Nursing Students’ Perceptions of Assisted Dying: A Qualitative Study

Assisted dying became a legal choice in November 2021 following the passing of the End of Life Choice Act (2019) in New Zealand. This new means of dying allows individuals to pursue the right to die should they meet the legislated criteria. The availability of assisted dying raises questions regarding nursing practices and responsibilities in relation to the service. The aim of this study was to gain insight into nursing students’ views about assisted dying in Aotearoa New Zealand. A qualitative descriptive study using a qualitative survey with a paper-based questionnaire was undertaken among nursing students enrolled in a Bachelor of Nursing (BN) programme at a single tertiary education organisation in 2019. Responses from 192 students were analysed using content analysis. Three categories were identified: supportive on the basis of personal choice; disapproval on the basis of personal beliefs; and taking a professional stand as a nurse. The categories present the distinct and opposing views expressed by nursing students regarding assisted dying, with the extent of support or disapproval being supported by their recognition of personal autonomy, their own belief systems and their views of roles expected of nurses. This research highlighted that nursing students’ views about assisted dying were influenced by both personal and professional factors, and at times these were dichotomous. Ethical and practice challenges concerning assisted dying must be recognised and acknowledged. The nursing education sector should include topics related to assisted dying in the curricula and work with students to, where necessary, reconcile any ethical issues that arise. This will ensure that future nurses are prepared and equipped with knowledge and skills in providing care to patients and families considering or requesting assisted dying. Ngā Ariā Matua I whakamanaia ā-turetia te mate whakaahuru o te tangata i te marama o Nōema 2021 i muri i te pāhitanga o te Ture mō te Whiringa mō te Mutunga o te Oranga (2019) i Aotearoa. Mā tēnei ara hou ki te matenga ka taea e te tangata takitahi te whai i tana tika kia mate, ki te tutuki i a ia ngā paearu ā-ture. Nā te wāteatanga mai o te mate whakaahuru mō te tangata, ka ara ake ētahi pātai mō ngā tikanga mahi tapuhi me ō rātou haepapa mō te kaupapa āwhina hou. Te whāinga o tēnei rangahau he whai kia mārama ki ngā whakaaro o ngā pia tapuhi ki te mate whakaahuru o te tangata i Aotearoa. I mahia tētahi rangahau whakaahua kounga nā te whakamahi uiuinga kounga, ki tētahi rārangi pātai pepa i waenga i ngā pia tapuhi i rēhitatia ki tētahi akoranga Paetahi mō Te Tapuhitanga (BN) i tētahi whare whakaako kotahi i 2019. I tātaritia ngā whakautu mai i ngā ākonga 192 nā te whakamahi tātaritanga kōrero. E toru ngā kāwai i tautuhitia: ērā i tautoko i runga i te whiringa whaiaro; te korenga e whakaae i runga i ngā whakapono tāngata takitahi; me te tū hei tangata ngaio, arā, hei tapuhi. Ko ngā kāwai kei te whakaari i ngā tū motuhake, tauaro hoki i whakapuakina e ngā pia tapuhi mō te mate whakaahuru, me kī, kei te āhua o tō rātou whakaae ki te mana motuhake o te tangata mōna anō, o ō rātou pūnaha whakapono, me tō rātou titiro ki ngā mahi e tika ana mā te tapuhi, te kaha tautoko, te kaha whakahē rānei ki te ara hou. Tā tēnei rangahau he whakatairanga i te kawenga o ngā whakaaro o ngā pia tapuhi mō te mate whakaahuru e ngā pūtake whaiaro, me ngā pūtake ngaio, ā, i ētahi wā he noho tauwehe ēnei pūtake e rua. Me mātua kite, me mātua urupare ki ngā wero matatika me ngā wero i te wāhi mahi o te mate whakaahuru. Me uru ki te rāngai akoranga tapuhi ētahi kaupapa e pā ana ki te mate whakaahuru i roto i te marautanga me te mahi tahi ki ngā ākonga ki te tuitui tahi i ngā take matatika ka ara ake, i ngā wāhi e tika ana. Mā konei ka tika te whakangungu, te hoatu pūkenga hoki ki ngā tapuhi o āpōpō, ka whiwhi hoki i te mātauranga me ngā pūkenga e tika ana hei tiaki i ngā tūroro me ō rātou whānau e whiriwhiri nei, e inoi nei rānei, ki te mate whakaahuru mō rātou. Ngā kupu matua mate whakaahuru; te taurimatanga i te mutunga o te ora; ngā ture; te akoranga tapuhi; ngā pia tapuhi; te rangahau kounga

