The Emotional Experiences of Non-Provider Health Professionals Involved in Assisted Dying in Aotearoa New Zealand

The Emotional Experiences of Non-Provider Health Professionals Involved in Assisted Dying in Aotearoa New Zealand

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Research question: what the emotional experiences of NPHPs involved in AD are, and what impacts these experiences?

Participants: Ten participants were involved in this study. Of them, nine identified as female and one as male. The ten participating NPHPs worked in a combination of primary care (n=2), secondary care (n=2), community care (n=5), and aged residential care (n=1) sectors. Among them were palliative care nurses (n=4), assisted dying support workers and advisors (n=2), spiritual care coordinators (n=1), community occupational therapists (n=1) and end-of-life doulas (n=1)

Introduction

(I havent start writing introduction, but here is what I submitted for my proposal)

New Zealand has legalised assisted dying (AD) by putting the End-of-Life Choice Act 2019 (the Act) into force in November 2021. The Act defines AD as the use of medication to hasten death, which is administered either by medical or nurse professionals or through self-administration of medication (End of Life Choice Act 2019). The Act allows patients with terminal illnesses to request AD from a health professional formally, provided they meet specific eligibility criteria. These criteria include being 18 years or older, a citizen or permanent resident of New Zealand, suffering from a terminal illness expected to end their life within six months, experiencing an advanced state of irreversible decline in physical capability, enduring unbearable suffering that cannot be relieved in a tolerable manner, and being competent to make an informed decision about AD.

Medical or nurse practitioners who hold a practising certificate (Ministry of Health [MOH], 2024) may choose to register with the Support and Consultation for End-of-Life New Zealand Group (SCENZ) to perform AD. For this proposed research, these practitioners are categorised as provider health professionals (PHPs); meanwhile, those who opt not to perform AD fall under the non-provider health professionals (NPHPs) category. They are health professionals caring for a person receiving AD but not performing AD. They may have different reasons for not performing AD, including lack of qualifications such as nurses, social workers, and spiritual carers (Brooks, 2019), inadequate skills or experiences, conscientious objection to AD, or working in settings with an institutional objection to AD (MOH, 2024; Snelling et al., 2023). Conscientious objection occurs when health professionals choose not to provide AD based on moral or conscientious grounds. Similarly, institutional objection refers to organisations declining to provide AD services, regardless of individual health professionals' willingness (Snelling et al., 2023). They, however, are obliged to provide information upon request (Snelling et al., 2023).

NPHPs play a unique role in assisting patients by providing information and care for them, even though they do not perform AD. AD has always been a debated issue from the perspectives of the public, scholars, health professionals, family members, and patients. Existing literature on AD primarily focuses on health professional attitudes (Blaschke et al., 2019; Braverman et al., 2017; Young et al., 2019), the medical and nurse practitioners' experiences (Snelling et al., 2023), including their emotional experiences (Voorhees et al., 2014). Little is known about the experiences of particularly NPHPs in caring for patients seeking AD, post legalisation in New Zealand. This proposed study aims to address this gap and contribute to existing knowledge in the AD research area.

Theoretical framework

The research topic on the emotional experience of NPHPs involved in AD has been an important topic to discuss following the legalisation of AD in Aotearoa (End-of-Life Choice Act 2019). In order to address the research questions adequately, a theoretical framework was needed that include Richard Lazaruss Cognitive-Motivational-Relational (CMR) Appraisal Theory of Emotion ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"QlyhajTG","properties":{"formattedCitation":"(Lazarus, 1991)","plainCitation":"(Lazarus, 1991)","noteIndex":0},"citationItems":[{"id":48,"uris":["http://zotero.org/users/14650052/items/5UVUTBIV"],"itemData":{"id":48,"type":"article-journal","issue":"8","language":"en","page":"819-834","title":"Progress on a cognitive-motivational-relational theory of emotion - ProQuest","volume":"46","author":[{"family":"Lazarus","given":"Richard S."}],"issued":{"date-parts":[["1991"]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Lazarus, 1991) and emotional labour ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"FigZGlKa","properties":{"formattedCitation":"(Hochschild, 1979, 2012)","plainCitation":"(Hochschild, 1979, 2012)","noteIndex":0},"citationItems":[{"id":42,"uris":["http://zotero.org/users/14650052/items/5NCZPRL5"],"itemData":{"id":42,"type":"article-journal","abstract":"This essay proposes an emotion-management perspective as a lens through which to inspect the self, interaction, and structure. Emotion, it is argued, can be and ofter is subject to acts of management. The individual often works on inducing or inhibiting feelings so as to render them "appropriate" to a situation. The emotion-management perspective draws on an interactive account of emotion. It differs from the dramaturgical perspective on the one hand and the psychoanalytic perspective on the other. It allows us to inspect at closer range than either of those perspectives the relation among emotive experience, emotion management, feeling rules, and ideology. Feeling rules are seen as the side of ideology that deals with emotion and feeling. Emotion management is the type of work it takes to cope with feeling rules. Meaning-making jobs, more common in the middle class, put more premium on the individual's capacity to do emotion work. A reexamination of class differences in child rearing suggest that middle-class families prepare their children for emotion management more and working-class families prepare them less. In this way each prepares its children to psychologically reproduce the class structure.","container-title":"American Journal of Sociology","ISSN":"0002-9602","issue":"3","page":"551-575","source":"JSTOR","title":"Emotion Work, Feeling Rules, and Social Structure","volume":"85","author":[{"family":"Hochschild","given":"Arlie Russell"}],"issued":{"date-parts":[["1979"]]}}},{"id":40,"uris":["http://zotero.org/users/14650052/items/KCUL259A"],"itemData":{"id":40,"type":"book","abstract":"In private life, we try to induce or suppress love, envy, and anger through deep acting or "emotion work," just as we manage our outer expressions of feeling through surface acting. In trying to bridge a gap between what we feel and what we "ought" to feel, we take guidance from "feeling rules" about what is owing to others in a given situation. Based on our private mutual understandings of feeling rules, we make a "gift exchange" of acts of emotion management. We bow to each other not simply from the waist, but from the heart. But what occurs when emotion work, feeling rules, and the gift of exchange are introduced into the public world of work? In search of the answer, Arlie Russell Hochschild closely examines two groups of public-contact workers: flight attendants and bill collectors. The flight attendants job is to deliver a service and create further demand for it, to enhance the status of the customer and be "nicer than natural." The bill collectors job is to collect on the service, and if necessary, to deflate the status of the customer by being "nastier than natural." Between these extremes, roughly one-third of American men and one-half of American women hold jobs that call for substantial emotional labor. In many of these jobs, they are trained to accept feeling rules and techniques of emotion management that serve the companys commercial purpose. Just as we have seldom recognized or understood emotional labor, we have not appreciated its cost to those who do it for a living. Like a physical laborer who becomes estranged from what he or she makes, an emotional laborer, such as a flight attendant, can become estranged not only from her own expressions of feeling (her smile is not "her" smile), but also from what she actually feels (her managed friendliness). This estrangement, though a valuable defense against stress, is also an important occupational hazard, because it is through our feelings that we are connected with those around us. On the basis of this book, Hochschild was featured in Key Sociological Thinkers, edited by Rob Stones. This book was also the winner of the Charles Cooley Award in 1983, awarded by the American Sociological Association and received an honorable mention for the C. Wright Mills Award.","edition":"1","ISBN":"978-0-520-27294-1","publisher":"University of California Press","source":"JSTOR","title":"The Managed Heart: Commercialization of Human Feeling","title-short":"The Managed Heart","URL":"https://www.jstor.org/stable/10.1525/j.ctt1pn9bk","author":[{"family":"Hochschild","given":"Arlie Russell"}],"accessed":{"date-parts":[["2024",7,23]]},"issued":{"date-parts":[["2012"]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Hochschild, 1979, 2012). Theoretical framework is crucial for guiding the research process and ensuring a well-structured dissertation ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"cIE5ren6","properties":{"formattedCitation":"(Grant & Osanloo, 2016)","plainCitation":"(Grant & Osanloo, 2016)","noteIndex":0},"citationItems":[{"id":377,"uris":["http://zotero.org/users/14650052/items/H5H3EEJ4"],"itemData":{"id":377,"type":"article-journal","DOI":"10.5929/2014.4.2.9","journalAbbreviation":"Administrative Issues Journal","page":"12-26","title":"Understanding, Selecting, and Integrating a Theoretical Framework in Dissertation Research: Creating the Blueprint for Your "House".","volume":"4","author":[{"family":"Grant","given":"C"},{"family":"Osanloo","given":"A"}],"issued":{"date-parts":[["2016"]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Grant & Osanloo, 2016). They provided a blueprint for the research process, influencing the selection of topics, development of research questions and conceptualisation of literature review.

CMR Theory

CMR theory explains emotions as how an individual perceives and appraises their relationship with the environment, and emotions are seen as the result of the evaluation process. CMR theory introduced 15 basic emotions: eight negative (anger, anxiety, fright, guilt, shame, sadness, envy and jealousy) and seven positive (happiness, pride, relief, hope, love, gratitude and compassion) emotions (Lazarus, 1991). CMR theory assisted in bringing meaning to understanding NPHPs cognitive response in generating emotion / how they manage patients AD requests and providing care to patients simultaneously.

CMR theory initially introduced cognitive evaluation (e.g., how the brain processes thoughts) to understand emotional experiences and responses, later expanded to include motivational factors (e.g., goals and desires) and relational factors (e.g., social and environmental influences), which all contribute to how individuals assess and respond to events (Lazarus, 1991; 1999). The inclusion of motivation and relational factors provides a more holistic perspective on why individuals in similar situations may react differently emotionally on different occasions ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"HI5bgExB","properties":{"formattedCitation":"(Smith & Kirby, 2009)","plainCitation":"(Smith & Kirby, 2009)","noteIndex":0},"citationItems":[{"id":50,"uris":["http://zotero.org/users/14650052/items/XR9Z2IU2",["http://zotero.org/users/14650052/items/XR9Z2IU2"]],"itemData":{"id":50,"type":"article-journal","abstract":"The present study examined a relational model of appraisal that specifies the situational and dispositional antecedents of appraised problem-focused coping potential, itself a hypothesised antecedent of the emotions of hope/challenge and resignation. The hypothesised relational antecedents of this appraisal were tested in a quasi-experiment in which individuals varying in self-perceived and objectively assessed math ability attempted to solve math problems on which difficulty was manipulated. Findings for the critical test problem largely conformed to predictions: Under difficult conditions, but not easy ones, increasing math ability was generally associated with elevated appraisals of problem-focused coping potential, increased hope/challenge, reduced resignation, and increased likelihood of solving the problem. However, problem-focused coping potential, hope/challenge, and the likelihood of solving the problem were all lower, and resignation was higher, for the highest ability participants, than would be predicted from their ability levels. Comparable findings were not observed for appraisals of emotion-focused coping potential or its theoretically associated emotion of anxiety, providing evidence of discriminant validity for the examined model. The results of a mediational analysis supported the hypothesis that the effects of the quasi-experimental design on hope/challenge and resignation were mediated by their effects on appraised problem-focused coping potential, lending support to the proposition that appraisals play a causal role in emotion elicitation.","container-title":"Cognition and Emotion","DOI":"10.1080/02699930802009464","ISSN":"0269-9931","issue":"3","page":"481-503","source":"Taylor and Francis+NEJM","title":"Relational antecedents of appraised problem-focused coping potential and its associated emotions","volume":"23","author":[{"family":"Smith","given":"Craig A."},{"family":"Kirby","given":"Leslie D."}],"issued":{"date-parts":[["2009",4,1]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Smith & Kirby, 2009). Thus, it highlights the importance of appraisal in this theory as it determining their emotions and motivations on how they react to the event.

CMR theory suggests that emotions arise from the core relational theme, which is a short summary of the meaning of the relationship between the individual and the environment. For example, the core relational theme for anger is a demeaning offence against me and mine, or hope is fearing the worst but yearning for better (Lazarus, 1991, p.122). Core relational themes consists of a summary of up to six independent appraisal judgements, divided into primary or secondary appraisals (Lazarus, 1991).

Primary appraisal refers to whether a situation or event is personally relevant, such as NPHPs values and goals and consist of three components: goal relevance, goal congruence and type of ego-involvement ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"JLVB83GF","properties":{"formattedCitation":"(Lazarus, 1991)","plainCitation":"(Lazarus, 1991)","noteIndex":0},"citationItems":[{"id":48,"uris":["http://zotero.org/users/14650052/items/5UVUTBIV"],"itemData":{"id":48,"type":"article-journal","issue":"8","language":"en","page":"819-834","title":"Progress on a cognitive-motivational-relational theory of emotion - ProQuest","volume":"46","author":[{"family":"Lazarus","given":"Richard S."}],"issued":{"date-parts":[["1991"]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Lazarus, 1991). Goal relevance refers to whether a person views a transaction as relevant to well-being. In effect, there is no emotion without a goal at stake, just as there is no stress. For example, primary appraisal occurs first. NPHPs evaluate whether AD aligns with their goals or values. Goal congruence (or incongruence) refers to whether the terms for exchange are what an individual wants. Goal congruence or incongruence refers to whether the conditions of a transaction either facilitate or hinder the persons wants or needs. For instance, a positive emotion will likely be evoked if the conditions are favourable and vice versa. Types of ego-involvement refers to commitment and the role of different goals in shaping emotions, such as self-and-social esteem, moral values, ego ideals, meanings and ideas, the well-being of others, and life goals. Thus, pride and ang er are consequences of the desire to preserve or enhance self-and-social esteem; guilt depends on moral values; shame depends on ego ideals; anxiety depends on an uncertain threat that has existential implications for ones identity, life and death and so on (Lazarus, 1999). In this process, they also consider their role in different goals and relate them to selected emotions.

Secondary appraisal is broadly related to NPHPs perceived coping options and consist of three components: evaluation of blame or credit, coping potential and future expectations. The assessment of blame or credit must determine who or what is responsible for harm, threat, and challenge. The evaluation is the assessment of the state of cognitive information. However, after an initial appraisal of harm, threat, and challenge, an emotional reaction may emerge temporarily after and/or before the emotional arousal, which in effect short-circuits or inhibits the emotional response. For instance, if we blame, we get angry; if we accept the credit, we feel proud. Besides that, coping potential stems from our personal beliefs about whether we can successfully act to improve or eliminate harm or threat or to achieve challenging or beneficial outcomes. Coping also involves emotion- and problem-focused coping ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"OW16Bf25","properties":{"formattedCitation":"(Smith & Kirby, 2009)","plainCitation":"(Smith & Kirby, 2009)","noteIndex":0},"citationItems":[{"id":50,"uris":["http://zotero.org/users/14650052/items/XR9Z2IU2",["http://zotero.org/users/14650052/items/XR9Z2IU2"]],"itemData":{"id":50,"type":"article-journal","abstract":"The present study examined a relational model of appraisal that specifies the situational and dispositional antecedents of appraised problem-focused coping potential, itself a hypothesised antecedent of the emotions of hope/challenge and resignation. The hypothesised relational antecedents of this appraisal were tested in a quasi-experiment in which individuals varying in self-perceived and objectively assessed math ability attempted to solve math problems on which difficulty was manipulated. Findings for the critical test problem largely conformed to predictions: Under difficult conditions, but not easy ones, increasing math ability was generally associated with elevated appraisals of problem-focused coping potential, increased hope/challenge, reduced resignation, and increased likelihood of solving the problem. However, problem-focused coping potential, hope/challenge, and the likelihood of solving the problem were all lower, and resignation was higher, for the highest ability participants, than would be predicted from their ability levels. Comparable findings were not observed for appraisals of emotion-focused coping potential or its theoretically associated emotion of anxiety, providing evidence of discriminant validity for the examined model. The results of a mediational analysis supported the hypothesis that the effects of the quasi-experimental design on hope/challenge and resignation were mediated by their effects on appraised problem-focused coping potential, lending support to the proposition that appraisals play a causal role in emotion elicitation.","container-title":"Cognition and Emotion","DOI":"10.1080/02699930802009464","ISSN":"0269-9931","issue":"3","page":"481-503","source":"Taylor and Francis+NEJM","title":"Relational antecedents of appraised problem-focused coping potential and its associated emotions","volume":"23","author":[{"family":"Smith","given":"Craig A."},{"family":"Kirby","given":"Leslie D."}],"issued":{"date-parts":[["2009",4,1]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Smith & Kirby, 2009). For things that cannot be changed, Individuals would make emotional adjustments or take action to address the cause of the emotion. Next, future expectations, such as NPHPs, would be bothered by the thought that accepting a patients AD request would positively or negatively influence their relationship with the patient.

The specific combination of primary and secondary appraisals is proposed to influence the intensity and type of emotion elicited. In addition to appraisals, how individuals responds to situations or events can influence the type and intensity of emotions they experience ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"eNvwxEZQ","properties":{"formattedCitation":"(Lazarus, 1991)","plainCitation":"(Lazarus, 1991)","noteIndex":0},"citationItems":[{"id":48,"uris":["http://zotero.org/users/14650052/items/5UVUTBIV"],"itemData":{"id":48,"type":"article-journal","issue":"8","language":"en","page":"819-834","title":"Progress on a cognitive-motivational-relational theory of emotion - ProQuest","volume":"46","author":[{"family":"Lazarus","given":"Richard S."}],"issued":{"date-parts":[["1991"]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Lazarus, 1991). From a CMR perspective, appraisal and coping represent proximal determinants of emotions. However, an emotion can be evoked in the absence of coping efforts. This does not apply, at least theoretically, to appraisal

Most emotions also have a corresponding tendency or urge to act, linking the emotion to its physiological or behavioural response. Negative stimuli, such as scary sounds, may produce a faster and more intense physiological response (Keltner et al., 2014 as cited in ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"luWSvLJP","properties":{"formattedCitation":"(Ouc0u8217{}Toole, 2017)","plainCitation":"(OToole, 2017)","dontUpdate":true,"noteIndex":0},"citationItems":[{"id":54,"uris":["http://zotero.org/users/14650052/items/6XPWS9BF",["http://zotero.org/users/14650052/items/6XPWS9BF"]],"itemData":{"id":54,"type":"article-journal","container-title":"New Zealand Journal of Psychology","ISSN":"0112109X","issue":"2","language":"English","page":"71-87","source":"go.gale.com","title":""I thought I was going to die": teachers' reflections on their emotions and cognitive appraisals in response to the February 2011 Christchurch earthquake","title-short":""I thought I was going to die"","volume":"46","author":[{"family":"O'Toole","given":"Veronica M."}],"issued":{"date-parts":[["2017",7,1]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} OToole, 2017). The tendency to act in anger may trigger the urge to attack; compassion may be the urge to help; fear or anxiety refers to the need to escape or avoid ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"1nwHFpFo","properties":{"formattedCitation":"(Lazarus, 2006)","plainCitation":"(Lazarus, 2006)","noteIndex":0},"citationItems":[{"id":49,"uris":["http://zotero.org/users/14650052/items/P8XI7CKS",["http://zotero.org/users/14650052/items/P8XI7CKS"]],"itemData":{"id":49,"type":"article-journal","DOI":"10.1111/j.1467-6494.2005.00368.x","issue":"1","page":"9-46","title":"Emotions and Interpersonal Relationships: Toward a PersonCentered Conceptualization of Emotions and Coping - Lazarus - 2006 - Journal of Personality - Wiley Online Library","volume":"74","author":[{"family":"Lazarus","given":"Richard S."}],"issued":{"date-parts":[["2006"]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Lazarus, 2006). These emotions may be associated with certain physiological responses and prompt individuals to act differently. This tendency is an unconscious primary appraisal of a situation, which may trigger a rapid approach or avoidance response (LeDoux, 1993 as cited in OToole, 2017). According to CMR theory, places physiological responses come after cognitive appraisals.

