian hospitals. Besides, many nursing students may also face this challenge while attending clinical settings in their hospital courses (1,4,9).
Given the importance of euthanasia from the perspectives of religion and culture in Iran, various studies were conducted among Iranian nurses and nursing students (1,4,10,11 Therefore, the study aimed to examine the attitude towards euthanasia in nursing students and its relationship with their personal beliefs.

Samples and Sampling
The current cross-sectional study was conducted in Qazvin during the education year of 2017-2018. All eligible nursing students were invited to participate in the present study. Totally, 121 nursing students accepted to participate. The inclusion criteria were to spend at least two semesters in hospital settings. The study objectives were explained to the participants before participating in the study and they were assured that they can withdrew at any time. After obtaining written informed consent, the questionnaires were distributed among the participants by the researchers, and they were asked to complete the questionnaires and return them to the researchers, who were present in the hospital, at the end of the training day. This process was carried out in hospital settings at the time of their clinical courses.

Instruments
In the current study, demographic data were collected using a researcher-made checklist. The  (17).

Palutzian & Ellison Spiritual Wellbeing Scale
This scale consists of 20 questions about religious wellbeing (10 items) and existential wellbeing 10 items) (18). The score of each dimension ranges between 10 and 60. For the subscales of religious and existential wellbeing, there is no leveling and the judgment is made based on the score obtained.
The higher the score measure, the higher the degree of religious and existential wellbeing will be. These scores of religious wellbeing (10 items) and existential wellbeing together make the spiritual wellbeing overall score for Palutzian & Ellison's spiritual wellbeing scale (overall score ranges from 20 to 120).
Critical care nurses and nursing students answered the items based on a 6-item Likert scale. The overall score of spiritual wellbeing is divided into three levels (low, when final score were between 20 to 40, moderate when final score were between 41 to 99, and high score when final score were 100 and higher

Data Analysis
Data were analyzed using SPSS 16.
Pearson's χ2 test, the independent t-test, and one-way ANOVA were performed to analyze the data. A Pvalue of less than 0.05 in all analytical tests was considered significant in the present study.

Demographic characteristics of nursing students
The response rate was 73.3% (121 of 165 nursing students). All of the nursing students in the present study were Muslim. Table 1 shows nursing students' demographics characteristics in more detail (Table 1).

Attitude towards euthanasia in nursing students
The mean overall score of attitude towards euthanasia in nursing students was 60. 24±  However, this difference was not statistically significant between groups (p= 0.281).

The relationship between attitude towards euthanasia and spiritual wellbeing in nursing students
In the current study, the Pearson correlation test was used to investigate the relationship between spiritual wellbeing and attitude towards euthanasia.
Based on the results, no significant relationship was observed between attitude towards euthanasia and spiritual wellbeing in nursing students (p=0.717). Table 2 shows the relationship between nursing students' attitudes towards euthanasia and spiritual wellbeing levels in more detail.  (8,10).
In the current study, the relationship between attitude towards euthanasia and one subscale of spirituality, which is spiritual wellbeing, was investigated among nursing students. Based on the findings, there was no significant relationship between these two variables. Limited studies have conducted in this regard that in most of them; spirituality in individuals has been evaluated by asking questions.
Our searches revealed that there is only one study in which the role of religion and its relationship with euthanasia among students was investigated in detail.
In the mentioned study that was conducted in 2013, Given the limited studies concerning the relationship between attitude towards euthanasia and spirituality among nursing students, and the debate between these studies, it seems that more precise and detailed studies are required to provide a more accurate view of this matter and in the current situation, we cannot judge precisely whether there is a relationship between these two matters.

Study limitations
All participants were Muslim and can be a problem to generalize the findings to nursing students with other religions.

Ethics approval for medical research
This article was extracted from a large research project that were approved by students' research committees in school of nursing and midwifery. All stages of the study were observed and controlled by the