Nursing Praxis in Aotearoa New Zealand Assisted dying became a legal choice in November 2021 following the passing of the End of Life Choice Act (2019) in New Zealand.This new means of dying allows individuals to pursue the right to die should they meet the legislated criteria.The availability of assisted dying raises questions regarding nursing practices and responsibilities in relation to the service.The aim of this study was to gain insight into nursing students' views about assisted dying in Aotearoa New Zealand.A qualitative descriptive study using a qualitative survey with a paper-based questionnaire was undertaken among nursing students enrolled in a Bachelor of Nursing (BN) programme at a single tertiary education organisation in 2019.Responses from 192 students were analysed using content analysis.Three categories were identified: supportive on the basis of personal choice; disapproval on the basis of personal beliefs; and taking a professional stand as a nurse.The categories present the distinct and opposing views expressed by nursing students regarding assisted dying, with the extent of support or disapproval being supported by their recognition of personal autonomy, their own belief systems and their views of roles expected of nurses.This research highlighted that nursing students' views about assisted dying were influenced by both personal and professional factors, and at times these were dichotomous.Ethical and practice challenges concerning assisted dying must be recognised and acknowledged.The nursing education sector should include topics related to assisted dying in the curricula and work with students to, where necessary, reconcile any ethical issues that arise.This will ensure that future nurses are prepared and equipped with knowledge and skills in providing care to patients and families considering or requesting assisted dying.