There are different version of appraisal theories (e.g., ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"srnLw6DA","properties":{"formattedCitation":"(Lang, 1994; Lazarus, 1991; Roseman & Smith, 2001)","plainCitation":"(Lang, 1994; Lazarus, 1991; Roseman & Smith, 2001)","dontUpdate":true,"noteIndex":0},"citationItems":[{"id":52,"uris":["http://zotero.org/users/14650052/items/QXWPRINM"],"itemData":{"id":52,"type":"article-journal","DOI":"10.1037/0033-295X.101.2.211","issue":"2","page":"211-221","title":"The varieties of emotional experience: A meditation on James-Lange theory","volume":"101","author":[{"family":"Lang","given":"P. J."}],"issued":{"date-parts":[["1994"]]}}},{"id":48,"uris":["http://zotero.org/users/14650052/items/5UVUTBIV"],"itemData":{"id":48,"type":"article-journal","issue":"8","language":"en","page":"819-834","title":"Progress on a cognitive-motivational-relational theory of emotion - ProQuest","volume":"46","author":[{"family":"Lazarus","given":"Richard S."}],"issued":{"date-parts":[["1991"]]}}},{"id":247,"uris":["http://zotero.org/users/14650052/items/V9N8V4V3"],"itemData":{"id":247,"type":"chapter","abstract":"What is appraisal theory? In simplest form, its essence is the claim that emotions are elicited by evaluations (appraisals) of events and situations. For example, sadness felt when a romantic relationship ends may be elicited by the appraisals that something desired has been lost, with certainty, and cannot be recovered (Roseman, 1984; see, e.g., Frijda, 1986; Oatley & Johnson-Laird, 1987; Scherer, 1993b; Smith & Lazarus, 1993; Stein & Levine, 1987).","container-title":"Appraisal Processes in Emotion: Theory, Methods, Research","ISBN":"978-0-19-513007-2","note":"DOI: 10.1093/oso/9780195130072.003.0001","page":"0","publisher":"Oxford University Press","source":"Silverchair","title":"Appraisal Theory Overview, Assumptions, Varieties, Controversies","URL":"https://doi.org/10.1093/oso/9780195130072.003.0001","author":[{"family":"Roseman","given":"Ira J"},{"family":"Smith","given":"Craig A"}],"editor":[{"family":"Scherer","given":"Klaus R"},{"family":"Schorr","given":"Angela"},{"family":"Johnstone","given":"Tom"}],"accessed":{"date-parts":[["2024",7,29]]},"issued":{"date-parts":[["2001",5,3]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} Lazarus, 1991; Roseman & Smith, 2001). Although differing slightly in detail, there have attempted to help us understand the role of cognition in generating emotion. Other appraisal theories, for example James-Lange Theory hypothesised that the experience of emotion is due to the perception of their physiological responses meaning that an individual first experiences a physiological response, then interprets it as certain emotion ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"NkY33Ezz","properties":{"formattedCitation":"(Lang, 1994)","plainCitation":"(Lang, 1994)","noteIndex":0},"citationItems":[{"id":52,"uris":["http://zotero.org/users/14650052/items/QXWPRINM"],"itemData":{"id":52,"type":"article-journal","DOI":"10.1037/0033-295X.101.2.211","issue":"2","page":"211-221","title":"The varieties of emotional experience: A meditation on James-Lange theory","volume":"101","author":[{"family":"Lang","given":"P. J."}],"issued":{"date-parts":[["1994"]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Lang, 1994). In response to the James-Lange theory, the Cannon-Bard theory proposed that physiological arousal and emotional experience happen simultaneously ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"BhmeJpXs","properties":{"formattedCitation":"(Statharakos et al., 2022)","plainCitation":"(Statharakos et al., 2022)","noteIndex":0},"citationItems":[{"id":246,"uris":["http://zotero.org/users/14650052/items/LF2AXHAP"],"itemData":{"id":246,"type":"chapter","container-title":"Psychology of Emotions","page":"21-50","publisher":"Cham: Springer International Publishing","title":"The Psychology of Anger","URL":"https://www.researchgate.net/profile/Hashim-Hashim-5/publication/369689272_The_Psychology_of_Angerpdf/data/64279bd3a1b72772e440eb4c/ThePsychology-ofAnger.pdf#page=31","author":[{"family":"Statharakos","given":"N"},{"family":"Alvares","given":"A. J."},{"family":"Statharakou","given":"A"}],"issued":{"date-parts":[["2022"]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Statharakos et al., 2022). Schachter-Singer Theory (also known as the two-factor theory) proposed that the perception of emotions depend on both sensory feedback from a physical response and the perceptions of the external event that may have cause that response. For instance, physiological and cognitive responses can simultaneously shape the experience of emotion, so if we are physiologically aroused, we do not feel specific emotions until we can label or identify the reason for the situation ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"bxMLJzqI","properties":{"formattedCitation":"(Statharakos et al., 2022)","plainCitation":"(Statharakos et al., 2022)","noteIndex":0},"citationItems":[{"id":246,"uris":["http://zotero.org/users/14650052/items/LF2AXHAP"],"itemData":{"id":246,"type":"chapter","container-title":"Psychology of Emotions","page":"21-50","publisher":"Cham: Springer International Publishing","title":"The Psychology of Anger","URL":"https://www.researchgate.net/profile/Hashim-Hashim-5/publication/369689272_The_Psychology_of_Angerpdf/data/64279bd3a1b72772e440eb4c/ThePsychology-ofAnger.pdf#page=31","author":[{"family":"Statharakos","given":"N"},{"family":"Alvares","given":"A. J."},{"family":"Statharakou","given":"A"}],"issued":{"date-parts":[["2022"]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Statharakos et al., 2022). These are the prominent appraisal theories of emotion that emphasise on the physiological response for interpreting emotion.

The facial-feedback theory of emotion by William James (1884, 1890, 1894) and Carl Lange (1885) focuses on facial expressions as non-verbal cues suggesting that emotions are directly tied to changes in facial muscles. Facial expressions are widely used in daily communication, counselling, and interviews. Facial-feedback theory includes various factors that could influence participant performance. For example, if participants are aware they are being recorded on video, they might alter their behaviour, either by reacting unnaturally or by controlling or amplifying their expressions ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"jYaestqM","properties":{"formattedCitation":"(Coles et al., 2019)","plainCitation":"(Coles et al., 2019)","noteIndex":0},"citationItems":[{"id":245,"uris":["http://zotero.org/users/14650052/items/PLPCGB2U"],"itemData":{"id":245,"type":"article-journal","issue":"6","journalAbbreviation":"Psychological bulletin","page":"610-651","title":"A meta-analysis of the facial feedback literature: Effects of facial feedback on emotional experience are small and variable.","volume":"145","author":[{"family":"Coles","given":"N. A."},{"family":"Larsen","given":"J. T."},{"family":"Lench","given":"H. C."}],"issued":{"date-parts":[["2019"]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Coles et al., 2019). This can introduce limitations to the study. Facial-feedback theory is unable to provide a wide range of information like a cognitive response to experience. While this theory will not be the primary theory for this study, it will be drawn on to help interpret participants facial expressions.

CMT theory was favoured over other appraisal theories as a theoretical framework for this study due to three primary reasons: 1) participants physiological responses were not recorded during the interview; 2) CMR theory is a multidimensional theory shedding light on a combination of personal reasons and external events; and 3) CMR provides information on how environment and relationship can shape emotions.

Emotional Work

Working in healthcare can be rewarding and fulfilling, but it can be emotionally demanding and stressful, particularly for NPHPs who often work with patients with terminal illnesses. Healthcare professionals who are perceived to be more compassionate and empathic gain more trust from their patients ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"ACLTxIlX","properties":{"formattedCitation":"(Kinman & Leggetter, 2016)","plainCitation":"(Kinman & Leggetter, 2016)","noteIndex":0},"citationItems":[{"id":38,"uris":["http://zotero.org/users/14650052/items/G4CXISBQ"],"itemData":{"id":38,"type":"article-journal","abstract":"Although compassionate care has wide-ranging benefits for patients, it can be emotionally demanding for healthcare staff. This may be a particular problem for those with little experience in a caring role. This study utilises the job demands-resources model to examine links between emotional labour and emotional exhaustion in student nurses. In line with the triple-match principlewhereby interactive effects are more likely when job demands, resources, and outcomes are within the same qualitative domainthe protective role of emotional support and emotion-focused coping (i.e., emotional venting) in the relationship between emotional labour and exhaustion is also explored. An online questionnaire was completed by 351 student nurses with experience working in healthcare settings. A strong positive relationship was found between emotional labour and emotional exhaustion, and some support was found for the moderating effects of emotional support and emotion-focused coping. Ways to help student and qualified nurses develop the emotional resilience required to protect their wellbeing, while providing high-quality compassionate care to patients are considered.","container-title":"Healthcare","DOI":"10.3390/healthcare4040089","ISSN":"2227-9032","issue":"4","journalAbbreviation":"Healthcare (Basel)","note":"PMID: 27916880nPMCID: PMC5198131","page":"89","source":"PubMed Central","title":"Emotional Labour and Wellbeing: What Protects Nurses?","title-short":"Emotional Labour and Wellbeing","volume":"4","author":[{"family":"Kinman","given":"Gail"},{"family":"Leggetter","given":"Sandra"}],"issued":{"date-parts":[["2016",11,30]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Kinman & Leggetter, 2016).

Hochschild introduced the notion of emotional labour, which is the management of emotion and manipulation of feeling through both surface and deep acting to create an appropriate, caring and professional image in front of client ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"dleRu8hJ","properties":{"formattedCitation":"(Hochschild, 1979)","plainCitation":"(Hochschild, 1979)","noteIndex":0},"citationItems":[{"id":42,"uris":["http://zotero.org/users/14650052/items/5NCZPRL5"],"itemData":{"id":42,"type":"article-journal","abstract":"This essay proposes an emotion-management perspective as a lens through which to inspect the self, interaction, and structure. Emotion, it is argued, can be and ofter is subject to acts of management. The individual often works on inducing or inhibiting feelings so as to render them "appropriate" to a situation. The emotion-management perspective draws on an interactive account of emotion. It differs from the dramaturgical perspective on the one hand and the psychoanalytic perspective on the other. It allows us to inspect at closer range than either of those perspectives the relation among emotive experience, emotion management, feeling rules, and ideology. Feeling rules are seen as the side of ideology that deals with emotion and feeling. Emotion management is the type of work it takes to cope with feeling rules. Meaning-making jobs, more common in the middle class, put more premium on the individual's capacity to do emotion work. A reexamination of class differences in child rearing suggest that middle-class families prepare their children for emotion management more and working-class families prepare them less. In this way each prepares its children to psychologically reproduce the class structure.","container-title":"American Journal of Sociology","ISSN":"0002-9602","issue":"3","page":"551-575","source":"JSTOR","title":"Emotion Work, Feeling Rules, and Social Structure","volume":"85","author":[{"family":"Hochschild","given":"Arlie Russell"}],"issued":{"date-parts":[["1979"]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Hochschild, 1979). Surface acting is when an individual displays expected emotions in a work interaction without regard to their inner feelings. Surface acting is truly acting in the sense that workers manage their display of emotions. Deep acting is when an individual genuinely feels and expresses the emotions evoked during interactions ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"q5Rx9EHV","properties":{"formattedCitation":"(Hochschild, 1979)","plainCitation":"(Hochschild, 1979)","noteIndex":0},"citationItems":[{"id":42,"uris":["http://zotero.org/users/14650052/items/5NCZPRL5"],"itemData":{"id":42,"type":"article-journal","abstract":"This essay proposes an emotion-management perspective as a lens through which to inspect the self, interaction, and structure. Emotion, it is argued, can be and ofter is subject to acts of management. The individual often works on inducing or inhibiting feelings so as to render them "appropriate" to a situation. The emotion-management perspective draws on an interactive account of emotion. It differs from the dramaturgical perspective on the one hand and the psychoanalytic perspective on the other. It allows us to inspect at closer range than either of those perspectives the relation among emotive experience, emotion management, feeling rules, and ideology. Feeling rules are seen as the side of ideology that deals with emotion and feeling. Emotion management is the type of work it takes to cope with feeling rules. Meaning-making jobs, more common in the middle class, put more premium on the individual's capacity to do emotion work. A reexamination of class differences in child rearing suggest that middle-class families prepare their children for emotion management more and working-class families prepare them less. In this way each prepares its children to psychologically reproduce the class structure.","container-title":"American Journal of Sociology","ISSN":"0002-9602","issue":"3","page":"551-575","source":"JSTOR","title":"Emotion Work, Feeling Rules, and Social Structure","volume":"85","author":[{"family":"Hochschild","given":"Arlie Russell"}],"issued":{"date-parts":[["1979"]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Hochschild, 1979).

Using the Hochschild concept, Boyle (2005) identified surface and deep performance strategies commonly used by paramedics to manage their own emotions and those of their patients. Emotional labour is viewed as positive, and acting is considered part of the job, sometimes requiring the suppression of negative emotions, such as disgust and the stimulation of positive emotions when dealing with drunk or adolescent patients. Or for example by using humour to reassure anxious or angry patients. Boyle also introduces the task-oriented approach, describing to treat a patient as a thing or object and is often used to deny or suppress emotions ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"EkWG2tgW","properties":{"formattedCitation":"(Boyle, 2005)","plainCitation":"(Boyle, 2005)","noteIndex":0},"citationItems":[{"id":251,"uris":["http://zotero.org/users/14650052/items/J92HURYY"],"itemData":{"id":251,"type":"chapter","abstract":"This chapter explores the connections between emotionalized regions within organizations and the kinds of emotional process work that occur within these regions. A study of an emergency service organization over an 18-month period found that the performance of emotional process work is a vital stage in the overall performance of emotional labor within this industry. Interviews with emergency service workers also indicated that a substantial amount of emotional process work occurs within one of three emotional regions within the organizationthe offstage (or nonwork) region. The organization in question, known here as the Department of Paramedical Services (DPS), relies heavily on informal off stage emotional support. Thoits's (1985) work on emotional process work and Goffman's (1959) work on regions are used to demonstrate how the individual management of emotion and the organizational ordering of emotional regions are intertwined closely. Organizational implications for the overreliance on offstage forms of support are also discussed briefly.","container-title":"Emotions in Organizational Behavior","ISBN":"978-1-4106-1189-5","note":"number-of-pages: 21","page":"64-84","publisher":"Psychology Press","title":"You Wait Until You Get Home: Emotional Regions, Emotional Process Work, and the Role of Onstage and Offstage Support","title-short":"3 You Wait Until You Get Home","author":[{"family":"Boyle","given":"Maree V."}],"issued":{"date-parts":[["2005"]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Boyle, 2005). Filstad (2010) interviewed 12 paramedics, similarly revealing the importance of buffering and emotional isolation to focus on medical care. Paramedics emphasise the importance of distancing themselves emotionally or dissociating from the patient as a person, which allows them to cope ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"LX9Mlvrx","properties":{"formattedCitation":"(Filstad, 2010)","plainCitation":"(Filstad, 2010)","noteIndex":0},"citationItems":[{"id":351,"uris":["http://zotero.org/users/14650052/items/SW33MUKT"],"itemData":{"id":351,"type":"article-journal","abstract":"The aim of this paper is to understand emotion in organisational learning, by exploring how newly-appointed emergency paramedics in an ambulance service are socialised and learn emotional management. Our research highlights the importance of trust among partners in emotional management and how emotional management is learned through informal debriefing and informal communities of coping. We find that emotional management is learned on the job, through practice and knowledge sharing among colleagues, and in informal learning arenas that provide debriefing among colleagues. Adjusting to hierarchical order is crucial. Emotional management also involves black humour and jokes as an important neutralisation strategy which creates a strong family feeling among colleagues.","container-title":"Int. J. of Work Organisation and Emotion","DOI":"10.1504/IJWOE.2010.035325","journalAbbreviation":"Int. J. of Work Organisation and Emotion","page":"368-383","source":"ResearchGate","title":"Learning to Be A Competent Paramedic: Emotional Management in Emotional Work","title-short":"Learning to Be A Competent Paramedic","volume":"3","author":[{"family":"Filstad","given":"Cathrine"}],"issued":{"date-parts":[["2010",9,1]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Filstad, 2010).

Paramedics are expected to maintain appropriate external performance, but the depth of performance they require varies. This variation may be due to the potentially emotional nature of paramedic work, dealing with human suffering, trauma and death. In addition, paramedics are examples of the caring profession, characterised by selfless concern for the well-being of others. The combination of care and human suffering requires more emotional labour to cope with and protect the emotions of paramedics ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"9jAIKojK","properties":{"formattedCitation":"(Williams, 2012)","plainCitation":"(Williams, 2012)","noteIndex":0},"citationItems":[{"id":249,"uris":["http://zotero.org/users/14650052/items/SYKLBHKZ"],"itemData":{"id":249,"type":"article-journal","abstract":"Contemporary paramedic practice involves the emergency assessment, management, treatment and transport of the public with minor and major; potentially","container-title":"Nurse Education Today","DOI":"10.1016/j.nedt.2011.05.008","ISSN":"0260-6917","issue":"4","language":"en-US","note":"publisher: Churchill Livingstone","page":"368-372","source":"www.sciencedirect.com","title":"Emotion work in paramedic practice: The implications for nurse educators","title-short":"Emotion work in paramedic practice","volume":"32","author":[{"family":"Williams","given":"J."}],"issued":{"date-parts":[["2012",5,1]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Williams, 2012).

NPHPs, in our study, are considered working in emotionally demanding situations, hence experiencing emotional labour, as they are involved in providing care for patients with terminal illnesses who are also undergoing the AD process. However, research about NPHPs experience of emotional labour who are involved in the AD context is limited. The currently available study has researched the emotional labour of other health professionals who also work with critically ill patients, such as nurses (Elmore et al., 2018; Freeman et al., 2021), critical care unit nurses (Chu, 2024; Mol et al., 2015) and hospice nurses (Barnett, 2022; Cross, 2019). Some others studied included compassion fatigue and demonstrated the relationship between emotional labour and compassion fatigue.

