Iran Journal of Nursing

Introduction
The primary task of nurses is to provide high-quality clinical care to patients, which not only requires a focus on scientific and technical aspects but also needs the ability to assess, manage, and address ethical dilemmas, since professional nursing practice is inherently intertwined with ethical considerations. Nurses, due to their involvement in making critical decisions about the health and lives of patients, consistently encounter ethical dilemmas. Ethics in nursing, because of its role in ensuring patient safety and rights, is an inseparable part of the concept of patient care. Ethical challenges in providing health services are becoming more complicated day by day due to the advancement of technology and treatment methods. For instance, the possibility of maintaining cardiac-respiratory function and feeding patients with unfavorable prognoses are some of the serious challenges for nurses. Such issues raise ethical dilemmas and complicate the provision of healthcare services. Ethical dilemmas in pediatric nursing are more challenging due to the involvement of families and caregivers, in addition to patients. Moreover, the young age of the patients and their lack of independent decision-making ability can increase the complexity of decision-making. 
One of the serious ethical challenges for nurses is providing care to patients who are in their last days of life. End-of-life care brings nurses multiple ethical dilemmas. One of these dilemmas is the acceptance or refusal of euthanasia. Euthanasia is not legal in Iran and is in conflict with religious values; however, it is legal in some countries and does not contradict religious values. The decision of nurses is directly related to their attitudes toward these values and can lead to legal challenges and serious problems for them. Therefore, investigating nurses’ perspectives on euthanasia is essential. This study aims to assess the relationship between ethical reasoning and attitude towards euthanasia in nurses of children’s hospitals in Iran.

Methods
This is a descriptive-correlational study that was conducted in 2023 on 194 nurses from children’s hospitals affiliated to Tehran University of Medical Sciences (Children’s Medical Center, and Bahrami Hospital). The inclusion criteria were at least a Bachelor’s degree in nursing, being employed in one of the selected hospitals, and a work experience of at least 6 months. Data were collected online and in-person, using three questionnaires. The first one was a demographic form surveying age, sex, marital status, years of work experience, department, and history of participation in nursing ethics educational courses. The second was the Nursing Dilemma Test (NDT). This questionnaire includes six scenarios, each of which presents an ethical dilemma. In each scenario, there are six options, and nurses are asked to prioritize them based on their perceived importance. Depending on the prioritization performed, each scenario has a nursing principled (NP) score, which indicates the ethical reasoning score. The NP score for each scenario ranges from 3 to 11. The total NP score ranges from 18 to 66, with higher scores indicating higher ethical reasoning in the nurse. The third questionnaire was the Euthanasia Attitude Scale (EAS), developed by Tordella and Neutens in 1979, with 21 items. In the Persian version of this tool, one item has been removed, resulting in 20 items. The items are rated on a five-point scale from “completely disagree” to “completely agree.” In this tool, items 20, 17, 15, 14, 9, 7, 4, and 2 have reversed scoring. A higher score indicates greater support for euthanasia. The data were analyzed in SPSS software, version 26 using descriptive statistics (frequency, percentage, and mean) and inferential statistics (independent t-test and Pearson’s correlation test). The significance level was set at 0.05.

Findings
The mean age of the nurses was 31.60±4.90, and their mean work experience was 10.37±5.90 years. Most of the participants were female (91.8%), had a bachelor’s degree (73.7%), were married (68%), and had no history of participating in nursing ethics courses (63.4%). Most of nurses were from general wards (46.9%), while the minority was from the emergency departments (23.7%). The mean NP score of ethical reasoning was 42.92±10.33, which is relatively higher the average score. There was no significant relationship between the NP score and age, work experience, sex, marital status, educational level, or history of participating in nursing ethics courses. However, the nurses’ department was found to be significantly related to the NP score. The nurses working in the emergency departments had the lowest scores, while nurses in the general wards achieved the highest scores.
The mean score of EAS was 2.65±0.12. Considering that a score less than 3 on EAS indicates a negative attitude towards euthanasia, it can be said that pediatric nurses had a negative attitude towards euthanasia. The EAS score towards  had no significant relationship with age, work experience, sex, marital status, educational level, or history of participating in nursing ethics courses. However, the nurses’ department was significantly related to the EAS score. The nurses in general wards had the least positive attitude, while nurses in special care wards had the most positive attitude towards euthanasia. Among the sub-scales of EAS, the lowest and highest scores were related to practical considerations and naturalistic beliefs, respectively. The results of Pearson correlation test indicated a significant negative correlation between the NP score and attitudes towards euthanasia. Additionally, there was a significant negative relationship between the NP score and all the EAS subscales, except for naturalistic beliefs.