INTRODUCTION
The implementation of the End of Life Choice Act (2019) (EoLC Act; the Act) in November 2021 was a watershed moment for death and dying practices in Aotearoa New Zealand.While this new means of dying permits individuals to pursue the right-to-die should they meet the application criteria of the legislation, it simultaneously raises questions regarding nursing practices and responsibilities in relation to the service.The Act includes the role of the nurse practitioner in relation to assisted dying service delivery.However, there remains a lack of guidance for registered nurses and nursing students, despite their extensive contribution to direct patient care.The New Zealand Nurses Organisation (NZNO) had called for registered nurses' roles in the Act to be visible when the legislation was drawn up.As such, this lack of clear legislative guidance places registered nurses and nursing students in a position of uncertainty in responding to and managing assisted dying service requests (Pesut, Thorne, Schiller, et al., 2020).Nurses value appropriate policies and guidelines to ensure their assisted dying practices are both ethical and safe (Sandham et al., 2022).
Not unexpectedly, this new means of dying has produced tension across healthcare service providers, and no more so than among nursing students who strive to provide highquality, appropriate care for those towards their end of life.The lack of clearly defined nursing responsibilities within the New Zealand assisted dying legislation, together with a lack of clinical guidelines and policies (Pesut, Thorne, Schiller, et al., 2020) leaves nursing students unsupported and potentially open to being misguided regarding their legal obligations in relation to the EoLC Act.On clinical placements, nursing students may potentially be asked about the assisted dying service, and, therefore, need to be prepared to respond as per the legislational requirements.While this may be ethically challenging for them, it is a competency requirement of the Nursing Council of New Zealand (NCNZ, 2022); for example, competency 2.4.
Moreover, nursing students need to be aware of their rights to conscientious objection in the face of not knowing when conversations about assisted dying will occur.Again, there is omission of clear guidelines within the legislation for this cohort of nurses.Furthermore, assisted dying services are intended to sit alongside currently available palliative care services.However, given the conscientious objection by some palliative care providers to the new service (Hospice NZ, 2022), together with hospice nurses, who ap-pear to view the introduction of assisted dying with a negative lens (Woods & Rook, 2022), implementing assisted dying may prove challenging for healthcare providers (Havill & Smales, 2020).
Furthermore, it is known that nurses' professional practices are influenced by life experiences, with their moral and ethical values underpinning their decision-making (Park, 2011).This may influence their positioning on the legalisation of assisted dying services and, subsequently, their responses to those in their care.Despite 67% of registered nurses supporting the legalisation of assisted dying in Aotearoa New Zealand (Wilson et al., 2019), there remains 33% for whom this new means of dying is potentially problematic.Those who request assisted dying services are therefore exposed to the subjectivity of the registered nurse or nursing student they approach.
Given the bi-cultural landscape of Aotearoa New Zealand and the known disparities in healthcare delivery between Māori (the Indigenous people of New Zealand), other culturally diverse populations, and New Zealanders of white European descent, cultural safety in relation to assisted dying services is a significant concern (Came et al., 2021;Lee, 2020).While nursing practice, based on a holistic approach to care, takes account of cultural diversity (NCNZ, 2012), the EoLC Act (2019) appears to sit in opposition to this philosophy, thus creating additional challenges for the delivery of nursing care.Specifically, the Act places responsibility for assisted dying conversations on the individual interested in the service but excludes the need for significant others, for example, whānau (families and extended families), to be involved at any point in the process unless invited to do so by the individual.Such a secularised legislation is problematic given the need for whakawhanaungatanga (the process of establishing relationships) and Te Ao Māori (Māori worldview) to be interwoven into the assisted dying journey for Māori (Manson, 2021).
Death, dying and palliative care conversations and associated clinical practices are challenging for many registered nurses, let alone nursing students, irrespective of educational and experience level (Hussain, 2019).As such, the introduction of assisted dying services adds both a psychological and emotional toll to this clinical burden (Davidson et al., 2022;Sandham et al., 2022).Furthermore, it is well documented that pre-registration end-of-life care training is often lacking, or even missing, from the nursing education curriculum, resulting in nursing students who are inade-Nursing Students' Perceptions of Assisted Dying: A Qualitative Study Nursing Praxis in Aotearoa New Zealand quately prepared to provide care to the dying while in clinical placement (Berndtsson et al., 2019).In the Aotearoa New Zealand context, Heath et al. (2020) concluded that 76% of education providers deliver some palliative care content, but this is often integrated across curricula rather than being independent modules for study, inferring that palliative care remains a less important subject matter for nursing students.This situation is further complicated by the anxiety experienced by nursing students when facing a suffering or dying patient and, more so if the death is sudden or unexpected (Strang et al., 2014).As such, assisted dying legislation adds another layer of complexity to nursing students' experiences in clinical practice, which may further heighten such emotive reactions regarding the realities of death and dying.
Such reactions may be heightened by the overall lack of professional development available regarding the assisted dying service.Currently, there are three short online professional development courses offered to health professionals and these are available via the Te Whatu Ora website (2023).There are a further five e-learning modules for nurse practitioners and doctors intending to provide assisted dying services.
The introduction of the EoLC Act (2019) to the health system adds further challenges to caring for those who are dying and will impact nursing practice across many specialties, including aged residential care sector, primary healthcare, hospice, as well as hospital services.Nurses will likely be involved, to varying degrees, in assisted dying service conversations or provision.Increasingly, many nurses, including students, will be required to participate in assisted dying service practice, and for some, this may be challenging.As such, it is imperative that nursing students' views about assisted dying are understood so that education providers and clinical practice can better support and prepare students for the realities of being a registered nurse.Therefore, the aim of this study was to gain insight into nursing students' views about assisted dying in Aotearoa New Zealand.

DESIGN AND METHODS
This study used a qualitative descriptive approach as the methodological lens to underpin this research.Qualitative description originates from a naturalistic paradigm and is used to describe and interpret participants' perspectives about phenomena (East et al., 2023).This methodology is not grounded in a theoretical position, and rather, it seeks to provide rich descriptions of a phenomenon where little is known and findings are presented in the participant's own language (Bradshaw et al., 2017).Therefore, a qualitative description was deemed the most appropriate methodology to address the research aim of this project.