The study conducted on palliative care mentioned that emotional labour is often overlooked ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"XMEbtUKb","properties":{"formattedCitation":"(Brighton et al., 2019)","plainCitation":"(Brighton et al., 2019)","noteIndex":0},"citationItems":[{"id":343,"uris":["http://zotero.org/users/14650052/items/B3NZBGTB"],"itemData":{"id":343,"type":"article-journal","abstract":"ObjectivenTo explore generalist palliative care providers experiences of emotional labour when undertaking conversations around palliative and end-of-life care with patients and families, to inform supportive strategies.nMethodsnSemi-structured interviews conducted with generalist staff (those providing primary or general palliative care, not palliative care specialists) who had attended a communication workshop. Sampling was purposive (by gender, profession, experience). Data were analysed using a framework approach; a sample of transcripts were double-coded for rigour. Data collection and analysis were informed by theories of emotional labour, coping, and communication.nResultsnFour ambulance staff, three nurses, two speech and language therapists, and one therapy assistant were interviewed. Five themes emerged: emotions experienced; emotion display rules; emotion management; support needs; and perceived impact of emotional labour. Participants reported balancing human and professional expressions of emotion. Support needs included time for emotion management, workplace cultures that normalise emotional experiences, formal emotional support, and palliative and end-of-life care skills training.nConclusionnDiverse strategies to support the emotional needs of generalist staff are crucial to ensure high-quality end-of-life care and communication, and to support staff well-being.nPractice implicationsnBoth formal and informal support is required, alongside skills training, to enable a supportive workplace culture and individual development.","container-title":"Patient Education and Counseling","DOI":"10.1016/j.pec.2018.10.013","ISSN":"0738-3991","issue":"3","journalAbbreviation":"Patient Education and Counseling","page":"494-502","source":"ScienceDirect","title":"Emotional labour in palliative and end-of-life care communication: A qualitative study with generalist palliative care providers","title-short":"Emotional labour in palliative and end-of-life care communication","volume":"102","author":[{"family":"Brighton","given":"Lisa Jane"},{"family":"Selman","given":"Lucy Ellen"},{"family":"Bristowe","given":"Katherine"},{"family":"Edwards","given":"Beth"},{"family":"Koffman","given":"Jonathan"},{"family":"Evans","given":"Catherine J."}],"issued":{"date-parts":[["2019",3,1]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Brighton et al., 2019). Caring for dying persons and their families is a source of emotional distress, and healthcare professionals grief may be suppressed, prevented through emotional detachment, or may spillover into their private lives ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"0OTJ8SKE","properties":{"formattedCitation":"(Funk et al., 2017)","plainCitation":"(Funk et al., 2017)","noteIndex":0},"citationItems":[{"id":346,"uris":["http://zotero.org/users/14650052/items/A7MC4WZK"],"itemData":{"id":346,"type":"article-journal","abstract":"The paid provision of care for dying persons and their families blends commodified emotion work and attachments to two often-conflicting role identities: the caring person and the professional. We explore how health care employees interpret personal grief related to patient death, drawing on interviews with 12 health care aides and 13 nurses. Data were analyzed collaboratively using an interpretively embedded thematic coding approach and constant comparison. Participant accounts of preventing, postponing, suppressing, and coping with grief revealed implicit meanings about the nature of grief and the appropriateness of grief display. Employees often struggled to find the time and space to deal with grief, and faced normative constraints on grief expression at work. Findings illustrate the complex ways health care employees negotiate and maintain both caring and professional identities in the context of cultural and material constraints. Implications of emotional labor for discourse and practice in health care settings are discussed.","container-title":"Qualitative Health Research","DOI":"10.1177/1049732317729139","ISSN":"1049-7323","issue":"14","journalAbbreviation":"Qual Health Res","language":"en","note":"publisher: SAGE Publications Inc","page":"2211-2221","source":"SAGE Journals","title":"The Emotional Labor of Personal Grief in Palliative Care: Balancing Caring and Professional Identities","title-short":"The Emotional Labor of Personal Grief in Palliative Care","volume":"27","author":[{"family":"Funk","given":"Laura M."},{"family":"Peters","given":"Sheryl"},{"family":"Roger","given":"Kerstin Stieber"}],"issued":{"date-parts":[["2017",12,1]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Funk et al., 2017).

Not delving too deep into compassion fatigue, in this study, we will use the emotional labour as the complementary concept to explore the emotional experience of NPHPs. Emotional labour would help understand how NPHPs manage and display their emotion when receiving AD requests and caring for these patients. The process of a patient making an AD request is a complex procedure and requires emotional labour from all health professionals ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"zqDHvWlr","properties":{"formattedCitation":"(Dees et al., 2013)","plainCitation":"(Dees et al., 2013)","noteIndex":0},"citationItems":[{"id":252,"uris":["http://zotero.org/users/14650052/items/LILXA85J"],"itemData":{"id":252,"type":"article-journal","abstract":"Background:Euthanasia has been legally performed in the Netherlands since 2002. Respect for patients autonomy is the underpinning ethical principal. However, patients have no right to euthanasia, and physicians have no obligation to provide it. Although over 3000 cases are conducted per year in the Netherlands, there is little known about how decision-making occurs and no guidance to support this difficult aspect of clinical practice.Aim:To explore the decision-making process in cases where patients request euthanasia and understand the different themes relevant to optimise this decision-making process.Design:A qualitative thematic analysis of interviews with patients making explicit requests for euthanasia, most-involved relative(s) and treating physician.Participants/setting:Thirty-two cases, 31 relatives and 28 treating physicians. Settings were patients and relatives homes and physicians offices.Results:Five main themes emerged: (1) initiation of sharing views and values about euthanasia, (2) building relationships as part of the negotiation, (3) fulfilling legal requirements, (4) detailed work of preparing and performing euthanasia and (5) aftercare and closing.Conclusions:A patients request for euthanasia entails a complex process that demands emotional work by all participants. It is characterised by an intensive period of sharing information, relationship building and negotiation in order to reach agreement. We hypothesise that making decisions about euthanasia demands a proactive approach towards participants preferences and values regarding end of life, towards the needs of relatives, towards the burden placed on physicians and a careful attention to shared decision-making. Future research should address the communicational skills professionals require for such complex decision-making.","container-title":"Palliative Medicine","DOI":"10.1177/0269216312463259","ISSN":"0269-2163","issue":"1","journalAbbreviation":"Palliat Med","language":"en","note":"publisher: SAGE Publications Ltd STM","page":"27-37","source":"SAGE Journals","title":"Perspectives of decision-making in requests for euthanasia: A qualitative research among patients, relatives and treating physicians in the Netherlands","title-short":"Perspectives of decision-making in requests for euthanasia","volume":"27","author":[{"family":"Dees","given":"Marianne K"},{"family":"Vernooij-Dassen","given":"Myrra J"},{"family":"Dekkers","given":"Wim J"},{"family":"Elwyn","given":"Glyn"},{"family":"Vissers","given":"Kris C"},{"family":"Weel","given":"Chris","non-dropping-particle":"van"}],"issued":{"date-parts":[["2013",1,1]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Dees et al., 2013).

They go for a walk afterconflicting (could be EW) ethical challenges, but why they still continue doing this is EW part (like they have what they feel)

Literature review

This chapter reviews several topics regarding emotional experience among NPHPs involved in the care of patients undergoing the AD process. (Outline the gap here). Topics reviewed will demonstrate the significance of my study in addressing this gap in the literature. A growing research on AD has been examined on the experiences and perspectives of healthcare professionals on AD, but the experiences specifically focused on NPHPs and their emotional experience are mostly neglected. To capture the emotional experience, I also draw on literature conducted in similar critical settings and studies that dealing with providing care for dying patients, such as hospice care and intensive care unit (ICU).

While not specifically focusing on AD, studies have explored the emotional toll on palliative care practitioners and nurses in intensive and hospice care settings caring for dying or cancer patients and showed that they experience emotional challenges and heightened stress due to constant exposure to death ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"65SPUxVg","properties":{"formattedCitation":"(Ablett & Jones, 2007; Boroujeni et al., 2009)","plainCitation":"(Ablett & Jones, 2007; Boroujeni et al., 2009)","noteIndex":0},"citationItems":[{"id":80,"uris":["http://zotero.org/users/14650052/items/IE6BUBZL",["http://zotero.org/users/14650052/items/IE6BUBZL"]],"itemData":{"id":80,"type":"article-journal","abstract":"Although working with cancer patients is considered stressful, palliative care staff experience similar levels of psychological distress and lower levels of burnout than staff working in other specialties. There are few empirical studies in palliative care to explain this. Since working in a stressful job does not inevitably lead to psychological distress, the antecedent factors that promote resilience and maintain a sense of well-being are worthy of study. This qualitative study used interpretative phenomenological analysis (IPA) to describe hospice nurses' experiences of work. During the analysis, themes emerged relating to the underlying interpersonal factors that influenced the nurses' decisions to begin and continue working in palliative care, and their attitudes towards life and work. The emergent themes were compared with the theoretical personality constructs of hardiness and sense of coherence, and this comparison highlighted many similarities. The nurses showed high levels of commitment, and imputed a sense of meaning and purpose to their work. An area of divergence was their response to change, and this is discussed in relation to hardiness and sense of coherence. The implications for staff well-being, and for staff training and support, which, in turn, may impact on the quality of patient care, are discussed. Copyright 2006 John Wiley & Sons, Ltd.","container-title":"Psycho-Oncology","DOI":"10.1002/pon.1130","ISSN":"1099-1611","issue":"8","language":"en","page":"733-740","source":"Wiley Online Library","title":"Resilience and well-being in palliative care staff: a qualitative study of hospice nurses' experience of work","title-short":"Resilience and well-being in palliative care staff","volume":"16","author":[{"family":"Ablett","given":"Janice R."},{"family":"Jones","given":"R. S. P."}],"issued":{"date-parts":[["2007"]]}}},{"id":354,"uris":["http://zotero.org/users/14650052/items/5TXJRN6U"],"itemData":{"id":354,"type":"article-journal","DOI":"10.1111/j.1365-2702.2008.02437.x","issue":"16","journalAbbreviation":"Journal of clinical nursing","page":"2328-2336","title":"Iranian nurses' preparation for loss: Finding a balance in endoflife care.","volume":"18","author":[{"family":"Boroujeni","given":"A. Z"},{"family":"Mohammadi","given":"R"},{"family":"Oskouie","given":"S. F. H."},{"family":"Sandberg","given":"J."}],"issued":{"date-parts":[["2009"]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Ablett & Jones, 2007; Boroujeni et al., 2009). However, there remains uncertainty regarding whether the emotional experiences of caring for dying patients and being involved in AD share similarities.

Emotional experiences among NPHPs in different roles

(this part contains information about the positive or negative emotional experience of NPHPs, including roles of NPHPs and their emotional experience, emotional experiences of experienced workers)