Conclusion
The results of this study support the presence of a negative correlation between ethical reasoning and attitudes toward euthanasia, indicating that nurses with higher ethical reasoning provide more support for life and are more opposed to euthanasia. In a study by Torabi and Eslami Panah [14], a positive correlation was reported between ethical reasoning and attitudes toward end-of-life care. In their research, a different tool was used, where higher scores imply a more positive attitude toward end-of-life care. Their findings are in line with our results. it seems that nurses with higher ethical reasoning skills may be more resistant to performing euthanasia and consider it against the patient-centered care principles.
Overall, it can be concluded that the ethical reasoning of pediatric nurses is at moderate level, and their attitudes toward euthanasia is negative. Nurses working in departments with complex working conditions had lower ethical reasoning but more positive attitudes toward euthanasia. This suggests the potential impact of nurses’ workplace on these variables. Since a significant negative correlation exists between ethical reasoning and attitudes towards euthanasia, a decrease in ethical reasoning may lead to more positive attitudes towards euthanasia. Given the vulnerability of children, it is essential to ensure that the performance of pediatric nurses is of the highest possible quality. As a positive attitude towards euthanasia can potentially lead nurses toward end-of-life care and support, necessary plans should be made to enhance the ethical reasoning of these nurses and improve their knowledge of euthanasia.

Ethical Considerations
Compliance with ethical guidelines
This study was approved by the ethics committee of Tehran University of Medical Sciences (Code: IR.TUMS.FNM.REC.1402.043). Prior to the study, explanations were provided to the participants about the study objectives, the confidentiality of their information, and their right to leave the study. They signed an informed consent form.

Funding
This study was funded by Tehran University of Medical Sciences.

Authors’ contributions
Conceptualization: Akram Sadat Sadat Hosseini, Mohammad Mehdi Rajabi, Hanie Tavasoli; Data Collection: Hanie Tavasoli; Data Analysis: Hadi Ranjbar; Final Approval: All Authors.

Conflict of interest
The authors declare no conflicts of interest.

Acknowledgments
The authors would like to express their gratitude to the Deputy for Research of Tehran University of Medical Sciences and all the nurses participated in this study for their support and cooperation.