Sampling and recruitment
Convenience sampling was used to invite all nursing students enrolled in a Bachelor of Nursing (BN) programme at a single tertiary education organisation in Aotearoa New Zealand to participate in this study.This type of sampling strategy draws on study participants who meet the inclusion criteria and are available and willing to participate in the research (Whitehead & Whitehead, 2020).Inclusion criteria were all students enrolled in a Bachelor of Nursing programme in a tertiary education institution.Data were collected for this study in 2019.Prior to data collection, posters were displayed on noticeboards at the educational institution where students were enrolled, outlining what the study was about, and describing the recruitment process.In addition, nurse educators were provided with information sheets about the study to give to students attending their classes.Students interested in participating then met with researchers on campus.An overview of the study was provided by researchers and an opportunity to ask any further questions.Those students interested in participating were given a consent form to sign.Researchers reinforced that participation in the study was voluntary and their individual responses would remain anonymous.Participants were able to withdraw at any time prior to the completion and collection of the questionnaires.

Data collection and analysis
Data were gathered via a qualitative paper-based survey.A qualitative survey was chosen as an economical means of collecting data from a large pool of participants.Prior to the commencement of data collection, the questions were piloted with a small group of nursing students and staff to determine the suitability and appropriateness of the questions to be asked of participants.Minor adjustments were made, and the final survey comprised of demographic information and open-ended questions.Examples of openended questions asked included: "Have you encountered or nursed a person who is dying; tell us about that experience"; "Do you support a law change to allow medical practitioners to assist people to die?Why/why not?" and "Are you comfortable nursing a person who has requested assisted dying?Why/why not?" Content analysis was used to make sense of the qualitative survey excerpts and is deemed congruent with utilising a qualitative descriptive methodology (Neville & Whitehead, 2020).Firstly, data from each of the questions were manually sorted under each of the study questions asked.Two of the authors (RJ, JM) individually read the excerpts in their entirety and units of text that answered the study questions were highlighted.These formed initial codes.These were then compared, discussed and agreed codes were determined and presented as categories.

Ethical Approval
Ethical approval was obtained from the Unitec Institute of Technology Research Ethics Committee (Number: 1014).

FINDINGS
A total of 200 nursing students participated in the qualitative paper-based survey, with 192 (96%) valid responses included in the analysis.The majority of the participants (46%) were aged 20 to 30 years old.There were 25 males (13%) and 166 females (87%) who participated in the study.The majority of the participants were first-and third-year nursing students (Table 1).Three categories were identified from the responses to the open-ended questions using content analysis: supportive on the basis of personal choice; disapproval on the basis of personal beliefs; and taking a professional stand as nurse.The categories present the distinct and opposing views expressed by nursing students regarding the EoLC Act (2019), with the extent of support or disapproval being supported by nursing students' recognition of personal autonomy, their own belief systems and their views of roles expected of nurses.

Supportive on the basis of personal choice
The majority of the responses supporting the EoLC Act were grounded on the right to exercise personal choice.Nursing students who supported the Act emphasised the importance of considering the matter as an expression of self-determination and individual rights, particularly when people lived with irreversible, painful and life-limiting conditions: If they have no quality of life, it should be their decision whether they want to live.Leaving people to suffer and prolonging life seems to me to be unethical.I think that the patient has every right as it is their own body, and they should be able to make a choice based on their prognosis.They should be able to die if that is what they really want to do.
Several approving responses were supported by narratives emphasising the importance of preventing unnecessary suffering and that individuals should have the control to make decisions about it: Sometimes the situation is unbearable and the person is suffering in a way that makes them miserable.So, when a person knows that with time it will become worse, then he or she should be allowed to do so [have an assisted death].I think it is their decision.I don't want to see people and their family suffering.It just isn't right … they should be able to choose.
Others were more specific about instances where nursing students supported assisted dying.These unanimously related to those people living with pain, particularly if the pain experienced was relentless and resulted in significant suffering: I believe in quality of life … people should not have to live in pain, particularly if it [the pain] is bad and difficult to control.I don't like seeing people in pain.We don't let animals suffer in pain and it is considered inhumane to leave them to suffer.If the person is in pain and they are suffering and they want to end their life because of that, we should respect their wishes.It is important to allow people to make that call if they feel this is right for them.