Different roles and levels of involvement of health professionals involved in AD contribute to varying emotional experiences with the process. NPHPs that were mainly mentioned in past research included these three roles: physicians (primary care physicians or medical practitioners), nurses (regular unit and palliative care), and social workers (regular and hospice). Other NPHPs like chaplains, mental health providers, pharmacists, and medical examiners also play vital roles in AD, but receive minimal attention regarding their roles and their impact on emotional experiences ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"r6dwrS4h","properties":{"formattedCitation":"(Carlson et al., 2005; De Bal et al., 2006; Denier et al., 2010; Elmore et al., 2018; Fujioka et al., 2018; Variath et al., 2020)","plainCitation":"(Carlson et al., 2005; De Bal et al., 2006; Denier et al., 2010; Elmore et al., 2018; Fujioka et al., 2018; Variath et al., 2020)","noteIndex":0},"citationItems":[{"id":258,"uris":["http://zotero.org/users/14650052/items/229BWI6M"],"itemData":{"id":258,"type":"article-journal","abstract":"Background: Oregons Death with Dignity Act (ODDA), which legalized physician-assistednsuicide (PAS) for terminally ill individuals, was enacted in 1997. Eighty-six percent of the 171npatients who have died by PAS were enrolled in hospice.nObjective: To survey hospice chaplains regarding their views on the ODDA and experiences working with patients who request PAS.nDesign: Single, anonymous, mailed survey.nSubjects: All chaplains affiliated with one of Oregons 50 hospices.nResults: Fifty of 77 hospice chaplains whom we identified (65%) returned the survey. Fortytwo percent of respondents opposed the ODDA and 40% supported it. Over half of respondents had, in the previous 3 years, worked with a patient who had made an explicit requestnfor assisted suicide. Conversation with patients around PAS focused on the role of faith andnspirituality in this decision, reasons for wanting hastened death, and family concerns or reactions to PAS. Chaplains did not feel that they had a strong influence on the patients decisions about PAS (mean score of 4 on a 010 scale), though three chaplains reported a patientnwho withdrew their request for PAS because of the chaplains involvement. Chaplains reported provision of a nonjudgmental presence helped the relationship with the patient.nConclusion: Oregon hospice chaplains are divided in their views on legalized PAS, but primarily see their role to deliver support to patients no matter what the patients final decisionnregarding PAS.","issue":"6","journalAbbreviation":"JOURNAL OF PALLIATIVE MEDICINE","language":"en","note":"DOI: 10.1089/jpm.2005.8.1160","page":"1160-1166","title":"Oregon Hospice Chaplains' Experiences with Patients Requesting Physician-Assisted Suicide","volume":"8","author":[{"family":"Carlson","given":"Bryant"},{"family":"Simopolous","given":"Nicole"},{"family":"Goy","given":"Elizabeth","suffix":"R."},{"family":"Jackson","given":"Ann"},{"family":"Ganzini","given":"Linda"}],"issued":{"date-parts":[["2005"]]}}},{"id":83,"uris":["http://zotero.org/users/14650052/items/JAVNFGHG",["http://zotero.org/users/14650052/items/JAVNFGHG"]],"itemData":{"id":83,"type":"article-journal","abstract":"BackgroundnAlthough nurses worldwide are confronted with euthanasia requests, how nurses experience their involvement in euthanasia remains unclear.nObjectivesnTo explore nurses involvement in the care for patients requesting euthanasia.nDesignnA qualitative grounded theory strategy.nSettingnTwo general hospitals (A, B) and a palliative care setting in Flanders (Belgium).nParticipantsnNurses who fulfilled the following inclusion criteria: (a) Dutch-speaking; (b) working for at least one year in hospital A or B; (c) working at least part-time (50%); and (d) ever received a euthanasia request. We collected data using purposeful sampling, superseded by theoretical sampling in a palliative care setting. The sample included one intensive care nurse, one oncology nurse, eight palliative care nurses, and five internal medicine nurses. All but five were women. Their age ranged from 24 to 49 years.nMethodsnWe conducted one-on-one semi-structured interviews between November 2001 and September 2002. Grounded theory was applied for guiding data collection and analysis. The trustworthiness of data was ensured by several strategies.nResultsnAlthough euthanasia was still illegal, the nurses unanimously stated that they had an important role in caring for patients requesting euthanasia. Their personal and intense involvement caused them to experience a spectrum of emotions, chief among them being a sense of powerlessness. Several elements contributed to the nurses conflicted involvement. Nurses became frustrated if the context (e.g., lack of time) hindered their efforts to provide compassionate care. The palliative care setting and its associated culture (group mentality, care philosophy) created the opportunity for nurses to take time to holistically support patients and their relatives.nConclusionsnHospital nurses are confronted with patients euthanasia requests. Each stage of this process requires that the nurses possess specific competencies. Their willingness to personally care for these patients, in addition to their specific care expertise, allows them to be skilled companions.","container-title":"International Journal of Nursing Studies","DOI":"10.1016/j.ijnurstu.2005.08.003","ISSN":"0020-7489","issue":"5","journalAbbreviation":"International Journal of Nursing Studies","page":"589-599","source":"ScienceDirect","title":"Involvement of nurses in caring for patients requesting euthanasia in Flanders (Belgium): A qualitative study","title-short":"Involvement of nurses in caring for patients requesting euthanasia in Flanders (Belgium)","volume":"43","author":[{"family":"De Bal","given":"Nele"},{"family":"Dierckx de Casterl","given":"Bernadette"},{"family":"Beer","given":"Tina De"},{"family":"Gastmans","given":"Chris"}],"issued":{"date-parts":[["2006",7,1]]}}},{"id":57,"uris":["http://zotero.org/users/14650052/items/SE2PXS34"],"itemData":{"id":57,"type":"article-journal","abstract":"The Belgian Act on Euthanasia came into force on 23 September 2002, making Belgium the second countryafter the Netherlandsto decriminalize euthanasia under certain due-care conditions. Since then, Belgian nurses have been increasingly involved in euthanasia care. In this paper, we report a qualitative study based on in-depth interviews with 18 nurses from Flanders (the Dutch-speaking part of Belgium) who have had experience in caring for patients requesting euthanasia since May 2002 (the approval of the Act). We found that the care process for patients requesting euthanasia is a complex and dynamic process, consisting of several stages, starting from the period preceding the euthanasia request and ending with the aftercare stage. When asked after the way in which they experience their involvement in the euthanasia care process, all nurses described it as a grave and difficult process, not only on an organizational and practical level, but also on an emotional level. Intense is the dominant feeling experienced by nurses. This is compounded by the presence of other feelings such as great concern and responsibility on the one hand, being content in truly helping the patient to die serenely, and doing everything in ones power to contribute to this; but also feeling unreal and ambivalent on the other hand, because death is arranged. Nurses feel a discrepancy, because although it is a nice death, which happens in dignity and with respect, it is also an unnatural death. The clinical ethical implications of these findings are discussed.","container-title":"Medicine, Health Care and Philosophy","DOI":"10.1007/s11019-009-9203-1","ISSN":"1572-8633","issue":"1","journalAbbreviation":"Med Health Care and Philos","language":"en","page":"41-48","source":"Springer Link","title":"Its intense, you know. Nurses experiences in caring for patients requesting euthanasia","volume":"13","author":[{"family":"Denier","given":"Yvonne"},{"family":"Dierckx de Casterl","given":"Bernadette"},{"family":"De Bal","given":"Nele"},{"family":"Gastmans","given":"Chris"}],"issued":{"date-parts":[["2010",2,1]]}}},{"id":86,"uris":["http://zotero.org/users/14650052/items/99D8KMWQ"],"itemData":{"id":86,"type":"article-journal","abstract":"Background: Legislative changes are resulting in assisted death as an option for people at the end of life. Although nurses experiences and perspectives are underrepresented within broader ethical discourses about assisted death, there is a small but significant body of literature examining nurses experiences of caring for people who request this option.nAim: To synthesize what has been learned about nurses experiences of caring for patients who request assisted death and to highlight what is morally at stake for nurses who undertake this type of care.nDesign: Qualitative meta-synthesis.nMethods: Six databases were searched: CINAHL, Medline, EMBASE, Joanna Briggs Institute, PsycINFO, and Web of Science. The search was completed on 22 October 2014 and updated in February 2016. Of 879 articles identified from the database searches, 16 articles were deemed relevant based on inclusion criteria. Following quality appraisal, 14 studies were retained for analysis and synthesis.nResults: The moral experience of the nurse is (1) defined by a profound sense of responsibility, (2) shaped by contextual forces that nurses navigate in everyday end-of-life care practice, and (3) sustained by intra-team moral and emotional support.nDiscussion: The findings of this synthesis support the view that nurses are moral agents who are deeply invested in the moral integrity of end-of-life care involving assisted death. The findings further demonstrate that to fully appreciate the ethics of assisted death from a nursing standpoint, it is necessary to understand the broader constraints on nurses moral agency that operate in everyday end-of-life care.nEthical considerations: Research ethics board approval was not required for this synthesis of previously published literature.nConclusion: In order to understand how to enact ethical practice in the area of assisted death, the moral experiences of nurses should be investigated and foregrounded.","container-title":"Nursing Ethics","DOI":"10.1177/0969733016679468","ISSN":"0969-7330","issue":"8","journalAbbreviation":"Nurs Ethics","language":"en","page":"955-972","source":"SAGE Journals","title":"Nurses moral experiences of assisted death: A meta-synthesis of qualitative research","title-short":"Nurses moral experiences of assisted death","volume":"25","author":[{"family":"Elmore","given":"James"},{"family":"Wright","given":"David Kenneth"},{"family":"Paradis","given":"Maude"}],"issued":{"date-parts":[["2018",12,1]]}}},{"id":65,"uris":["http://zotero.org/users/14650052/items/2KDC45VR",["http://zotero.org/users/14650052/items/2KDC45VR"]],"itemData":{"id":65,"type":"article-journal","abstract":"Research AimsnWith the growing interest in Medical Assistance in Dying (MAiD), understanding health care professionals' roles and experiences in handling requests is necessary to evaluate the quality, consistency, and efficacy of current practices. This scoping review sought to map the existing literature on health care providers' perspectives of their involvement in MAiD.nMethodsnA scoping review was conducted to address the following: 1) What are the roles of diverse health care professionals in the provision of MAiD? and 2) What professional challenges arise when confronted with MAiD requests? A literature search in electronic databases and gray literature sources was performed. Articles were screened, and a thematic content analysis synthesized key findings.nResultsnAfter evaluating 1715 citations and 148 full-text papers, 33 articles were included. Perspectives of nurses (n=10), physicians (n=7), mental health providers (n=7), pharmacists (n=4), social workers (n=3), and medical examiners (n=1) were explored. Professional roles included consulting/supporting patients and/or other staff members with requests, assessing eligibility, administering/dispensing the lethal drugs, providing aftercare to bereaved relatives, and regulatory oversight. Challenges included lack of clear guidelines/protocols, role ambiguity, evaluating capacity/consent, conscientious objection, and lack of interprofessional collaboration.nConclusionnEvidence from various jurisdictions highlighted a need for clear guidelines and protocols that define each profession's role, scope of practice, and legal boundaries for MAiD. Comprehensive models of care that incorporate multidisciplinary teams alongside improved clinician education may be effective to support MAiD implementation. Little is known about health care providers' perspectives in handling requests, especially outside physician practice and nursing.","container-title":"Journal of Pain and Symptom Management","DOI":"10.1016/j.jpainsymman.2018.02.011","ISSN":"0885-3924","issue":"6","journalAbbreviation":"Journal of Pain and Symptom Management","page":"1564-1576.e9","source":"ScienceDirect","title":"Implementation of Medical Assistance in Dying: A Scoping Review of Health Care Providers' Perspectives","title-short":"Implementation of Medical Assistance in Dying","volume":"55","author":[{"family":"Fujioka","given":"Jamie K."},{"family":"Mirza","given":"Raza M."},{"family":"McDonald","given":"P. Lynn"},{"family":"Klinger","given":"Christopher A."}],"issued":{"date-parts":[["2018",6,1]]}}},{"id":335,"uris":["http://zotero.org/users/14650052/items/9HTGAZZB"],"itemData":{"id":335,"type":"article-journal","abstract":"Background:Family members and healthcare providers play an integral role in a persons assisted dying journey. Their own needs during the assisted dying journey are often, however, unrecognized and underrepresented in policies and guidelines. Circumstances under which people choose assisted dying, and relational contexts such as the sociopolitical environment, may influence the experiences of family members and healthcare providers.Ethical considerations:Ethics approval was not required to conduct this review.Aim:This scoping review aims to identify the relational influences on the experiences of family members and healthcare providers of adults who underwent assisted dying and of those unable to access assisted dying due to the loss of capacity to consent.Methods:A literature search was conducted in four databases, including MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature (CINAHL) and PsycINFO. The search retrieved 12,074 articles, a number narrowed down to 172 articles for full-text screening. Thirty-six articles met the established inclusion criteria. A feminist relational framework guided the data analysis.Results:Five key themes on the influences of family members and healthcare providers experiences throughout the assisted dying process were synthesized from the data. They include (1) relationships as central to beginning the process, (2) social and political influences on decision making, (3) complex roles and responsibilities of family members and healthcare providers, (4) a unique experience of death, and (5) varying experiences following death.Conclusion:The feminist relational lens, used to guide analysis, shed light on the effect of the sociopolitical influences and the relationships among patients, families, and healthcare providers on each others experiences. Addressing the needs of the family members and healthcare providers is vital to improving the assisted dying process. Including families and healthcare providers needs within institutional policies and enhancing collaboration and communication among those involved could improve the overall experience.","container-title":"Nursing Ethics","DOI":"10.1177/0969733020921493","ISSN":"0969-7330","issue":"7","journalAbbreviation":"Nurs Ethics","language":"en","note":"publisher: SAGE Publications Ltd","page":"1501-1516","source":"SAGE Journals","title":"Relational influences on experiences with assisted dying: A scoping review","title-short":"Relational influences on experiences with assisted dying","volume":"27","author":[{"family":"Variath","given":"Caroline"},{"family":"Peter","given":"Elizabeth"},{"family":"Cranley","given":"Lisa"},{"family":"Godkin","given":"Dianne"},{"family":"Just","given":"Danielle"}],"issued":{"date-parts":[["2020",11,1]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Carlson et al., 2005; De Bal et al., 2006; Denier et al., 2010; Elmore et al., 2018; Fujioka et al., 2018; Variath et al., 2020). The involvement of health professionals often places them in ethically complex situations. It can be influenced by their social relationships and context, rather than being purely individualistic or isolated ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"WWOcwKRu","properties":{"formattedCitation":"(Guc0u243{}mez-Vuc0u237{}rseda et al., 2020)","plainCitation":"(Gmez-Vrseda et al., 2020)","noteIndex":0},"citationItems":[{"id":367,"uris":["http://zotero.org/users/14650052/items/2LZYILWC"],"itemData":{"id":367,"type":"article-journal","abstract":"Respect for autonomy is a paramount principle in end-of-life ethics. Nevertheless, empirical studies show that decision-making, exclusively focused on the individual exercise of autonomy fails to align well with patients preferences at the end of life. The need for a more contextualized approach that meets real-life complexities experienced in end-of-life practices has been repeatedly advocated. In this regard, the notion of relational autonomy may be a suitable alternative approach. Relational autonomy has even been advanced as a foundational notion of palliative care, shared decision-making, and advance-care planning. However, relational autonomy in end-of-life care is far from being clearly conceptualized or practically operationalized.","container-title":"BMC Medical Ethics","DOI":"10.1186/s12910-020-00495-1","ISSN":"1472-6939","issue":"1","journalAbbreviation":"BMC Medical Ethics","page":"50","source":"BioMed Central","title":"Relational autonomy in end-of-life care ethics: a contextualized approach to real-life complexities","title-short":"Relational autonomy in end-of-life care ethics","volume":"21","author":[{"family":"Gmez-Vrseda","given":"Carlos"},{"family":"Maeseneer","given":"Yves","non-dropping-particle":"de"},{"family":"Gastmans","given":"Chris"}],"issued":{"date-parts":[["2020",6,30]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Gmez-Vrseda et al., 2020), such as personal values, professional ethics, the wishes of patients and their families, and institutional policies. This is so-called relational autonomy. It helps navigate NPHPs dilemmas by promoting a more inclusive decision-making process that respects the contribution and concerns of all involved parties ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"m28Zdufq","properties":{"formattedCitation":"(Variath et al., 2020)","plainCitation":"(Variath et al., 2020)","noteIndex":0},"citationItems":[{"id":335,"uris":["http://zotero.org/users/14650052/items/9HTGAZZB"],"itemData":{"id":335,"type":"article-journal","abstract":"Background:Family members and healthcare providers play an integral role in a persons assisted dying journey. Their own needs during the assisted dying journey are often, however, unrecognized and underrepresented in policies and guidelines. Circumstances under which people choose assisted dying, and relational contexts such as the sociopolitical environment, may influence the experiences of family members and healthcare providers.Ethical considerations:Ethics approval was not required to conduct this review.Aim:This scoping review aims to identify the relational influences on the experiences of family members and healthcare providers of adults who underwent assisted dying and of those unable to access assisted dying due to the loss of capacity to consent.Methods:A literature search was conducted in four databases, including MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature (CINAHL) and PsycINFO. The search retrieved 12,074 articles, a number narrowed down to 172 articles for full-text screening. Thirty-six articles met the established inclusion criteria. A feminist relational framework guided the data analysis.Results:Five key themes on the influences of family members and healthcare providers experiences throughout the assisted dying process were synthesized from the data. They include (1) relationships as central to beginning the process, (2) social and political influences on decision making, (3) complex roles and responsibilities of family members and healthcare providers, (4) a unique experience of death, and (5) varying experiences following death.Conclusion:The feminist relational lens, used to guide analysis, shed light on the effect of the sociopolitical influences and the relationships among patients, families, and healthcare providers on each others experiences. Addressing the needs of the family members and healthcare providers is vital to improving the assisted dying process. Including families and healthcare providers needs within institutional policies and enhancing collaboration and communication among those involved could improve the overall experience.","container-title":"Nursing Ethics","DOI":"10.1177/0969733020921493","ISSN":"0969-7330","issue":"7","journalAbbreviation":"Nurs Ethics","language":"en","note":"publisher: SAGE Publications Ltd","page":"1501-1516","source":"SAGE Journals","title":"Relational influences on experiences with assisted dying: A scoping review","title-short":"Relational influences on experiences with assisted dying","volume":"27","author":[{"family":"Variath","given":"Caroline"},{"family":"Peter","given":"Elizabeth"},{"family":"Cranley","given":"Lisa"},{"family":"Godkin","given":"Dianne"},{"family":"Just","given":"Danielle"}],"issued":{"date-parts":[["2020",11,1]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Variath et al., 2020) as interconnected with the professionals relationships and values. By saying that, NPHPs choices about involvement in AD are not made in isolation. They are influenced by their relationships with patients, families, colleagues, and the broader healthcare team. For instance, a nurses decision to not participate in AD may be affected by their relationship with the patient, the familys expectations, and the support or opposition from colleagues (citation).

NPHPs reported having mixed and contradictory emotions including feelings of loneliness, tension, and even trauma, when participating in AD ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"PcRQoQu8","properties":{"formattedCitation":"(Fujioka et al., 2018; Gerson, Preston, et al., 2020; Ward et al., 2022)","plainCitation":"(Fujioka et al., 2018; Gerson, Preston, et al., 2020; Ward et al., 2022)","noteIndex":0},"citationItems":[{"id":65,"uris":["http://zotero.org/users/14650052/items/2KDC45VR",["http://zotero.org/users/14650052/items/2KDC45VR"]],"itemData":{"id":65,"type":"article-journal","abstract":"Research AimsnWith the growing interest in Medical Assistance in Dying (MAiD), understanding health care professionals' roles and experiences in handling requests is necessary to evaluate the quality, consistency, and efficacy of current practices. This scoping review sought to map the existing literature on health care providers' perspectives of their involvement in MAiD.nMethodsnA scoping review was conducted to address the following: 1) What are the roles of diverse health care professionals in the provision of MAiD? and 2) What professional challenges arise when confronted with MAiD requests? A literature search in electronic databases and gray literature sources was performed. Articles were screened, and a thematic content analysis synthesized key findings.nResultsnAfter evaluating 1715 citations and 148 full-text papers, 33 articles were included. Perspectives of nurses (n=10), physicians (n=7), mental health providers (n=7), pharmacists (n=4), social workers (n=3), and medical examiners (n=1) were explored. Professional roles included consulting/supporting patients and/or other staff members with requests, assessing eligibility, administering/dispensing the lethal drugs, providing aftercare to bereaved relatives, and regulatory oversight. Challenges included lack of clear guidelines/protocols, role ambiguity, evaluating capacity/consent, conscientious objection, and lack of interprofessional collaboration.nConclusionnEvidence from various jurisdictions highlighted a need for clear guidelines and protocols that define each profession's role, scope of practice, and legal boundaries for MAiD. Comprehensive models of care that incorporate multidisciplinary teams alongside improved clinician education may be effective to support MAiD implementation. Little is known about health care providers' perspectives in handling requests, especially outside physician practice and nursing.","container-title":"Journal of Pain and Symptom Management","DOI":"10.1016/j.jpainsymman.2018.02.011","ISSN":"0885-3924","issue":"6","journalAbbreviation":"Journal of Pain and Symptom Management","page":"1564-1576.e9","source":"ScienceDirect","title":"Implementation of Medical Assistance in Dying: A Scoping Review of Health Care Providers' Perspectives","title-short":"Implementation of Medical Assistance in Dying","volume":"55","author":[{"family":"Fujioka","given":"Jamie K."},{"family":"Mirza","given":"Raza M."},{"family":"McDonald","given":"P. Lynn"},{"family":"Klinger","given":"Christopher A."}],"issued":{"date-parts":[["2018",6,1]]}}},{"id":76,"uris":["http://zotero.org/users/14650052/items/A5CZMHGC",["http://zotero.org/users/14650052/items/A5CZMHGC"]],"itemData":{"id":76,"type":"article-journal","abstract":"ContextnMany jurisdictions around the world have passed medical aid in dying (MAID) laws allowing competent eligible individuals facing life-limiting illness to self-administer prescribed medication to control timing of death. These laws do not prevent some patients who are receiving hospice services from dying by suicide without assistance.nObjectivesnTo explore hospice professionals' experiences of patients who die by suicide or intentionally hasten death with or without legal assistance in an area where there is legalized MAID.nMethodsnSemistructured in-depth qualitative interviews were conducted with 21 home hospice professionals (seven nurses, seven social workers, four physicians, and three chaplains). Thematic analysis was carried out to analyze the data.nResultsnThree primary themes were identified from the interviews: 1) dealing with and differentiating between hastened death and suicide, 2) MAID access and affordability, and 3) how patients have hastened their own deaths. Analysis of these data indicates that there are some patients receiving hospice services who die by suicide because they are not eligible for, have no knowledge of, or lack access to legalized MAID. Hospice professionals do not consistently identify patients' deaths as suicide when they are self-inflicted and sometimes view these deaths as justified.nConclusionnSuicide and hastened deaths continue to be an unexamined cause of death for some home hospice patients who may have requested MAID. Open communication and increased education and training is needed for palliative care professionals regarding legal options, issues of suicide, and suicide assessment.","container-title":"Journal of Pain and Symptom Management","DOI":"10.1016/j.jpainsymman.2019.10.021","ISSN":"0885-3924","issue":"3","journalAbbreviation":"Journal of Pain and Symptom Management","page":"679-686.e1","source":"ScienceDirect","title":"Medical Aid in Dying, Hastened Death, and Suicide: AQualitative Study of Hospice Professionals' Experiences From Washington State","title-short":"Medical Aid in Dying, Hastened Death, and Suicide","volume":"59","author":[{"family":"Gerson","given":"Sheri Mila"},{"family":"Preston","given":"Nancy J."},{"family":"Bingley","given":"Amanda F."}],"issued":{"date-parts":[["2020",3,1]]}}},{"id":77,"uris":["http://zotero.org/users/14650052/items/MM73NPH4",["http://zotero.org/users/14650052/items/MM73NPH4"]],"itemData":{"id":77,"type":"article-journal","abstract":"BackgroundMedical assistance in Dying (MAiD) is offered across diverse settings, including hospices. There is little research exploring the experiences of hospice care providers who support patients who undergo MAiD at an off-site location.PurposeTo describe hospice care provider perceptions of MAiD in an in-patient hospice facility that does not provide MAiD.MethodsParticipants included hospice administrators, nurses, staff and volunteers who provide care at an in-patient hospice facility in a geographically isolated medium sized city (population <100,000) in a western Canadian province. Using a qualitative descriptive approach, eight in-depth semi-structured interviews were undertaken. Data were digitally recorded, transcribed, analyzed inductively, and organized thematically.ResultsIntroduction of MAiD challenged and disrupted care practices. Themes included: Situating MAiD within hospice and palliative care, caring for patients undergoing MAiD within a non-provider facility, and balancing interpersonal dynamics in an interdisciplinary team environment. Themes were underpinned by participants attempts to reconcile MAiD within personal beliefs and work environment.ConclusionCaring for patients who chose MAiD changed the dynamic of care. Participants focused on providing patient-centred care while attempting to normalize the MAiD process. Educational resources to support patient-centred care for patients who undergo MAiD off-site, address care provider self-care, and to facilitate safe and effective interdisciplinary communication are needed.","container-title":"Canadian Journal of Nursing Research","DOI":"10.1177/0844562120985995","ISSN":"0844-5621","issue":"1","journalAbbreviation":"Can J Nurs Res","language":"en","page":"3-14","source":"SAGE Journals","title":"Hospice Care Provider Perspectives of Medical Assistance in Dying in a Canadian Hospice That Does Not Provide Medical Assistance in Dying","volume":"54","author":[{"family":"Ward","given":"Valerie"},{"family":"Freeman","given":"Shannon"},{"family":"Banner","given":"Davina"}],"issued":{"date-parts":[["2022",3,1]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Fujioka et al., 2018; Gerson, Preston, et al., 2020; Ward et al., 2022). Ward's (2022) study reported that NPHPs in non-AD provider hospice settings experience uncertainty in taking care of patients because their role in providing care to patients would end prematurely as AD is not allowed to be performed on hospice premises, forcing patients to transfer out of the hospice care facility to die somewhere else using AD. The premature termination of the patient-NPHP relationship left them in an awkward state, and not knowing how best to care for and communicate with the patient during the imminent period before the patients death ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"xnUq4cRB","properties":{"formattedCitation":"(Ward et al., 2022)","plainCitation":"(Ward et al., 2022)","noteIndex":0},"citationItems":[{"id":77,"uris":["http://zotero.org/users/14650052/items/MM73NPH4",["http://zotero.org/users/14650052/items/MM73NPH4"]],"itemData":{"id":77,"type":"article-journal","abstract":"BackgroundMedical assistance in Dying (MAiD) is offered across diverse settings, including hospices. There is little research exploring the experiences of hospice care providers who support patients who undergo MAiD at an off-site location.PurposeTo describe hospice care provider perceptions of MAiD in an in-patient hospice facility that does not provide MAiD.MethodsParticipants included hospice administrators, nurses, staff and volunteers who provide care at an in-patient hospice facility in a geographically isolated medium sized city (population <100,000) in a western Canadian province. Using a qualitative descriptive approach, eight in-depth semi-structured interviews were undertaken. Data were digitally recorded, transcribed, analyzed inductively, and organized thematically.ResultsIntroduction of MAiD challenged and disrupted care practices. Themes included: Situating MAiD within hospice and palliative care, caring for patients undergoing MAiD within a non-provider facility, and balancing interpersonal dynamics in an interdisciplinary team environment. Themes were underpinned by participants attempts to reconcile MAiD within personal beliefs and work environment.ConclusionCaring for patients who chose MAiD changed the dynamic of care. Participants focused on providing patient-centred care while attempting to normalize the MAiD process. Educational resources to support patient-centred care for patients who undergo MAiD off-site, address care provider self-care, and to facilitate safe and effective interdisciplinary communication are needed.","container-title":"Canadian Journal of Nursing Research","DOI":"10.1177/0844562120985995","ISSN":"0844-5621","issue":"1","journalAbbreviation":"Can J Nurs Res","language":"en","page":"3-14","source":"SAGE Journals","title":"Hospice Care Provider Perspectives of Medical Assistance in Dying in a Canadian Hospice That Does Not Provide Medical Assistance in Dying","volume":"54","author":[{"family":"Ward","given":"Valerie"},{"family":"Freeman","given":"Shannon"},{"family":"Banner","given":"Davina"}],"issued":{"date-parts":[["2022",3,1]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Ward et al., 2022). Another study reported having similar mixed feelings among NPHPs who were facing a relatively difference situation Voluntarily Stop Eating and Drinking (VSED). VSED is one way to hasten death, which is legally available to patients in most countries. Those NPHPs caring for patients who had adopted VSED described feeling emotionally isolated but supported the patients decision, while others not supporting them ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"G29P6LO7","properties":{"formattedCitation":"(Gerson, Preston, et al., 2020)","plainCitation":"(Gerson, Preston, et al., 2020)","noteIndex":0},"citationItems":[{"id":76,"uris":["http://zotero.org/users/14650052/items/A5CZMHGC",["http://zotero.org/users/14650052/items/A5CZMHGC"]],"itemData":{"id":76,"type":"article-journal","abstract":"ContextnMany jurisdictions around the world have passed medical aid in dying (MAID) laws allowing competent eligible individuals facing life-limiting illness to self-administer prescribed medication to control timing of death. These laws do not prevent some patients who are receiving hospice services from dying by suicide without assistance.nObjectivesnTo explore hospice professionals' experiences of patients who die by suicide or intentionally hasten death with or without legal assistance in an area where there is legalized MAID.nMethodsnSemistructured in-depth qualitative interviews were conducted with 21 home hospice professionals (seven nurses, seven social workers, four physicians, and three chaplains). Thematic analysis was carried out to analyze the data.nResultsnThree primary themes were identified from the interviews: 1) dealing with and differentiating between hastened death and suicide, 2) MAID access and affordability, and 3) how patients have hastened their own deaths. Analysis of these data indicates that there are some patients receiving hospice services who die by suicide because they are not eligible for, have no knowledge of, or lack access to legalized MAID. Hospice professionals do not consistently identify patients' deaths as suicide when they are self-inflicted and sometimes view these deaths as justified.nConclusionnSuicide and hastened deaths continue to be an unexamined cause of death for some home hospice patients who may have requested MAID. Open communication and increased education and training is needed for palliative care professionals regarding legal options, issues of suicide, and suicide assessment.","container-title":"Journal of Pain and Symptom Management","DOI":"10.1016/j.jpainsymman.2019.10.021","ISSN":"0885-3924","issue":"3","journalAbbreviation":"Journal of Pain and Symptom Management","page":"679-686.e1","source":"ScienceDirect","title":"Medical Aid in Dying, Hastened Death, and Suicide: AQualitative Study of Hospice Professionals' Experiences From Washington State","title-short":"Medical Aid in Dying, Hastened Death, and Suicide","volume":"59","author":[{"family":"Gerson","given":"Sheri Mila"},{"family":"Preston","given":"Nancy J."},{"family":"Bingley","given":"Amanda F."}],"issued":{"date-parts":[["2020",3,1]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Gerson, Preston, et al., 2020). Although NPHPs face intense and mixed feelings (what kind of feeling), their patient-centred attitude always leads them to be supportive and respect every decision they make and the right to choose AD ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"Fe9tOWXW","properties":{"formattedCitation":"(Gerson, Preston, et al., 2020; Ward et al., 2022)","plainCitation":"(Gerson, Preston, et al., 2020; Ward et al., 2022)","noteIndex":0},"citationItems":[{"id":76,"uris":["http://zotero.org/users/14650052/items/A5CZMHGC",["http://zotero.org/users/14650052/items/A5CZMHGC"]],"itemData":{"id":76,"type":"article-journal","abstract":"ContextnMany jurisdictions around the world have passed medical aid in dying (MAID) laws allowing competent eligible individuals facing life-limiting illness to self-administer prescribed medication to control timing of death. These laws do not prevent some patients who are receiving hospice services from dying by suicide without assistance.nObjectivesnTo explore hospice professionals' experiences of patients who die by suicide or intentionally hasten death with or without legal assistance in an area where there is legalized MAID.nMethodsnSemistructured in-depth qualitative interviews were conducted with 21 home hospice professionals (seven nurses, seven social workers, four physicians, and three chaplains). Thematic analysis was carried out to analyze the data.nResultsnThree primary themes were identified from the interviews: 1) dealing with and differentiating between hastened death and suicide, 2) MAID access and affordability, and 3) how patients have hastened their own deaths. Analysis of these data indicates that there are some patients receiving hospice services who die by suicide because they are not eligible for, have no knowledge of, or lack access to legalized MAID. Hospice professionals do not consistently identify patients' deaths as suicide when they are self-inflicted and sometimes view these deaths as justified.nConclusionnSuicide and hastened deaths continue to be an unexamined cause of death for some home hospice patients who may have requested MAID. Open communication and increased education and training is needed for palliative care professionals regarding legal options, issues of suicide, and suicide assessment.","container-title":"Journal of Pain and Symptom Management","DOI":"10.1016/j.jpainsymman.2019.10.021","ISSN":"0885-3924","issue":"3","journalAbbreviation":"Journal of Pain and Symptom Management","page":"679-686.e1","source":"ScienceDirect","title":"Medical Aid in Dying, Hastened Death, and Suicide: AQualitative Study of Hospice Professionals' Experiences From Washington State","title-short":"Medical Aid in Dying, Hastened Death, and Suicide","volume":"59","author":[{"family":"Gerson","given":"Sheri Mila"},{"family":"Preston","given":"Nancy J."},{"family":"Bingley","given":"Amanda F."}],"issued":{"date-parts":[["2020",3,1]]}}},{"id":77,"uris":["http://zotero.org/users/14650052/items/MM73NPH4",["http://zotero.org/users/14650052/items/MM73NPH4"]],"itemData":{"id":77,"type":"article-journal","abstract":"BackgroundMedical assistance in Dying (MAiD) is offered across diverse settings, including hospices. There is little research exploring the experiences of hospice care providers who support patients who undergo MAiD at an off-site location.PurposeTo describe hospice care provider perceptions of MAiD in an in-patient hospice facility that does not provide MAiD.MethodsParticipants included hospice administrators, nurses, staff and volunteers who provide care at an in-patient hospice facility in a geographically isolated medium sized city (population <100,000) in a western Canadian province. Using a qualitative descriptive approach, eight in-depth semi-structured interviews were undertaken. Data were digitally recorded, transcribed, analyzed inductively, and organized thematically.ResultsIntroduction of MAiD challenged and disrupted care practices. Themes included: Situating MAiD within hospice and palliative care, caring for patients undergoing MAiD within a non-provider facility, and balancing interpersonal dynamics in an interdisciplinary team environment. Themes were underpinned by participants attempts to reconcile MAiD within personal beliefs and work environment.ConclusionCaring for patients who chose MAiD changed the dynamic of care. Participants focused on providing patient-centred care while attempting to normalize the MAiD process. Educational resources to support patient-centred care for patients who undergo MAiD off-site, address care provider self-care, and to facilitate safe and effective interdisciplinary communication are needed.","container-title":"Canadian Journal of Nursing Research","DOI":"10.1177/0844562120985995","ISSN":"0844-5621","issue":"1","journalAbbreviation":"Can J Nurs Res","language":"en","page":"3-14","source":"SAGE Journals","title":"Hospice Care Provider Perspectives of Medical Assistance in Dying in a Canadian Hospice That Does Not Provide Medical Assistance in Dying","volume":"54","author":[{"family":"Ward","given":"Valerie"},{"family":"Freeman","given":"Shannon"},{"family":"Banner","given":"Davina"}],"issued":{"date-parts":[["2022",3,1]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Gerson, Preston, et al., 2020; Ward et al., 2022).