References

1. Cerit B, Dinç L. Ethical decision-making and professional behaviour among nurses: A correlational study. Nurs Ethics. 2013; 20(2):200-12. [DOI:10.1177/0969733012455562] [PMID]
2. Yuguero O, Esquerda M, Viñas J, Soler-Gonzalez J, Pifarré J. Ethics and empathy: The relationship between moral reasoning, ethical sensitivity and empathy in medical students. Rev Clin Esp. 2019; 219(2):73-8. [DOI:10.1016/j.rce.2018.09.002]
3. Rızalar S, Baltacı N. Ethical decision-making levels of nurses and it’s affecting factors. Int J Caring Sci. 2020; 13(1):42-52. [Link]
4. Mallari MGD, Tariman JD. Ethical frameworks for decision-making in nursing practice and research: An integrative review. DePaul Online J Nurs Res. 2016; 7(1):1-27. [Link]
5. Aydogdu ALF. Ethical dilemmas experienced by nurses while caring for patients during the COVID-19 pandemic: An integrative review of qualitative studies. J Nurs Manag. 2022; 30(7):2245-58. [DOI:10.1111/jonm.13585] [PMID]
6. Arsang-Jang S, Khoramirad A, Pourmarzi D, Raisi M. Relationship between spiritual intelligence and ethical decision making in Iranian nurses. J Humanist Psychol. 2020; 60(3):330-41. [DOI:10.1177/0022167817704319]
7. Bagnasco A, Cadorin L, Barisone M, Bressan V, Iemmi M, Prandi M, et al. Ethical dimensions of paediatric nursing: A rapid evidence assessment. Nurs Ethics. 2018; 25(1):111-22. [DOI:10.1177/0969733016631161] [PMID]
8. Arslan S, Türer Öztik S, Kuzu Kurban N. Do moral development levels of the nurses affect their ethical decision making? A descriptive correlational study. Clin Ethics. 2021; 16(1):9-16. [DOI:10.1177/1477750920930375]
9. Baysal E, Sari D, Erdem H. Ethical decision-making levels of oncology nurses. Nurs Ethics. 2019; 26(7-8):2204-12. [DOI:10.1177/0969733018803662] [PMID]
10. Trotochaud K, Coleman JR, Krawiecki N, McCracken C. Moral distress in pediatric healthcare providers.  J Pediatr Nurs. 2015; 30(6):908-14. [DOI:10.1016/j.pedn.2015.03.001] [PMID]
11. Ghasemi E, Negarandeh R, Janani L. Moral distress in Iranian pediatric nurses. Nurs Ethics. 2019; 26(3):663-73. [DOI:10.1177/0969733017722824] [PMID]
12. Tahmasebi S, Sabeti F, Hagani H, Mohammadi R. [Investigating the relationship between clinical decision making and moral distress of nurses working in pediatric intensive care unit (Persian)]. Nurs Midwifery J. 2022; 20(2):137-46. [DOI:10.52547/unmf.20.2.137]
13. Amiri R, Gaeeni M, Ahmari H, Momenyan S. [The relationship between moral reasoning and the caring behavior of nurses in emergency departments of Qom, 2015 (Persian)]. Iran J Emerg Care. 2017; 1(3):1-10. [Link]
14. Torabi M, Eslamipanah M. [Evaluating the level of ethical decision making of nurses and its relationship with the attitudes of end-of-life care of patients with COVID-19 (Persian)]. Iran JMed Ethics Hist Med. 2021; 14(0):333-47. [Link]
15. Cayetano-Penman J, Malik G, Whittall D. Nurses’ perceptions and attitudes about Euthanasia: A Scoping review. J Holist Nurs. 2021; 39(1):66-84. [DOI:10.1177/0898010120923419] [PMID]
16. Terkamo-Moisio A, Gastmans C, Ryynänen OP, Pietilä AM. Finnish nurses’ attitudes towards their role in the euthanasia process. Nurs Ethics. 2019; 26(3):700-14. [DOI:10.1177/0969733017720850] [PMID]
17. Moghadas T, Momeni M, Baghaee M, Ahmadi S. [Euthanasia and care for dying patients: Attitudes of ICU nurses (Persian)]. Iran J Med Ethics Hist Med. 2012; 5(4):75-83. [Link]
18. Crisham P. Measuring moral judgment in nursing dilemmas. Nurs Res. 1981; 30(2):104-10. [PMID]
19. Borhani F, Abbaszadeh A, Kohan M, Fazael MA. [Nurses and nursing students’ ethical reasoning in facing with dilemmas: A comparative study (Persian)]. Iran J Med Ethics Hist Med. 2010; 3(4):71-81. [Link]
20. Tordella MA, Neutens JJ. An instrument to appraise attitudes of college students toward euthanasia. J Sch Health. 1979; 49(6):351-2. [DOI:10.1111/j.1746-1561.1979.tb07728.x] [PMID]
21. Aghababaei N. [Assessing attitudes toward euthanasia (Persian)]. Iran J Med Ethics Hist Med. 2011; 5(1):59-70. [Link]
22. Safarpour H, Keykha R, Varasteh S, Sargazi V, Mirmortazavi M, Tavakolian N. Attitude of nurses towards euthanasia: A cross-sectional study in Iran. Int J Palliat Nurs. 2019; 25(6):274-82. [DOI:10.12968/ijpn.2019.25.6.274] [PMID]
23. Fazljoo E, Borhani F, Abbaszadeh A, Dadgari A. [Assessment of moral reasoning ability of the nurses in dealing with moral dilemmas (Persian)]. Med Ethics. 2016; 10(36):47-54. [Link]
24. Goethals S, Gastmans C, de Casterlé BD. Nurses’ ethical reasoning and behaviour: A literature review. Int J Nurs Stud. 2010; 47(5):635-50. [DOI:10.1016/j.ijnurstu.2009.12.010] [PMID]
25. Koohi A, Khaghanizade M, Ebadi A. [The relationship between ethical reasoning and demographic characteristics of nurses (Persian)]. Iran J Med Ethics Hist Med. 2016; 9(1):26-36. [Link]
26. Naseh L, Rafiei H, Heidari M. Nurses’ attitudes towards euthanasia: A cross-sectional study in Iran. Int J Palliat Nurs. 2015; 21(1):43-8. [DOI:10.12968/ijpn.2015.21.1.43] [PMID]
27. Alborzi J, Sabeti F, Baraz S, Miladinia M, Saidkhani V, Sharhani A. Investigating of moral distress and attitude to euthanasia in the intensive care unit nurses. Int J Pediatr. 2018; 6(11):8475-82. [Link]