Disapproval on the basis of own personal beliefs
The previous category clearly argued the need to support the EoLC Act ( 2019) by considering and supporting an individual's personal autonomy and right to choose to end their life or not.However, this was not everyone's view and disapproval driven by nursing students' personal views about the 'sanctity' of life was evident: I just don't agree.Why do we have the right to choose how someone gets to die?I just don't believe it is right.I believe in the sanctity of life.For me life is sacred and we have no right to have any influence on anyone who is wanting to put an end to their life.Death is a natural process and we must wait for it to happen in its own time.
In the responses where participants did not support assisted dying, we elicited reasons for taking this position.The majority of participants argued for not supporting assisted dying based on their religious values and beliefs.
As horrible as it may be for someone, this Act goes against my religious beliefs.I strongly believe in God.I understand suffering may be unbearable, but I personally feel uncomfortable to be a part of assisting someone to end their life.It is not our decision to decide when it is time for someone to die.God is our creator and divine being, only he can decide when the time is right for someone to die.
The disapproval expressed by participants was grounded in religious beliefs, including the sanctity of life and a belief in God.This created a dichotomous position between being true to their personal beliefs, which was antithetical to providing nursing care that was patient-centred.

Taking a professional stand as a nurse
Participants who were uncomfortable with supporting assisted dying were clear that they would remain professional and continue to offer a nursing service that supported a person's choice.This is aligned with the NCNZ Code of Conduct for Nurses (2012): It is important to be present for the patient and to support their choice.This is even though I personally don't agree with assisted dying, it makes me uncomfortable.So while I don't believe in it, I have a professional responsibility as a nurse to make sure they [the person] get the care they need and they will have my support regardless of their decision.I respect their choice and realise it is their wish, not mine; my role is to make them comfortable.

Another stated:
While I don't believe in this [assisted dying], it is important I remain professional in my approach because the patient should be the one to make the call.I will provide care within my scope of practice but will not agree to be the one who directly assisted in the procedure.
A number of participants were clear that they had a professional responsibility to work in partnership with people to promote and protect their well-being.This includes ensuring that people opting for assisted dying were in no way coerced into making their decision: When a person makes such an important decision as dying, I would want to make sure there is no evidence of coercion.If they are competent to make the decision then it is their choice because they are the one living with the condition and having to make the decision, not their family or friends.Providing the guidelines for the decision is met and the family screened to ensure there is no pressure from the family to push or rush the person to make a decision [to die].
Regardless of personal beliefs, participants were mindful of their professional responsibilities as a nurse.This included supporting people making assisted dying decisions of their own volition.