Physician

Physicians play an essential part in AD decisions for patients (Denier et al., 2010). This includes providing care, treatment, prognosis, and consultation to patients (citation). Physicians are often portrayed as having ultimate responsibility for care decisions, sometimes ignoring the nursing voice in decision-making, which can make aspects of patients unique experience and background around end-of-life choices invisible ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"SYfO9n8S","properties":{"formattedCitation":"(Elmore et al., 2018)","plainCitation":"(Elmore et al., 2018)","noteIndex":0},"citationItems":[{"id":86,"uris":["http://zotero.org/users/14650052/items/99D8KMWQ"],"itemData":{"id":86,"type":"article-journal","abstract":"Background: Legislative changes are resulting in assisted death as an option for people at the end of life. Although nurses experiences and perspectives are underrepresented within broader ethical discourses about assisted death, there is a small but significant body of literature examining nurses experiences of caring for people who request this option.nAim: To synthesize what has been learned about nurses experiences of caring for patients who request assisted death and to highlight what is morally at stake for nurses who undertake this type of care.nDesign: Qualitative meta-synthesis.nMethods: Six databases were searched: CINAHL, Medline, EMBASE, Joanna Briggs Institute, PsycINFO, and Web of Science. The search was completed on 22 October 2014 and updated in February 2016. Of 879 articles identified from the database searches, 16 articles were deemed relevant based on inclusion criteria. Following quality appraisal, 14 studies were retained for analysis and synthesis.nResults: The moral experience of the nurse is (1) defined by a profound sense of responsibility, (2) shaped by contextual forces that nurses navigate in everyday end-of-life care practice, and (3) sustained by intra-team moral and emotional support.nDiscussion: The findings of this synthesis support the view that nurses are moral agents who are deeply invested in the moral integrity of end-of-life care involving assisted death. The findings further demonstrate that to fully appreciate the ethics of assisted death from a nursing standpoint, it is necessary to understand the broader constraints on nurses moral agency that operate in everyday end-of-life care.nEthical considerations: Research ethics board approval was not required for this synthesis of previously published literature.nConclusion: In order to understand how to enact ethical practice in the area of assisted death, the moral experiences of nurses should be investigated and foregrounded.","container-title":"Nursing Ethics","DOI":"10.1177/0969733016679468","ISSN":"0969-7330","issue":"8","journalAbbreviation":"Nurs Ethics","language":"en","page":"955-972","source":"SAGE Journals","title":"Nurses moral experiences of assisted death: A meta-synthesis of qualitative research","title-short":"Nurses moral experiences of assisted death","volume":"25","author":[{"family":"Elmore","given":"James"},{"family":"Wright","given":"David Kenneth"},{"family":"Paradis","given":"Maude"}],"issued":{"date-parts":[["2018",12,1]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Elmore et al., 2018). In Snelling et al study, one of the physicians described the feeling of discomfort of having a patients AD request treated as confidential, leaving physicians on call unprepared and unable to take care of them the patient, until they received the message that the patient has received AD administration ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"rIPb1w5L","properties":{"formattedCitation":"(Snelling et al., 2023)","plainCitation":"(Snelling et al., 2023)","noteIndex":0},"citationItems":[{"id":97,"uris":["http://zotero.org/users/14650052/items/6RW5BWH5"],"itemData":{"id":97,"type":"article-journal","abstract":"In November 2021, assisted dying (AD) became lawful in Aotearoa New Zealand. A terminally ill person may now request, and receive, pharmacological assistance (self-administered or provided by a medical practitioner/nurse practitioner) to end their life, subject to specific legal criteria and processes. Exploring the experiences of health providers in the initial stage of the implementation of the End of Life Choice Act 2019 is vital to inform the ongoing development of safe and effective AD practice, policy and law.","container-title":"BMC Palliative Care","DOI":"10.1186/s12904-023-01222-4","ISSN":"1472-684X","issue":"1","journalAbbreviation":"BMC Palliative Care","page":"101","source":"BioMed Central","title":"Health care providers early experiences of assisted dying in Aotearoa New Zealand: an evolving clinical service","title-short":"Health care providers early experiences of assisted dying in Aotearoa New Zealand","volume":"22","author":[{"family":"Snelling","given":"Jeanne"},{"family":"Young","given":"Jessica"},{"family":"Beaumont","given":"Sophie"},{"family":"Diesfeld","given":"Kate"},{"family":"White","given":"Ben"},{"family":"Willmott","given":"Lindy"},{"family":"Robinson","given":"Jacqualine"},{"family":"Moeke-Maxwell","given":"Tess"}],"issued":{"date-parts":[["2023",7,22]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Snelling et al., 2023).

Nurse

Compared to physicians, nurses are generally reported being less involved in decision-making ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"BD7rwXBY","properties":{"formattedCitation":"(Fujioka et al., 2018)","plainCitation":"(Fujioka et al., 2018)","noteIndex":0},"citationItems":[{"id":65,"uris":["http://zotero.org/users/14650052/items/2KDC45VR",["http://zotero.org/users/14650052/items/2KDC45VR"]],"itemData":{"id":65,"type":"article-journal","abstract":"Research AimsnWith the growing interest in Medical Assistance in Dying (MAiD), understanding health care professionals' roles and experiences in handling requests is necessary to evaluate the quality, consistency, and efficacy of current practices. This scoping review sought to map the existing literature on health care providers' perspectives of their involvement in MAiD.nMethodsnA scoping review was conducted to address the following: 1) What are the roles of diverse health care professionals in the provision of MAiD? and 2) What professional challenges arise when confronted with MAiD requests? A literature search in electronic databases and gray literature sources was performed. Articles were screened, and a thematic content analysis synthesized key findings.nResultsnAfter evaluating 1715 citations and 148 full-text papers, 33 articles were included. Perspectives of nurses (n=10), physicians (n=7), mental health providers (n=7), pharmacists (n=4), social workers (n=3), and medical examiners (n=1) were explored. Professional roles included consulting/supporting patients and/or other staff members with requests, assessing eligibility, administering/dispensing the lethal drugs, providing aftercare to bereaved relatives, and regulatory oversight. Challenges included lack of clear guidelines/protocols, role ambiguity, evaluating capacity/consent, conscientious objection, and lack of interprofessional collaboration.nConclusionnEvidence from various jurisdictions highlighted a need for clear guidelines and protocols that define each profession's role, scope of practice, and legal boundaries for MAiD. Comprehensive models of care that incorporate multidisciplinary teams alongside improved clinician education may be effective to support MAiD implementation. Little is known about health care providers' perspectives in handling requests, especially outside physician practice and nursing.","container-title":"Journal of Pain and Symptom Management","DOI":"10.1016/j.jpainsymman.2018.02.011","ISSN":"0885-3924","issue":"6","journalAbbreviation":"Journal of Pain and Symptom Management","page":"1564-1576.e9","source":"ScienceDirect","title":"Implementation of Medical Assistance in Dying: A Scoping Review of Health Care Providers' Perspectives","title-short":"Implementation of Medical Assistance in Dying","volume":"55","author":[{"family":"Fujioka","given":"Jamie K."},{"family":"Mirza","given":"Raza M."},{"family":"McDonald","given":"P. Lynn"},{"family":"Klinger","given":"Christopher A."}],"issued":{"date-parts":[["2018",6,1]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Fujioka et al., 2018). Nurses described their role as providing practical and ongoing care and support throughout the AD process (De Bal et al., 2006; Denier et al., 2009). Their level of involvement varies ranging from listening to conversations between physicians and patients at a distance, to being present at the death ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"r9vmfzML","properties":{"formattedCitation":"(Beuthin et al., 2018)","plainCitation":"(Beuthin et al., 2018)","noteIndex":0},"citationItems":[{"id":70,"uris":["http://zotero.org/users/14650052/items/Y4HWYM4Q",["http://zotero.org/users/14650052/items/Y4HWYM4Q"]],"itemData":{"id":70,"type":"article-journal","abstract":"Medical assistance in dying (MAiD) represents a historic change in Canadian society and the provision of end-of-life care. In this descriptive narrative inquiry, 17 nurses were interviewed during the first 6 months of assisted dying becoming a legal option for patients in Canada. Nurses experiences of either providing care for a patient who had chosen MAiD, or declining to participate in MAiD, were explored. Findings describe three themes and eight storylines of the impact of MAiD on nurses view of the profession, clinical practice, and personally. While most nurses perceived MAiD as an extension of the profession and their nursing practice, a small number also expressed moral distress as they grappled with assisted dying. Narratives illustrated an ongoing sensemaking process and spectrum of emotions. These findings offer insight and provide direction for nurses and managers in this new clinical and legal reality. Further research is needed to understand more fully the moral distress of some nurses, as well as the importance of communicating openly and nonjudgmentally with patients, families, and the health-care team.","container-title":"Nursing Forum","DOI":"10.1111/nuf.12280","ISSN":"1744-6198","issue":"4","language":"en","license":" 2018 The Authors. Nursing Forum published by Wiley Periodicals, Inc.","page":"511-520","source":"Wiley Online Library","title":"Medical assistance in dying (MAiD): Canadian nurses experiences","title-short":"Medical assistance in dying (MAiD)","volume":"53","author":[{"family":"Beuthin","given":"Rosanne"},{"family":"Bruce","given":"Anne"},{"family":"Scaia","given":"Margaret"}],"issued":{"date-parts":[["2018"]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Beuthin et al., 2018). This leaves nurses feeling intense, conflicted, guilty, and sometimes powerless throught the care process (De Bal et al., 2006; Denier et al., 2009).

Besides that, nurses are often the first person that the patient will reach out to when asking for AD information (De Bal et al., 2006; ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"3wMLsJXY","properties":{"formattedCitation":"(van Bruchem-van de Scheur et al., 2008)","plainCitation":"(van Bruchem-van de Scheur et al., 2008)","dontUpdate":true,"noteIndex":0},"citationItems":[{"id":45,"uris":["http://zotero.org/users/14650052/items/I5ET2XFY",["http://zotero.org/users/14650052/items/I5ET2XFY"]],"itemData":{"id":45,"type":"article-journal","abstract":"BACKGROUND: Issues concerning legislation and regulation with respect to the role of nurses in euthanasia and physician-assisted suicide gave the Minister for Health reason to commission a study of the role of nurses in medical end-of-life decisions in hospitals, home care and nursing homes.nAIM: This paper reports the findings of a study of the role of nurses in euthanasia and physician-assisted suicide, conducted as part of a study of the role of nurses in medical end-of-life decisions. The findings for hospitals, home care and nursing homes are described and compared.nMETHOD: A questionnaire was sent to 1509 nurses, employed in 73 hospitals, 55 home care organisations and 63 nursing homes. 1179 responses (78.1%) were suitable for analysis. The questionnaire was pilot-tested among 106 nurses, with a response rate of 85%.nRESULTS: In 37.0% of cases, the nurse was the first person with whom patients discussed their request for euthanasia or physician-assisted suicide. Consultation between physicians and nurses during the decision-making process took place quite often in hospitals (78.8%) and nursing homes (81.3%) and less frequently in home care situations (41.2%). In some cases (12.2%), nurses administered the euthanatics.nCONCLUSIONS: The results show substantial differences between the intramural sector (hospitals and nursing homes) and the extramural sector (home care), which are probably linked to the organisational structure of the institutions. Consultation between physicians and nurses during the decision-making process needs improvement, particularly in home care. Some nurses had administered euthanatics, although this task is by law exclusively reserved to physicians.","container-title":"Journal of Medical Ethics","DOI":"10.1136/jme.2006.018507","ISSN":"1473-4257","issue":"4","journalAbbreviation":"J Med Ethics","language":"eng","note":"PMID: 18375675","page":"254-258","source":"PubMed","title":"The role of nurses in euthanasia and physician-assisted suicide in The Netherlands","volume":"34","author":[{"family":"Bruchem-van de Scheur","given":"G. G.","non-dropping-particle":"van"},{"family":"Arend","given":"A. J. G.","non-dropping-particle":"van der"},{"family":"Abu-Saad","given":"H. Huijer"},{"family":"Spreeuwenberg","given":"C."},{"family":"Wijmen","given":"F. C. B.","non-dropping-particle":"van"},{"family":"Meulen","given":"R. H. J.","non-dropping-particle":"ter"}],"issued":{"date-parts":[["2008",4]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} van Bruchem-van de Scheur et al., 2008). Nurses take their position in the care of patients requesting AD very seriously, stating that it is their responsibility to represent the patients voice and to facilitate open communication between patients, their families, and the healthcare team (Elmore et al., 2018). On occasions where a physician focuses primarily on curing the patient or ignores the AD request or resists palliative care support, nurses would become frustrated thinking that they did not do a good job in representing the patients stance (De Bal et al., 2006). It can be seen when nurses witness the death of a patient, it can bring negative emotion to them, however, if it is to give support to the patients, nurses are more acceptable.

