Nursing students' attitudes, future role, knowledge, and skills regarding euthanasia due to unbearable mental suffering

This PhD-dissertation is constructed using all the papers published in scientific journals during the course of this doctoral programme regarding euthanasia due to unbearable mental suffering (UMS euthanasia).
Chapter 1 provides a comprehensive introduction regarding euthanasia and nursing education outlining the background and concepts specific to this study. It then delves deeper into euthanasia in general before focusing, specifically on the Belgian context. This includes a detailed explanation of the Belgian euthanasia law and the implementation of euthanasia in Belgium. We then present the registrations of euthanasia over the years. Finally, we explain the challenges related to UMS euthanasia, as this is the main topic of this dissertation. We explore the role of nurses in euthanasia and discuss nursing education from both a European and a Flemish perspective. This chapter concludes with the research methods and structure of this dissertation.
The overarching goal of this chapter is twofold. On the one hand, we strive for a clear definition of the concepts, and on the other hand, we want to place these concepts within an international context and within our own society.
Chapter 2 includes a detailed description of the first pilot study. This study aims to investigate the attitudes, and perceived future roles, knowledge of psychiatric nurses regarding UMS euthanasia. The participants in this pilot study were employed in psychiatric wards, both within general hospitals and psychiatric hospitals. A standardized questionnaire was applied for that purpose, based on existing literature and research instruments.
The central findings of this study indicate that a significant proportion of mental health nurses consider the possibility of UMS euthanasia. Nevertheless, they simultaneously express caution in the practical implementation of this process. In most cases, psychiatric nurses engage in the decision-making process regarding UMS euthanasia, albeit mainly in a consulting role. The results of this study highlight the urgent need for additional information, knowledge acquisition and skill development regarding this complex ethical issue.
Chapter 3 outlines a second pilot study with the main objective of examining nursing students' attitudes, and perceived roles, knowledge. This research phase was conducted within one nursing training institution at both the EQF Level 5 and EQF Level 6. To implement this objective, a standardized questionnaire was used, which was based on existing literature and research instruments.
The results of this study indicate that the nursing students in our study seem to support the possibility of UMS euthanasia. Moreover, they highlight the essential role that nurses play in the decision-making process regarding euthanasia. It is important that nursing education not only focuses on knowledge and skills related to euthanasia, but also pays attention to the broader context of palliative care and end-of-life counselling. This should include the specific challenges of euthanasia in mental suffering, with sufficient space for critical reflection and inclusion of transcultural perspectives.
Chapter 4 includes both the validation process of the applied questionnaire to survey the attitudes of Flemish final-year nursing students at the EQF (bachelor's) level 6 and the presentation of the results of this survey. For this survey, all Flemish undergraduate nursing programmes were invited to participate, to which eight of the eleven Flemish colleges responded positively.
The translation of the Euthanasia Attitude Scale into Dutch and its adaptation for UMS euthanasia confirmed that the UMS-EAS-NL is a reliable instrument, with similar
psychometric properties as previously established. Students showed a positive attitude toward UMS euthanasia. Moreover, clinically relevant differences were observed among students who had previously been involved in euthanasia. The UMS-EAS-NL questionnaire may serve to evaluate attitudes toward UMS euthanasia and may be a valuable contribution to broader education, which should focus more on integrating knowledge and skills related to UMS euthanasia.
Chapter 5 on the one hand includes data derived from a quantitative survey on the views of final-year nursing students at EQF Level 6 in Flanders regarding their future role in euthanasia and their perceived knowledge about UMS euthanasia. This quantitative survey was conducted simultaneously with the research described in Chapter 4. This chapter also includes data obtained from focus groups held in three different colleges, discussing attitudes toward UMS euthanasia, the future role of nurses, and perceptions of their knowledge in this area.
Final-year nursing students see a clear and meaningful role for nurses in UMS euthanasia. They emphasize their valuable contribution to the decision-making process and to supporting patients and their families before, during and after UMS euthanasia. When they have had experience in psychiatry or have already been involved in euthanasia cases, their conviction of the importance of this role grows even stronger. However, they do not see a role for themselves in administering the euthanasia medication. Students also express their need for more knowledge and skills to adequately manage UMS euthanasia. A possible approach to enhance these skills and better prepare students for their future responsibilities includes a combination of theoretical knowledge, clinical practice experience, open discussions, reflection, and simulation training.
Chapter 6 sheds light on the development, feedback, and perceptions of final-year nursing students regarding a simulation module focused on dealing with euthanasia requests. This study was conducted in two Flemish colleges and included sessions that took place within the students' individual class groups, as well as in mixed groups composed of both colleges. In addition, both experienced simulation education students and inexperienced students participated in this study.
Although this module was developed primarily for nursing programmes, it may also be relevant to other professions. The findings of this study can support educators in designing and evaluating simulation training programmes focused on euthanasia. In addition, this module will add value to broader education, which should focus on integrating knowledge and skills related to euthanasia. Students indicated that they viewed this simulation module as valuable in their education and for their future careers as nurses.
Chapter 7 marks the concluding section of this doctoral dissertation. It summarizes the main findings, as well as discusses the strengths and limitations of this study. The main findings are thoroughly discussed, followed by concluding considerations and suggestions for policy, practice, and further research directions.
In Belgium, despite the introduction of euthanasia legislation more than two decades ago, UMS euthanasia remains a controversial topic. Despite efforts to raise awareness, the need for more comprehensive education about euthanasia and its relationship to palliative care remains. Palliative care is often understudied in nursing courses, even though initiatives have been launched to address this. In terms of research, Belgium and the Netherlands, because of their extensive experience in health care and euthanasia, can play a leading role.
This dissertation represents only part of the ongoing research to better understand UMS euthanasia. Although it is a complex issue, it is nothing compared to the suffering of those who request UMS euthanasia.