DISCUSSION
The findings from this study, conducted prior to the legalisation of the assisted dying service in Aotearoa New Zealand, offers clarity around pre-registration nursing students' beliefs and attitudes towards the End of Life Choice Act (2019) prior to implementation of the service.These views aligned with common general public responses towards this new means of dying (Wilson et al., 2019), which are often polarised between the prevalent right-to-die discourse and those who feel it contravenes their religious or moral beliefs.However, despite such divergent opinions, most nursing students were able to differentiate between their personal beliefs and the legal rights of others to make individual choices, demonstrating a high level of professionalism given their non-qualified status.
In keeping with previous literature, participants in this study considered the EoLC Act (2019) would give individuals the right to make personal choices regarding how life may end, and comfort in knowing that suffering may be avoided (Pesut, Thorne, Storch, et al., 2020).Moreover, the notion of suffering was extended beyond that of the self and self-determination, to include the experiences of family/whānau.As such, these findings align with the right-tochoice and right-to-die discourses that have dominated the voluntary euthanasia space for the last two decades (Booth & Blake, 2020).While the right-to-choice was supported by the majority of participants and aligns with Wilson et al.'s (2019) findings regarding registered nurses' support of assisted dying, the Act was not endorsed by all.In keeping with much of the literature, such positioning in relation to ending life prematurely was most often found in religious beliefs and the sanctity-of-life discourse (Smith & Blazeby, 2018).
The findings from this study, particularly those related to how student nurses position themselves in relation to the EoLC Act (2019), mirror global literature.However, what is interesting and novel is that despite the polarisation of views on the new legislation, many nursing students in this study simultaneously demonstrated a level of professionalism and advocacy for those in their care, irrespective of the choices being made.As such, these findings aligned with Pesut, Thorne, Storch et al. (2020), who indicated that nurses remained professional and responsive to those in their care, irrespective of the clinical challenges or personal views they held.Some of those nursing students who opposed the EoLC Act on the grounds of religious beliefs and the sanctity of life expressed that despite experiencing personal discomfort with an individual seeking an assisted death, they would continue to both support and advocate for the person concerned.Similarly, Pesut, Thorne, Storch et al. (2020) acknowledged the existence of external influences on nurses regarding the provision of assisted dying services and found that having religious beliefs, for example, was not automatically equated with non-involvement with assisted dying provision, though occasionally, this was the case.
Participants in the present study clearly understood the nursing role in terms of the EoLC Act (2019), and there was a need to be responsive given the changes to clinical practice this legislation enacts.Yet, simultaneously, participants highlighted the broad-ranging ethical challenges this new means of dying presented to their professional responsibilities on registration as a nurse.Specifically, given the lack of inclusivity in the construction of the Act, including for Māori, guiding principles of ethical care such as rangatiratanga (autonomy to make decisions, and self-determination), manaakitanga (caring for the needs of others and showing kindness), and wairuatanga (holistic wellbeing of an individual) are missing (Manson, 2021;New Zealand Nurses Organisation, 2019).This leaves nursing students in a position of uncertainty regarding care, particularly given the emphasis of such principles across pre-registration cur-Nursing Students' Perceptions of Assisted Dying: A Qualitative Study Nursing Praxis in Aotearoa New Zealand ricula.As such, the professional awareness, accountability, and practice implications noted by these pre-registration nursing students demonstrate a maturity of attitude to what, for many, is a contentious and, often, a very personal issue.
This study offers a novel and interesting perspective of the realities of the right-to-die discourse in the context of pre-registration nursing education and the potential impact such legislation has both personally and professionally on students in Aotearoa New Zealand.Despite more recent studies occurring (Wilson et al., 2019), nursing students remain unrepresented in terms of their views and experiences, which suggests that further research in this field would prove helpful in identifying education and supportive mechanisms as service provision advances for assisted dying.As such, these findings highlight the challenges students face when learning to be a nurse.However, despite these challenges, most participants in this study either supported assisted dying or were able to put aside their own personal beliefs about assisted dying and continue to develop their professional identity as a nurse.
While this research focuses upon pre-registration nursing students in Aotearoa New Zealand, these findings have the potential to be relevant to nursing students overseas where assisted dying services already exist or in countries considering the introduction of assisted dying.Understanding the complex intersectionality of personal beliefs and professional accountability is necessary to provide adequate guidance for nurses caring for those who seek this new means of dying.Specifically, while individual nursing students may struggle with the tension between their beliefs and assisted dying services, they remain bound by ethical considerations of prioritising patient well-being, rights, and autonomy (NZNO, 2019), thus presenting a challenging narrative through which they must navigate.These challenges suggest that more targeted pre-registration education regarding assisted dying and the EoLC Act (2019) may provide a starting point from which to begin to understand the complexities of this service, and the inclusion of Māori principles in service construction.Further research is needed.Firstly, to repeat the study post implementation of the Act across a number of educational institutions, and secondly, to explore further the influences of religion, culture and ethnicity on student attitudes to assisted dying.

Limitations
Firstly, individual interviews with participants would have allowed us to delve deeper into student views about assisted dying.However, it did allow for a larger sample size.This data was obtained prior to the implementation of the EoLC Act (2019) and, therefore, current student opinions and perspectives may differ.Secondly, ethnicity was not recorded.Doing so may have offered insight into cultural considerations and engagement with Māori regarding this new health service.Manson (2021) identified that nursing practice is underpinned by Te Tiriti o Waitangi; therefore, Māori perspectives about assisted dying must be heard.Finally, participants were asked questions related to medical practitioners and therefore did not acknowledge the important role nurse practitioners have in assisted dying.

CONCLUSION
Nurses are expected to respond to changes in health policy and legislation and put aside their personal views to ensure they continue to provide care to consumers of health services that align with their scope of practice.This research highlighted that nursing students' views about assisted dying are influenced by both personal and professional factors, and at times these are dichotomous.It is important that these ethical and practice challenges concerning assisted dying and the enactment of the End of Life Choice Act (2019) are recognised and acknowledged.The nursing education sector should include topics related to assisted dying in the curriculum and work with students to where necessary reconcile any ethical issues that arise.This will ensure that future nurses are prepared and equipped with knowledge and skills in providing care to patients and families considering or requesting assisted dying.