A study conducted on regarding relational autonomy of nurses, the studies mentioned that nurses must inform their nurse leaders about their decision not to be involved in AD and so nurse leaders can make specific arrangements to protect nurses moral agency ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"8KJL9Cir","properties":{"formattedCitation":"(Variath et al., 2020)","plainCitation":"(Variath et al., 2020)","noteIndex":0},"citationItems":[{"id":335,"uris":["http://zotero.org/users/14650052/items/9HTGAZZB"],"itemData":{"id":335,"type":"article-journal","abstract":"Background:Family members and healthcare providers play an integral role in a persons assisted dying journey. Their own needs during the assisted dying journey are often, however, unrecognized and underrepresented in policies and guidelines. Circumstances under which people choose assisted dying, and relational contexts such as the sociopolitical environment, may influence the experiences of family members and healthcare providers.Ethical considerations:Ethics approval was not required to conduct this review.Aim:This scoping review aims to identify the relational influences on the experiences of family members and healthcare providers of adults who underwent assisted dying and of those unable to access assisted dying due to the loss of capacity to consent.Methods:A literature search was conducted in four databases, including MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature (CINAHL) and PsycINFO. The search retrieved 12,074 articles, a number narrowed down to 172 articles for full-text screening. Thirty-six articles met the established inclusion criteria. A feminist relational framework guided the data analysis.Results:Five key themes on the influences of family members and healthcare providers experiences throughout the assisted dying process were synthesized from the data. They include (1) relationships as central to beginning the process, (2) social and political influences on decision making, (3) complex roles and responsibilities of family members and healthcare providers, (4) a unique experience of death, and (5) varying experiences following death.Conclusion:The feminist relational lens, used to guide analysis, shed light on the effect of the sociopolitical influences and the relationships among patients, families, and healthcare providers on each others experiences. Addressing the needs of the family members and healthcare providers is vital to improving the assisted dying process. Including families and healthcare providers needs within institutional policies and enhancing collaboration and communication among those involved could improve the overall experience.","container-title":"Nursing Ethics","DOI":"10.1177/0969733020921493","ISSN":"0969-7330","issue":"7","journalAbbreviation":"Nurs Ethics","language":"en","note":"publisher: SAGE Publications Ltd","page":"1501-1516","source":"SAGE Journals","title":"Relational influences on experiences with assisted dying: A scoping review","title-short":"Relational influences on experiences with assisted dying","volume":"27","author":[{"family":"Variath","given":"Caroline"},{"family":"Peter","given":"Elizabeth"},{"family":"Cranley","given":"Lisa"},{"family":"Godkin","given":"Dianne"},{"family":"Just","given":"Danielle"}],"issued":{"date-parts":[["2020",11,1]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Variath et al., 2020). For example, for some nurses who conscientiously object to AD, their involvement with a patient who intends to pursue AD will be limited to routine care ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"TQw1mPfl","properties":{"formattedCitation":"(Variath et al., 2020)","plainCitation":"(Variath et al., 2020)","noteIndex":0},"citationItems":[{"id":335,"uris":["http://zotero.org/users/14650052/items/9HTGAZZB"],"itemData":{"id":335,"type":"article-journal","abstract":"Background:Family members and healthcare providers play an integral role in a persons assisted dying journey. Their own needs during the assisted dying journey are often, however, unrecognized and underrepresented in policies and guidelines. Circumstances under which people choose assisted dying, and relational contexts such as the sociopolitical environment, may influence the experiences of family members and healthcare providers.Ethical considerations:Ethics approval was not required to conduct this review.Aim:This scoping review aims to identify the relational influences on the experiences of family members and healthcare providers of adults who underwent assisted dying and of those unable to access assisted dying due to the loss of capacity to consent.Methods:A literature search was conducted in four databases, including MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature (CINAHL) and PsycINFO. The search retrieved 12,074 articles, a number narrowed down to 172 articles for full-text screening. Thirty-six articles met the established inclusion criteria. A feminist relational framework guided the data analysis.Results:Five key themes on the influences of family members and healthcare providers experiences throughout the assisted dying process were synthesized from the data. They include (1) relationships as central to beginning the process, (2) social and political influences on decision making, (3) complex roles and responsibilities of family members and healthcare providers, (4) a unique experience of death, and (5) varying experiences following death.Conclusion:The feminist relational lens, used to guide analysis, shed light on the effect of the sociopolitical influences and the relationships among patients, families, and healthcare providers on each others experiences. Addressing the needs of the family members and healthcare providers is vital to improving the assisted dying process. Including families and healthcare providers needs within institutional policies and enhancing collaboration and communication among those involved could improve the overall experience.","container-title":"Nursing Ethics","DOI":"10.1177/0969733020921493","ISSN":"0969-7330","issue":"7","journalAbbreviation":"Nurs Ethics","language":"en","note":"publisher: SAGE Publications Ltd","page":"1501-1516","source":"SAGE Journals","title":"Relational influences on experiences with assisted dying: A scoping review","title-short":"Relational influences on experiences with assisted dying","volume":"27","author":[{"family":"Variath","given":"Caroline"},{"family":"Peter","given":"Elizabeth"},{"family":"Cranley","given":"Lisa"},{"family":"Godkin","given":"Dianne"},{"family":"Just","given":"Danielle"}],"issued":{"date-parts":[["2020",11,1]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Variath et al., 2020). Other nursing responsibilities included completing paperwork, finding witnesses, guiding, counselling, and supporting patients and family members, and organising the care process ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"tv9p6vxa","properties":{"formattedCitation":"(Beuthin et al., 2018; de Casterluc0u233{} et al., 2006; Denier et al., 2009, 2010; van Bruchem-van de Scheur et al., 2008)","plainCitation":"(Beuthin et al., 2018; de Casterl et al., 2006; Denier et al., 2009, 2010; van Bruchem-van de Scheur et al., 2008)","noteIndex":0},"citationItems":[{"id":70,"uris":["http://zotero.org/users/14650052/items/Y4HWYM4Q",["http://zotero.org/users/14650052/items/Y4HWYM4Q"]],"itemData":{"id":70,"type":"article-journal","abstract":"Medical assistance in dying (MAiD) represents a historic change in Canadian society and the provision of end-of-life care. In this descriptive narrative inquiry, 17 nurses were interviewed during the first 6 months of assisted dying becoming a legal option for patients in Canada. Nurses experiences of either providing care for a patient who had chosen MAiD, or declining to participate in MAiD, were explored. Findings describe three themes and eight storylines of the impact of MAiD on nurses view of the profession, clinical practice, and personally. While most nurses perceived MAiD as an extension of the profession and their nursing practice, a small number also expressed moral distress as they grappled with assisted dying. Narratives illustrated an ongoing sensemaking process and spectrum of emotions. These findings offer insight and provide direction for nurses and managers in this new clinical and legal reality. Further research is needed to understand more fully the moral distress of some nurses, as well as the importance of communicating openly and nonjudgmentally with patients, families, and the health-care team.","container-title":"Nursing Forum","DOI":"10.1111/nuf.12280","ISSN":"1744-6198","issue":"4","language":"en","license":" 2018 The Authors. Nursing Forum published by Wiley Periodicals, Inc.","page":"511-520","source":"Wiley Online Library","title":"Medical assistance in dying (MAiD): Canadian nurses experiences","title-short":"Medical assistance in dying (MAiD)","volume":"53","author":[{"family":"Beuthin","given":"Rosanne"},{"family":"Bruce","given":"Anne"},{"family":"Scaia","given":"Margaret"}],"issued":{"date-parts":[["2018"]]}}},{"id":274,"uris":["http://zotero.org/users/14650052/items/GI35V9IA","http://zotero.org/users/14650052/items/6MZDY7R2"],"itemData":{"id":274,"type":"article-journal","issue":"4","journalAbbreviation":"Journal of medical ethics","title":"Nurses views on their involvement in euthanasia: a qualitative study in Flanders (Belgium)","volume":"32","author":[{"family":"Casterl","given":"B. Dierckx","non-dropping-particle":"de","dropping-particle":"de"},{"family":"Verpoort","given":"C."},{"family":"Bal","given":"N.","non-dropping-particle":"de"},{"family":"Gastmans","given":"C."}],"issued":{"date-parts":[["2006"]]}}},{"id":84,"uris":["http://zotero.org/users/14650052/items/W2Y8PT7A"],"itemData":{"id":84,"type":"article-journal","abstract":"This study explored nurses' involvement in the care process for mentally competent, terminally ill patients requesting euthanasia in general hospitals in Flanders, Belgium. In-depth interviews with 18 nurses who had experience in caring for patients requesting euthanasia since May 2002 were analyzed using grounded theory qualitative methods. We found that the involvement of nurses in the care process is influenced by their predominant perspective on it: the procedural, action-focused perspective, from which good practical organization of the care process is essential; or the existential-interpretative perspective, from which it is important to understand the patient's request within a dialogue-focused and communicational atmosphere. Findings show that the two perspectives are not mutually exclusive, but rather complementary dimensions of the euthanasia care process. Hence, sufficient support for nurses to reach a well-balanced integration of both perspectives is essential.","container-title":"Journal of Palliative Care","ISSN":"0825-8597","issue":"4","journalAbbreviation":"J Palliat Care","language":"eng","note":"PMID: 20131583","page":"264-274","source":"PubMed","title":"Involvement of nurses in the euthanasia care process in Flanders (Belgium): an exploration of two perspectives","title-short":"Involvement of nurses in the euthanasia care process in Flanders (Belgium)","volume":"25","author":[{"family":"Denier","given":"Yvonne"},{"family":"Dierckx de Casterl","given":"Bernadette"},{"family":"De Bal","given":"Nele"},{"family":"Gastmans","given":"Chris"}],"issued":{"date-parts":[["2009"]]}}},{"id":57,"uris":["http://zotero.org/users/14650052/items/SE2PXS34"],"itemData":{"id":57,"type":"article-journal","abstract":"The Belgian Act on Euthanasia came into force on 23 September 2002, making Belgium the second countryafter the Netherlandsto decriminalize euthanasia under certain due-care conditions. Since then, Belgian nurses have been increasingly involved in euthanasia care. In this paper, we report a qualitative study based on in-depth interviews with 18 nurses from Flanders (the Dutch-speaking part of Belgium) who have had experience in caring for patients requesting euthanasia since May 2002 (the approval of the Act). We found that the care process for patients requesting euthanasia is a complex and dynamic process, consisting of several stages, starting from the period preceding the euthanasia request and ending with the aftercare stage. When asked after the way in which they experience their involvement in the euthanasia care process, all nurses described it as a grave and difficult process, not only on an organizational and practical level, but also on an emotional level. Intense is the dominant feeling experienced by nurses. This is compounded by the presence of other feelings such as great concern and responsibility on the one hand, being content in truly helping the patient to die serenely, and doing everything in ones power to contribute to this; but also feeling unreal and ambivalent on the other hand, because death is arranged. Nurses feel a discrepancy, because although it is a nice death, which happens in dignity and with respect, it is also an unnatural death. The clinical ethical implications of these findings are discussed.","container-title":"Medicine, Health Care and Philosophy","DOI":"10.1007/s11019-009-9203-1","ISSN":"1572-8633","issue":"1","journalAbbreviation":"Med Health Care and Philos","language":"en","page":"41-48","source":"Springer Link","title":"Its intense, you know. Nurses experiences in caring for patients requesting euthanasia","volume":"13","author":[{"family":"Denier","given":"Yvonne"},{"family":"Dierckx de Casterl","given":"Bernadette"},{"family":"De Bal","given":"Nele"},{"family":"Gastmans","given":"Chris"}],"issued":{"date-parts":[["2010",2,1]]}}},{"id":45,"uris":["http://zotero.org/users/14650052/items/I5ET2XFY",["http://zotero.org/users/14650052/items/I5ET2XFY"]],"itemData":{"id":45,"type":"article-journal","abstract":"BACKGROUND: Issues concerning legislation and regulation with respect to the role of nurses in euthanasia and physician-assisted suicide gave the Minister for Health reason to commission a study of the role of nurses in medical end-of-life decisions in hospitals, home care and nursing homes.nAIM: This paper reports the findings of a study of the role of nurses in euthanasia and physician-assisted suicide, conducted as part of a study of the role of nurses in medical end-of-life decisions. The findings for hospitals, home care and nursing homes are described and compared.nMETHOD: A questionnaire was sent to 1509 nurses, employed in 73 hospitals, 55 home care organisations and 63 nursing homes. 1179 responses (78.1%) were suitable for analysis. The questionnaire was pilot-tested among 106 nurses, with a response rate of 85%.nRESULTS: In 37.0% of cases, the nurse was the first person with whom patients discussed their request for euthanasia or physician-assisted suicide. Consultation between physicians and nurses during the decision-making process took place quite often in hospitals (78.8%) and nursing homes (81.3%) and less frequently in home care situations (41.2%). In some cases (12.2%), nurses administered the euthanatics.nCONCLUSIONS: The results show substantial differences between the intramural sector (hospitals and nursing homes) and the extramural sector (home care), which are probably linked to the organisational structure of the institutions. Consultation between physicians and nurses during the decision-making process needs improvement, particularly in home care. Some nurses had administered euthanatics, although this task is by law exclusively reserved to physicians.","container-title":"Journal of Medical Ethics","DOI":"10.1136/jme.2006.018507","ISSN":"1473-4257","issue":"4","journalAbbreviation":"J Med Ethics","language":"eng","note":"PMID: 18375675","page":"254-258","source":"PubMed","title":"The role of nurses in euthanasia and physician-assisted suicide in The Netherlands","volume":"34","author":[{"family":"Bruchem-van de Scheur","given":"G. G.","non-dropping-particle":"van"},{"family":"Arend","given":"A. J. G.","non-dropping-particle":"van der"},{"family":"Abu-Saad","given":"H. Huijer"},{"family":"Spreeuwenberg","given":"C."},{"family":"Wijmen","given":"F. C. B.","non-dropping-particle":"van"},{"family":"Meulen","given":"R. H. J.","non-dropping-particle":"ter"}],"issued":{"date-parts":[["2008",4]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Beuthin et al., 2018; de Casterl et al., 2006; Denier et al., 2009, 2010; van Bruchem-van de Scheur et al., 2008). Some nurses utilised procedural checklists to fulfil their role in meeting the requirements of assisted dying, while others emphasised the importance of seeing each case of AD as unique and reflective of each individuals needs ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"UFA4K8N2","properties":{"formattedCitation":"(de Casterluc0u233{} et al., 2006; Denier et al., 2009)","plainCitation":"(de Casterl et al., 2006; Denier et al., 2009)","noteIndex":0},"citationItems":[{"id":274,"uris":["http://zotero.org/users/14650052/items/GI35V9IA","http://zotero.org/users/14650052/items/6MZDY7R2"],"itemData":{"id":274,"type":"article-journal","issue":"4","journalAbbreviation":"Journal of medical ethics","title":"Nurses views on their involvement in euthanasia: a qualitative study in Flanders (Belgium)","volume":"32","author":[{"family":"Casterl","given":"B. Dierckx","non-dropping-particle":"de","dropping-particle":"de"},{"family":"Verpoort","given":"C."},{"family":"Bal","given":"N.","non-dropping-particle":"de"},{"family":"Gastmans","given":"C."}],"issued":{"date-parts":[["2006"]]}}},{"id":84,"uris":["http://zotero.org/users/14650052/items/W2Y8PT7A"],"itemData":{"id":84,"type":"article-journal","abstract":"This study explored nurses' involvement in the care process for mentally competent, terminally ill patients requesting euthanasia in general hospitals in Flanders, Belgium. In-depth interviews with 18 nurses who had experience in caring for patients requesting euthanasia since May 2002 were analyzed using grounded theory qualitative methods. We found that the involvement of nurses in the care process is influenced by their predominant perspective on it: the procedural, action-focused perspective, from which good practical organization of the care process is essential; or the existential-interpretative perspective, from which it is important to understand the patient's request within a dialogue-focused and communicational atmosphere. Findings show that the two perspectives are not mutually exclusive, but rather complementary dimensions of the euthanasia care process. Hence, sufficient support for nurses to reach a well-balanced integration of both perspectives is essential.","container-title":"Journal of Palliative Care","ISSN":"0825-8597","issue":"4","journalAbbreviation":"J Palliat Care","language":"eng","note":"PMID: 20131583","page":"264-274","source":"PubMed","title":"Involvement of nurses in the euthanasia care process in Flanders (Belgium): an exploration of two perspectives","title-short":"Involvement of nurses in the euthanasia care process in Flanders (Belgium)","volume":"25","author":[{"family":"Denier","given":"Yvonne"},{"family":"Dierckx de Casterl","given":"Bernadette"},{"family":"De Bal","given":"Nele"},{"family":"Gastmans","given":"Chris"}],"issued":{"date-parts":[["2009"]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (de Casterl et al., 2006; Denier et al., 2009). Nurses strive to support and comfort patients and family members ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"2gZKReP9","properties":{"formattedCitation":"(de Casterluc0u233{} et al., 2006; Denier et al., 2009)","plainCitation":"(de Casterl et al., 2006; Denier et al., 2009)","noteIndex":0},"citationItems":[{"id":274,"uris":["http://zotero.org/users/14650052/items/GI35V9IA","http://zotero.org/users/14650052/items/6MZDY7R2"],"itemData":{"id":274,"type":"article-journal","issue":"4","journalAbbreviation":"Journal of medical ethics","title":"Nurses views on their involvement in euthanasia: a qualitative study in Flanders (Belgium)","volume":"32","author":[{"family":"Casterl","given":"B. Dierckx","non-dropping-particle":"de","dropping-particle":"de"},{"family":"Verpoort","given":"C."},{"family":"Bal","given":"N.","non-dropping-particle":"de"},{"family":"Gastmans","given":"C."}],"issued":{"date-parts":[["2006"]]}}},{"id":84,"uris":["http://zotero.org/users/14650052/items/W2Y8PT7A"],"itemData":{"id":84,"type":"article-journal","abstract":"This study explored nurses' involvement in the care process for mentally competent, terminally ill patients requesting euthanasia in general hospitals in Flanders, Belgium. In-depth interviews with 18 nurses who had experience in caring for patients requesting euthanasia since May 2002 were analyzed using grounded theory qualitative methods. We found that the involvement of nurses in the care process is influenced by their predominant perspective on it: the procedural, action-focused perspective, from which good practical organization of the care process is essential; or the existential-interpretative perspective, from which it is important to understand the patient's request within a dialogue-focused and communicational atmosphere. Findings show that the two perspectives are not mutually exclusive, but rather complementary dimensions of the euthanasia care process. Hence, sufficient support for nurses to reach a well-balanced integration of both perspectives is essential.","container-title":"Journal of Palliative Care","ISSN":"0825-8597","issue":"4","journalAbbreviation":"J Palliat Care","language":"eng","note":"PMID: 20131583","page":"264-274","source":"PubMed","title":"Involvement of nurses in the euthanasia care process in Flanders (Belgium): an exploration of two perspectives","title-short":"Involvement of nurses in the euthanasia care process in Flanders (Belgium)","volume":"25","author":[{"family":"Denier","given":"Yvonne"},{"family":"Dierckx de Casterl","given":"Bernadette"},{"family":"De Bal","given":"Nele"},{"family":"Gastmans","given":"Chris"}],"issued":{"date-parts":[["2009"]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (de Casterl et al., 2006; Denier et al., 2009) by minimising environmental stimuli and providing a serene, dignified, and peaceful space for provision ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"DYR5nJAA","properties":{"formattedCitation":"(Denier et al., 2010)","plainCitation":"(Denier et al., 2010)","noteIndex":0},"citationItems":[{"id":57,"uris":["http://zotero.org/users/14650052/items/SE2PXS34"],"itemData":{"id":57,"type":"article-journal","abstract":"The Belgian Act on Euthanasia came into force on 23 September 2002, making Belgium the second countryafter the Netherlandsto decriminalize euthanasia under certain due-care conditions. Since then, Belgian nurses have been increasingly involved in euthanasia care. In this paper, we report a qualitative study based on in-depth interviews with 18 nurses from Flanders (the Dutch-speaking part of Belgium) who have had experience in caring for patients requesting euthanasia since May 2002 (the approval of the Act). We found that the care process for patients requesting euthanasia is a complex and dynamic process, consisting of several stages, starting from the period preceding the euthanasia request and ending with the aftercare stage. When asked after the way in which they experience their involvement in the euthanasia care process, all nurses described it as a grave and difficult process, not only on an organizational and practical level, but also on an emotional level. Intense is the dominant feeling experienced by nurses. This is compounded by the presence of other feelings such as great concern and responsibility on the one hand, being content in truly helping the patient to die serenely, and doing everything in ones power to contribute to this; but also feeling unreal and ambivalent on the other hand, because death is arranged. Nurses feel a discrepancy, because although it is a nice death, which happens in dignity and with respect, it is also an unnatural death. The clinical ethical implications of these findings are discussed.","container-title":"Medicine, Health Care and Philosophy","DOI":"10.1007/s11019-009-9203-1","ISSN":"1572-8633","issue":"1","journalAbbreviation":"Med Health Care and Philos","language":"en","page":"41-48","source":"Springer Link","title":"Its intense, you know. Nurses experiences in caring for patients requesting euthanasia","volume":"13","author":[{"family":"Denier","given":"Yvonne"},{"family":"Dierckx de Casterl","given":"Bernadette"},{"family":"De Bal","given":"Nele"},{"family":"Gastmans","given":"Chris"}],"issued":{"date-parts":[["2010",2,1]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Denier et al., 2010).

The emotional impact of witnessing death may sometimes depend on the patients preparedness when facing death. For example, nurses claimed to have uplifting experiences when patient were much more ready for their death ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"NhoSvNuf","properties":{"formattedCitation":"(Beuthin et al., 2018)","plainCitation":"(Beuthin et al., 2018)","noteIndex":0},"citationItems":[{"id":70,"uris":["http://zotero.org/users/14650052/items/Y4HWYM4Q",["http://zotero.org/users/14650052/items/Y4HWYM4Q"]],"itemData":{"id":70,"type":"article-journal","abstract":"Medical assistance in dying (MAiD) represents a historic change in Canadian society and the provision of end-of-life care. In this descriptive narrative inquiry, 17 nurses were interviewed during the first 6 months of assisted dying becoming a legal option for patients in Canada. Nurses experiences of either providing care for a patient who had chosen MAiD, or declining to participate in MAiD, were explored. Findings describe three themes and eight storylines of the impact of MAiD on nurses view of the profession, clinical practice, and personally. While most nurses perceived MAiD as an extension of the profession and their nursing practice, a small number also expressed moral distress as they grappled with assisted dying. Narratives illustrated an ongoing sensemaking process and spectrum of emotions. These findings offer insight and provide direction for nurses and managers in this new clinical and legal reality. Further research is needed to understand more fully the moral distress of some nurses, as well as the importance of communicating openly and nonjudgmentally with patients, families, and the health-care team.","container-title":"Nursing Forum","DOI":"10.1111/nuf.12280","ISSN":"1744-6198","issue":"4","language":"en","license":" 2018 The Authors. Nursing Forum published by Wiley Periodicals, Inc.","page":"511-520","source":"Wiley Online Library","title":"Medical assistance in dying (MAiD): Canadian nurses experiences","title-short":"Medical assistance in dying (MAiD)","volume":"53","author":[{"family":"Beuthin","given":"Rosanne"},{"family":"Bruce","given":"Anne"},{"family":"Scaia","given":"Margaret"}],"issued":{"date-parts":[["2018"]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Beuthin et al., 2018). At times, patients use self-deprecating comments in the dying process, giving nurses unanticipated humour and heart-opening moments. Beuthin et al (2018) reported that the nurses recognised their emotional and sad reaction to the occurrence of an AD event was a natural response; whereas positive emotions were more surprising when they felt calm and surprised, and were often shared discreetly in public ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"7RjJAaCH","properties":{"formattedCitation":"(Beuthin et al., 2018)","plainCitation":"(Beuthin et al., 2018)","noteIndex":0},"citationItems":[{"id":70,"uris":["http://zotero.org/users/14650052/items/Y4HWYM4Q",["http://zotero.org/users/14650052/items/Y4HWYM4Q"]],"itemData":{"id":70,"type":"article-journal","abstract":"Medical assistance in dying (MAiD) represents a historic change in Canadian society and the provision of end-of-life care. In this descriptive narrative inquiry, 17 nurses were interviewed during the first 6 months of assisted dying becoming a legal option for patients in Canada. Nurses experiences of either providing care for a patient who had chosen MAiD, or declining to participate in MAiD, were explored. Findings describe three themes and eight storylines of the impact of MAiD on nurses view of the profession, clinical practice, and personally. While most nurses perceived MAiD as an extension of the profession and their nursing practice, a small number also expressed moral distress as they grappled with assisted dying. Narratives illustrated an ongoing sensemaking process and spectrum of emotions. These findings offer insight and provide direction for nurses and managers in this new clinical and legal reality. Further research is needed to understand more fully the moral distress of some nurses, as well as the importance of communicating openly and nonjudgmentally with patients, families, and the health-care team.","container-title":"Nursing Forum","DOI":"10.1111/nuf.12280","ISSN":"1744-6198","issue":"4","language":"en","license":" 2018 The Authors. Nursing Forum published by Wiley Periodicals, Inc.","page":"511-520","source":"Wiley Online Library","title":"Medical assistance in dying (MAiD): Canadian nurses experiences","title-short":"Medical assistance in dying (MAiD)","volume":"53","author":[{"family":"Beuthin","given":"Rosanne"},{"family":"Bruce","given":"Anne"},{"family":"Scaia","given":"Margaret"}],"issued":{"date-parts":[["2018"]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Beuthin et al., 2018).

Nurses would also feel positive when they have supported a good death ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"S1pl9Ltn","properties":{"formattedCitation":"(Beuthin et al., 2018)","plainCitation":"(Beuthin et al., 2018)","noteIndex":0},"citationItems":[{"id":70,"uris":["http://zotero.org/users/14650052/items/Y4HWYM4Q",["http://zotero.org/users/14650052/items/Y4HWYM4Q"]],"itemData":{"id":70,"type":"article-journal","abstract":"Medical assistance in dying (MAiD) represents a historic change in Canadian society and the provision of end-of-life care. In this descriptive narrative inquiry, 17 nurses were interviewed during the first 6 months of assisted dying becoming a legal option for patients in Canada. Nurses experiences of either providing care for a patient who had chosen MAiD, or declining to participate in MAiD, were explored. Findings describe three themes and eight storylines of the impact of MAiD on nurses view of the profession, clinical practice, and personally. While most nurses perceived MAiD as an extension of the profession and their nursing practice, a small number also expressed moral distress as they grappled with assisted dying. Narratives illustrated an ongoing sensemaking process and spectrum of emotions. These findings offer insight and provide direction for nurses and managers in this new clinical and legal reality. Further research is needed to understand more fully the moral distress of some nurses, as well as the importance of communicating openly and nonjudgmentally with patients, families, and the health-care team.","container-title":"Nursing Forum","DOI":"10.1111/nuf.12280","ISSN":"1744-6198","issue":"4","language":"en","license":" 2018 The Authors. Nursing Forum published by Wiley Periodicals, Inc.","page":"511-520","source":"Wiley Online Library","title":"Medical assistance in dying (MAiD): Canadian nurses experiences","title-short":"Medical assistance in dying (MAiD)","volume":"53","author":[{"family":"Beuthin","given":"Rosanne"},{"family":"Bruce","given":"Anne"},{"family":"Scaia","given":"Margaret"}],"issued":{"date-parts":[["2018"]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Beuthin et al., 2018). The nurses refused the debriefing session after witnessing the death as they described it as a very positive experience, with patients dying peacefully with family by their side. Nurses believed that patient was not satisfied, but death is what the patient wanted. However, there was also a case where they botched a good death. The information about bad death and how the nurses felt was missing in the study. The study recognised it as a bad death as the nurses used more negative language to describe the bad death event than describing the good death event, such as messed up and horrible (Beuthin et al., 2018, p. 5).

Social Worker

Social workers also play an important part in supporting patients throughout the AD process, especially when physicians and nurses are overwhelmed with their day-to-day responsibilities. There is a variety of research on social workers working alongside community nurses and social services to provide direct service to patients and members of the public. Although the widespread use of social workers, the roles of social workers play in palliative or assisted dying remain unclear in supporting health professionals and play in caring for patients ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"Ez6kQGM1","properties":{"formattedCitation":"(Herber & Johnston, 2013)","plainCitation":"(Herber & Johnston, 2013)","noteIndex":0},"citationItems":[{"id":366,"uris":["http://zotero.org/users/14650052/items/K72ZR8RX"],"itemData":{"id":366,"type":"article-journal","abstract":"Despite the widespread use of Health Care Support Workers (HCSWs) in providing palliative and end-of-life care, there is little information available about their contributions towards supporting patients who want to be cared for at home or to die at home. Between January and April 2011, a systematic review was conducted to address two questions: (i) What particular tasks/roles do HCSWs perform when caring for people at the end of life and their families to comply with their desire to remain at home?; (ii) What are the challenges and supporting factors that influence HCSWs ability to provide palliative and end-of-life care in the community? Databases searched for relevant articles published between 1990 until April 2011 included CINAHL, EMBASE, PsychINFO, British Nursing Index, Web of Science, Medline and ASSIA. In total, 1695 papers were identified and their titles and abstracts were read. Ten papers met the eligibility criteria of the study. After the methodological quality of the studies was appraised, nine papers were included in the review. Judgements regarding eligibility and quality were undertaken independently by the authors. The findings indicate that HCSWs invest a great deal of their time on emotional and social support as well as on assisting in the provision of personal care. They are also involved in providing care for the dying, respite care for family members and offer domestic support. Although it is important to acknowledge the many positive aspects that HCSWs provide, the findings suggest three challenges in the HCSWs role: emotional attachment, role ambiguity and inadequate training. Support factors such as informal peer grief-support groups, sense of cohesiveness among HCSWs and task orientation enabled HCSWs to overcome these challenges. To conclude, induction and training programmes, a defined period of preceptorship, appropriate support, supervision and clearly defined role boundaries may be helpful in reducing the challenges identified in HCSWs roles.","container-title":"Health & Social Care in the Community","DOI":"10.1111/j.1365-2524.2012.01092.x","ISSN":"1365-2524","issue":"3","language":"en","license":" 2012 Blackwell Publishing Ltd","note":"_eprint: https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1365-2524.2012.01092.x","page":"225-235","source":"Wiley Online Library","title":"The role of healthcare support workers in providing palliative and end-of-life care in the community: a systematic literature review","title-short":"The role of healthcare support workers in providing palliative and end-of-life care in the community","volume":"21","author":[{"family":"Herber","given":"Oliver R."},{"family":"Johnston","given":"Bridget M."}],"issued":{"date-parts":[["2013"]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Herber & Johnston, 2013) and often not clear or stated in the AD legislation (Norton & Miller, 2012), not to mention the emotional experience of social workers involved in AD. The role of ambiguity in end-of-life care can lead to emotional distress and a sense of incompetence ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"mjieMfao","properties":{"formattedCitation":"(Herber & Johnston, 2013)","plainCitation":"(Herber & Johnston, 2013)","noteIndex":0},"citationItems":[{"id":366,"uris":["http://zotero.org/users/14650052/items/K72ZR8RX"],"itemData":{"id":366,"type":"article-journal","abstract":"Despite the widespread use of Health Care Support Workers (HCSWs) in providing palliative and end-of-life care, there is little information available about their contributions towards supporting patients who want to be cared for at home or to die at home. Between January and April 2011, a systematic review was conducted to address two questions: (i) What particular tasks/roles do HCSWs perform when caring for people at the end of life and their families to comply with their desire to remain at home?; (ii) What are the challenges and supporting factors that influence HCSWs ability to provide palliative and end-of-life care in the community? Databases searched for relevant articles published between 1990 until April 2011 included CINAHL, EMBASE, PsychINFO, British Nursing Index, Web of Science, Medline and ASSIA. In total, 1695 papers were identified and their titles and abstracts were read. Ten papers met the eligibility criteria of the study. After the methodological quality of the studies was appraised, nine papers were included in the review. Judgements regarding eligibility and quality were undertaken independently by the authors. The findings indicate that HCSWs invest a great deal of their time on emotional and social support as well as on assisting in the provision of personal care. They are also involved in providing care for the dying, respite care for family members and offer domestic support. Although it is important to acknowledge the many positive aspects that HCSWs provide, the findings suggest three challenges in the HCSWs role: emotional attachment, role ambiguity and inadequate training. Support factors such as informal peer grief-support groups, sense of cohesiveness among HCSWs and task orientation enabled HCSWs to overcome these challenges. To conclude, induction and training programmes, a defined period of preceptorship, appropriate support, supervision and clearly defined role boundaries may be helpful in reducing the challenges identified in HCSWs roles.","container-title":"Health & Social Care in the Community","DOI":"10.1111/j.1365-2524.2012.01092.x","ISSN":"1365-2524","issue":"3","language":"en","license":" 2012 Blackwell Publishing Ltd","note":"_eprint: https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1365-2524.2012.01092.x","page":"225-235","source":"Wiley Online Library","title":"The role of healthcare support workers in providing palliative and end-of-life care in the community: a systematic literature review","title-short":"The role of healthcare support workers in providing palliative and end-of-life care in the community","volume":"21","author":[{"family":"Herber","given":"Oliver R."},{"family":"Johnston","given":"Bridget M."}],"issued":{"date-parts":[["2013"]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Herber & Johnston, 2013) and also linked to feelings of stress (Fleming & Taylor, 2006 as cited in Herber & Johnston, 2013) and is negatively related to satisfaction (Rizzo et al., 1970 as cited in Herber & Johnston, 2013).

However, social workers see their role in caring for patients and providing consultation and support to patients, and facilitating discussion to resolve internal conflict between a patients desire to utilise AD and a support person who is against it (Fujioka et al., 2018; Norton & Miller, 2012). Social workers who have been involved in AD reported to have positive experiences as they perceived it to be consistent with their professional values and they were mostly agree with the AD legislation and assist patient in seeking AD (Gaston et al., 2018). As part of the care team, social workers can not only help assess a patients ability to utilise AD, but they can also connect the patient with appropriate resources for that utilisation (Norton & Miller, 2012). Herber and Johnston (2013) researched on the role of social workers. These are the roles that they concluded after systematic review, which included addressing patients personal needs, offering emotional and social support like listening and talking to families when nurses were unreachable for families and other domestic tasks that were not articulated in their job description, like household cleaning duties, as they were unclear their role boundaries and collaborated with professional and family carers to provide essential information regarding the patients current condition ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"mxhydKdH","properties":{"formattedCitation":"(Herber & Johnston, 2013)","plainCitation":"(Herber & Johnston, 2013)","noteIndex":0},"citationItems":[{"id":366,"uris":["http://zotero.org/users/14650052/items/K72ZR8RX"],"itemData":{"id":366,"type":"article-journal","abstract":"Despite the widespread use of Health Care Support Workers (HCSWs) in providing palliative and end-of-life care, there is little information available about their contributions towards supporting patients who want to be cared for at home or to die at home. Between January and April 2011, a systematic review was conducted to address two questions: (i) What particular tasks/roles do HCSWs perform when caring for people at the end of life and their families to comply with their desire to remain at home?; (ii) What are the challenges and supporting factors that influence HCSWs ability to provide palliative and end-of-life care in the community? Databases searched for relevant articles published between 1990 until April 2011 included CINAHL, EMBASE, PsychINFO, British Nursing Index, Web of Science, Medline and ASSIA. In total, 1695 papers were identified and their titles and abstracts were read. Ten papers met the eligibility criteria of the study. After the methodological quality of the studies was appraised, nine papers were included in the review. Judgements regarding eligibility and quality were undertaken independently by the authors. The findings indicate that HCSWs invest a great deal of their time on emotional and social support as well as on assisting in the provision of personal care. They are also involved in providing care for the dying, respite care for family members and offer domestic support. Although it is important to acknowledge the many positive aspects that HCSWs provide, the findings suggest three challenges in the HCSWs role: emotional attachment, role ambiguity and inadequate training. Support factors such as informal peer grief-support groups, sense of cohesiveness among HCSWs and task orientation enabled HCSWs to overcome these challenges. To conclude, induction and training programmes, a defined period of preceptorship, appropriate support, supervision and clearly defined role boundaries may be helpful in reducing the challenges identified in HCSWs roles.","container-title":"Health & Social Care in the Community","DOI":"10.1111/j.1365-2524.2012.01092.x","ISSN":"1365-2524","issue":"3","language":"en","license":" 2012 Blackwell Publishing Ltd","note":"_eprint: https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1365-2524.2012.01092.x","page":"225-235","source":"Wiley Online Library","title":"The role of healthcare support workers in providing palliative and end-of-life care in the community: a systematic literature review","title-short":"The role of healthcare support workers in providing palliative and end-of-life care in the community","volume":"21","author":[{"family":"Herber","given":"Oliver R."},{"family":"Johnston","given":"Bridget M."}],"issued":{"date-parts":[["2013"]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Herber & Johnston, 2013).

Other professional groups

Other professional groups such as chaplains, mental health providers, and pharmacists also have a role in the AD process. Chaplains mainly provide emotional and spiritual support to patients (Carlson et al., 2015). Mental health providers could be involved through the assessment of eligibility and competency to consent to AD (Fujioka et al., 2018). They could also be responsible for providing consultation and support to patients and providers and aftercare to bereaved family members (Fujioka et al., 2018?). Pharmacists are responsible for dispensing AD lethal medications and may also be involved in providing regulatory oversight and consultation to providers regarding the dosage. Medical examiners help with AD reports and regulatory oversights. However, the emotional experience of these roles is unclear (Fujioka et al., 2018).

Experienced NPHPs

Besides that, studies have shown that NPHPs constantly working in challenging or critical environments or with extensive experience have a slightly different emotional perspective compared to those new their role, workplace and those working in regular units. Studies also mentioned that With increasing experience, and on seeing firsthand the benefits of assisted dying, some HCPs became more comfortable and gained clarity in their role ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"u0Bk4Izv","properties":{"formattedCitation":"(Denier et al., 2009, 2010; Dobscha et al., 2004)","plainCitation":"(Denier et al., 2009, 2010; Dobscha et al., 2004)","noteIndex":0},"citationItems":[{"id":84,"uris":["http://zotero.org/users/14650052/items/W2Y8PT7A"],"itemData":{"id":84,"type":"article-journal","abstract":"This study explored nurses' involvement in the care process for mentally competent, terminally ill patients requesting euthanasia in general hospitals in Flanders, Belgium. 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Hence, sufficient support for nurses to reach a well-balanced integration of both perspectives is essential.","container-title":"Journal of Palliative Care","ISSN":"0825-8597","issue":"4","journalAbbreviation":"J Palliat Care","language":"eng","note":"PMID: 20131583","page":"264-274","source":"PubMed","title":"Involvement of nurses in the euthanasia care process in Flanders (Belgium): an exploration of two perspectives","title-short":"Involvement of nurses in the euthanasia care process in Flanders (Belgium)","volume":"25","author":[{"family":"Denier","given":"Yvonne"},{"family":"Dierckx de Casterl","given":"Bernadette"},{"family":"De Bal","given":"Nele"},{"family":"Gastmans","given":"Chris"}],"issued":{"date-parts":[["2009"]]}}},{"id":57,"uris":["http://zotero.org/users/14650052/items/SE2PXS34"],"itemData":{"id":57,"type":"article-journal","abstract":"The Belgian Act on Euthanasia came into force on 23 September 2002, making Belgium the second countryafter the Netherlandsto decriminalize euthanasia under certain due-care conditions. Since then, Belgian nurses have been increasingly involved in euthanasia care. In this paper, we report a qualitative study based on in-depth interviews with 18 nurses from Flanders (the Dutch-speaking part of Belgium) who have had experience in caring for patients requesting euthanasia since May 2002 (the approval of the Act). We found that the care process for patients requesting euthanasia is a complex and dynamic process, consisting of several stages, starting from the period preceding the euthanasia request and ending with the aftercare stage. When asked after the way in which they experience their involvement in the euthanasia care process, all nurses described it as a grave and difficult process, not only on an organizational and practical level, but also on an emotional level. Intense is the dominant feeling experienced by nurses. This is compounded by the presence of other feelings such as great concern and responsibility on the one hand, being content in truly helping the patient to die serenely, and doing everything in ones power to contribute to this; but also feeling unreal and ambivalent on the other hand, because death is arranged. Nurses feel a discrepancy, because although it is a nice death, which happens in dignity and with respect, it is also an unnatural death. The clinical ethical implications of these findings are discussed.","container-title":"Medicine, Health Care and Philosophy","DOI":"10.1007/s11019-009-9203-1","ISSN":"1572-8633","issue":"1","journalAbbreviation":"Med Health Care and Philos","language":"en","page":"41-48","source":"Springer Link","title":"Its intense, you know. Nurses experiences in caring for patients requesting euthanasia","volume":"13","author":[{"family":"Denier","given":"Yvonne"},{"family":"Dierckx de Casterl","given":"Bernadette"},{"family":"De Bal","given":"Nele"},{"family":"Gastmans","given":"Chris"}],"issued":{"date-parts":[["2010",2,1]]}}},{"id":85,"uris":["http://zotero.org/users/14650052/items/5ZEB2RIL"],"itemData":{"id":85,"type":"article-journal","issue":"3","journalAbbreviation":"Journal of palliative medicine","page":"451-461","title":"Oregon physicians' responses to requests for assisted suicide: A qualitative study","volume":"7","author":[{"family":"Dobscha","given":"Steven"},{"family":"Heintz","given":"Ronald"},{"family":"Press","given":"Nancy"},{"family":"Ganzini","given":"Linda"}],"issued":{"date-parts":[["2004"]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Denier et al., 2009, 2010; Dobscha et al., 2004). Studies on nurses with low AD experience, experienced regular unit nurses, intensive care and hospice care nurses have noted that as these nurses gain experience, they become more comfortable with AD requests ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"MqUeeqgO","properties":{"formattedCitation":"(De Bal et al., 2006; Denier et al., 2010; Freeman et al., 2021)","plainCitation":"(De Bal et al., 2006; Denier et al., 2010; Freeman et al., 2021)","noteIndex":0},"citationItems":[{"id":83,"uris":["http://zotero.org/users/14650052/items/JAVNFGHG",["http://zotero.org/users/14650052/items/JAVNFGHG"]],"itemData":{"id":83,"type":"article-journal","abstract":"BackgroundnAlthough nurses worldwide are confronted with euthanasia requests, how nurses experience their involvement in euthanasia remains unclear.nObjectivesnTo explore nurses involvement in the care for patients requesting euthanasia.nDesignnA qualitative grounded theory strategy.nSettingnTwo general hospitals (A, B) and a palliative care setting in Flanders (Belgium).nParticipantsnNurses who fulfilled the following inclusion criteria: (a) Dutch-speaking; (b) working for at least one year in hospital A or B; (c) working at least part-time (50%); and (d) ever received a euthanasia request. We collected data using purposeful sampling, superseded by theoretical sampling in a palliative care setting. The sample included one intensive care nurse, one oncology nurse, eight palliative care nurses, and five internal medicine nurses. All but five were women. Their age ranged from 24 to 49 years.nMethodsnWe conducted one-on-one semi-structured interviews between November 2001 and September 2002. Grounded theory was applied for guiding data collection and analysis. The trustworthiness of data was ensured by several strategies.nResultsnAlthough euthanasia was still illegal, the nurses unanimously stated that they had an important role in caring for patients requesting euthanasia. Their personal and intense involvement caused them to experience a spectrum of emotions, chief among them being a sense of powerlessness. Several elements contributed to the nurses conflicted involvement. Nurses became frustrated if the context (e.g., lack of time) hindered their efforts to provide compassionate care. The palliative care setting and its associated culture (group mentality, care philosophy) created the opportunity for nurses to take time to holistically support patients and their relatives.nConclusionsnHospital nurses are confronted with patients euthanasia requests. Each stage of this process requires that the nurses possess specific competencies. Their willingness to personally care for these patients, in addition to their specific care expertise, allows them to be skilled companions.","container-title":"International Journal of Nursing Studies","DOI":"10.1016/j.ijnurstu.2005.08.003","ISSN":"0020-7489","issue":"5","journalAbbreviation":"International Journal of Nursing Studies","page":"589-599","source":"ScienceDirect","title":"Involvement of nurses in caring for patients requesting euthanasia in Flanders (Belgium): A qualitative study","title-short":"Involvement of nurses in caring for patients requesting euthanasia in Flanders (Belgium)","volume":"43","author":[{"family":"De Bal","given":"Nele"},{"family":"Dierckx de Casterl","given":"Bernadette"},{"family":"Beer","given":"Tina De"},{"family":"Gastmans","given":"Chris"}],"issued":{"date-parts":[["2006",7,1]]}}},{"id":57,"uris":["http://zotero.org/users/14650052/items/SE2PXS34"],"itemData":{"id":57,"type":"article-journal","abstract":"The Belgian Act on Euthanasia came into force on 23 September 2002, making Belgium the second countryafter the Netherlandsto decriminalize euthanasia under certain due-care conditions. Since then, Belgian nurses have been increasingly involved in euthanasia care. In this paper, we report a qualitative study based on in-depth interviews with 18 nurses from Flanders (the Dutch-speaking part of Belgium) who have had experience in caring for patients requesting euthanasia since May 2002 (the approval of the Act). We found that the care process for patients requesting euthanasia is a complex and dynamic process, consisting of several stages, starting from the period preceding the euthanasia request and ending with the aftercare stage. When asked after the way in which they experience their involvement in the euthanasia care process, all nurses described it as a grave and difficult process, not only on an organizational and practical level, but also on an emotional level. Intense is the dominant feeling experienced by nurses. This is compounded by the presence of other feelings such as great concern and responsibility on the one hand, being content in truly helping the patient to die serenely, and doing everything in ones power to contribute to this; but also feeling unreal and ambivalent on the other hand, because death is arranged. Nurses feel a discrepancy, because although it is a nice death, which happens in dignity and with respect, it is also an unnatural death. The clinical ethical implications of these findings are discussed.","container-title":"Medicine, Health Care and Philosophy","DOI":"10.1007/s11019-009-9203-1","ISSN":"1572-8633","issue":"1","journalAbbreviation":"Med Health Care and Philos","language":"en","page":"41-48","source":"Springer Link","title":"Its intense, you know. Nurses experiences in caring for patients requesting euthanasia","volume":"13","author":[{"family":"Denier","given":"Yvonne"},{"family":"Dierckx de Casterl","given":"Bernadette"},{"family":"De Bal","given":"Nele"},{"family":"Gastmans","given":"Chris"}],"issued":{"date-parts":[["2010",2,1]]}}},{"id":75,"uris":["http://zotero.org/users/14650052/items/W4WMA66N"],"itemData":{"id":75,"type":"article-journal","abstract":"Rapid implementation of Medical Assistance in Dying (MAiD) across care settings has challenged providers and organizations, including hospices, to develop and implement new modes of practice. The aim of this study was to examine the effects that legalization of MAiD has had on hospice care provider roles within the non-provider context.","container-title":"BMC Palliative Care","DOI":"10.1186/s12904-021-00740-3","ISSN":"1472-684X","issue":"1","journalAbbreviation":"BMC Palliative Care","page":"55","source":"BioMed Central","title":"Hospice care providers experiences of grappling with medical assistance in dying in a hospice setting: a qualitative descriptive study","title-short":"Hospice care providers experiences of grappling with medical assistance in dying in a hospice setting","volume":"20","author":[{"family":"Freeman","given":"Shannon"},{"family":"Banner","given":"Davina"},{"family":"Ward","given":"Valerie"}],"issued":{"date-parts":[["2021",4,12]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (De Bal et al., 2006; Denier et al., 2010; Freeman et al., 2021). These NPHPs experience a variety of emotions initially feeling insecure and fearful of dealing with AD requests (Denier et al., 2010), feeling surprised and shocked when approached for AD-related discussion (De Bal et al., 2006) to the stage where they treated the request of AD as more of a routine (De Bal et al., 2006; Denier et al., 2010). Palliative care nurses who often deal with dying patients report less difficulty and less intense emotion compared to those nurses working in regular units (De Bal et al., 2006).

There are several reasons for these NPHPs experiencing less intense emotion. The first reason for this gradual improvement attributed to emotional readiness as they become more familiar and more prepared to manage patients awaiting procedures like AD (De Bal et al., 2006; Denier et al., 2010). Second reason is that palliative care nurses care for dying patients daily, they are experts in pain and symptom control as well as in communication (De Bal et al., 2006). They demonstrate improvement due to having better coping mechanisms and skills as compared to less experienced and regular unit nurses ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"qnvoqyne","properties":{"formattedCitation":"(De Bal et al., 2006)","plainCitation":"(De Bal et al., 2006)","noteIndex":0},"citationItems":[{"id":83,"uris":["http://zotero.org/users/14650052/items/JAVNFGHG",["http://zotero.org/users/14650052/items/JAVNFGHG"]],"itemData":{"id":83,"type":"article-journal","abstract":"BackgroundnAlthough nurses worldwide are confronted with euthanasia requests, how nurses experience their involvement in euthanasia remains unclear.nObjectivesnTo explore nurses involvement in the care for patients requesting euthanasia.nDesignnA qualitative grounded theory strategy.nSettingnTwo general hospitals (A, B) and a palliative care setting in Flanders (Belgium).nParticipantsnNurses who fulfilled the following inclusion criteria: (a) Dutch-speaking; (b) working for at least one year in hospital A or B; (c) working at least part-time (50%); and (d) ever received a euthanasia request. We collected data using purposeful sampling, superseded by theoretical sampling in a palliative care setting. The sample included one intensive care nurse, one oncology nurse, eight palliative care nurses, and five internal medicine nurses. All but five were women. Their age ranged from 24 to 49 years.nMethodsnWe conducted one-on-one semi-structured interviews between November 2001 and September 2002. Grounded theory was applied for guiding data collection and analysis. The trustworthiness of data was ensured by several strategies.nResultsnAlthough euthanasia was still illegal, the nurses unanimously stated that they had an important role in caring for patients requesting euthanasia. Their personal and intense involvement caused them to experience a spectrum of emotions, chief among them being a sense of powerlessness. Several elements contributed to the nurses conflicted involvement. Nurses became frustrated if the context (e.g., lack of time) hindered their efforts to provide compassionate care. The palliative care setting and its associated culture (group mentality, care philosophy) created the opportunity for nurses to take time to holistically support patients and their relatives.nConclusionsnHospital nurses are confronted with patients euthanasia requests. Each stage of this process requires that the nurses possess specific competencies. Their willingness to personally care for these patients, in addition to their specific care expertise, allows them to be skilled companions.","container-title":"International Journal of Nursing Studies","DOI":"10.1016/j.ijnurstu.2005.08.003","ISSN":"0020-7489","issue":"5","journalAbbreviation":"International Journal of Nursing Studies","page":"589-599","source":"ScienceDirect","title":"Involvement of nurses in caring for patients requesting euthanasia in Flanders (Belgium): A qualitative study","title-short":"Involvement of nurses in caring for patients requesting euthanasia in Flanders (Belgium)","volume":"43","author":[{"family":"De Bal","given":"Nele"},{"family":"Dierckx de Casterl","given":"Bernadette"},{"family":"Beer","given":"Tina De"},{"family":"Gastmans","given":"Chris"}],"issued":{"date-parts":[["2006",7,1]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (De Bal et al., 2006). Last reason is related to the supportive culture and environment of the workplace team, and the willingness to allocate time and resources to provide comprehensive support to patients and families (De Bal et al., 2006). This point about support leads nicely to the next section that address the availability of well-being support, which influences their emotional experience.

Availability of (well-being) support

(this part contains info mostly about the current support system, NPHPs views on this support system and the influence of lacking support)

When engaging in AD services, clear policy, supervision or peer-support and communication training, and supporting resources can provide required knowledge to NPHPs when undertaking the steps of AD ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"u5PQFkRJ","properties":{"formattedCitation":"(Snelling et al., 2023)","plainCitation":"(Snelling et al., 2023)","noteIndex":0},"citationItems":[{"id":97,"uris":["http://zotero.org/users/14650052/items/6RW5BWH5"],"itemData":{"id":97,"type":"article-journal","abstract":"In November 2021, assisted dying (AD) became lawful in Aotearoa New Zealand. A terminally ill person may now request, and receive, pharmacological assistance (self-administered or provided by a medical practitioner/nurse practitioner) to end their life, subject to specific legal criteria and processes. Exploring the experiences of health providers in the initial stage of the implementation of the End of Life Choice Act 2019 is vital to inform the ongoing development of safe and effective AD practice, policy and law.","container-title":"BMC Palliative Care","DOI":"10.1186/s12904-023-01222-4","ISSN":"1472-684X","issue":"1","journalAbbreviation":"BMC Palliative Care","page":"101","source":"BioMed Central","title":"Health care providers early experiences of assisted dying in Aotearoa New Zealand: an evolving clinical service","title-short":"Health care providers early experiences of assisted dying in Aotearoa New Zealand","volume":"22","author":[{"family":"Snelling","given":"Jeanne"},{"family":"Young","given":"Jessica"},{"family":"Beaumont","given":"Sophie"},{"family":"Diesfeld","given":"Kate"},{"family":"White","given":"Ben"},{"family":"Willmott","given":"Lindy"},{"family":"Robinson","given":"Jacqualine"},{"family":"Moeke-Maxwell","given":"Tess"}],"issued":{"date-parts":[["2023",7,22]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Snelling et al., 2023). The structured psychosocial support for healthcare providers, no matter involved in AD or hospice care setting, is lacking despite the need for adequate support for these professionals ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"E9ODNTvb","properties":{"formattedCitation":"(Antonacci et al., 2021; Bravo et al., 2023; Elmore et al., 2018; Sandham et al., 2022)","plainCitation":"(Antonacci et al., 2021; Bravo et al., 2023; Elmore et al., 2018; Sandham et al., 2022)","noteIndex":0},"citationItems":[{"id":74,"uris":["http://zotero.org/users/14650052/items/8VXWF4BJ"],"itemData":{"id":74,"type":"article-journal","abstract":"Background:With the legalization of medical assistance in dying (MAiD) in Canada, physicians and nurse practitioners now have another option within their scope of practice to consider alongside hospice palliative care (HPC) to support the patient and family regardless of their choice toward natural or medically assisted death. To elucidate insights and experiences with MAiD since its inception and to help adjust to this new end-of-life care environment, the membership of the Canadian Hospice Palliative Care Association (CHPCA) was surveyed.Methods:The CHPCA developed and distributed a 16-item survey to its membership in June 2017, one year following the legalization of MAiD. Data were arranged in Microsoft Excel and open-ended responses were analyzed thematically using NVivo 12 software.Results:From across Canada, 452 responses were received (response rate: 15%). The majority of individuals worked as nurses (n = 161, 33%), administrators (n = 79, 16%), volunteers (n = 76, 16%) and physicians (n = 56, 11%). Almost 75% (n = 320) of all respondents indicated that they had experienced a patient in their program who had requested MAiD. Participants expressed dissatisfaction with the current psychological and professional support being provided by their health care organization and Ministry of Health - during and after the MAiD procedure.Conclusion:The new complexities of MAiD present unique challenges to those working in the health-care field. There needs to be an increased focus on educating/training providers as without proper support, health-care workers will be unable to perform to their full potential/scope of practice while also providing patients with holistic and accessible care.","container-title":"Journal of Palliative Care","DOI":"10.1177/0825859719865548","ISSN":"0825-8597","issue":"3","journalAbbreviation":"J Palliat Care","language":"en","page":"151-156","source":"SAGE Journals","title":"Hospice Palliative Care (HPC) and Medical Assistance in Dying (MAiD): Results From a Canada-Wide Survey","title-short":"Hospice Palliative Care (HPC) and Medical Assistance in Dying (MAiD)","volume":"36","author":[{"family":"Antonacci","given":"Rebecca"},{"family":"Baxter","given":"Sharon"},{"family":"Henderson","given":"J. David"},{"family":"Mirza","given":"Raza M."},{"family":"Klinger","given":"Christopher A."}],"issued":{"date-parts":[["2021",7,1]]}}},{"id":60,"uris":["http://zotero.org/users/14650052/items/NWNTKLXF"],"itemData":{"id":60,"type":"article-journal","abstract":"As part of a larger survey, we asked social workers whether they had been involved in medical assistance in dying (MAID) so far. Of the 367 survey participants, 141 reported that they had. These were invited to describe their roles, needs, and sense of competence, focusing on their last MAID experience. Roles were diversified, beginning before and extending beyond the provision of MAID. Nearly 60% needed training on MAID. Perceived competence was lower among those lacking training. Findings point to educational needs that must be addressed to ensure the quality of end-of-life care and the well-being of social workers who engage in MAID.","container-title":"Social Work in Health Care","DOI":"10.1080/00981389.2023.2210624","ISSN":"0098-1389","issue":"5","note":"PMID: 37183409","page":"193205","source":"Taylor and Francis+NEJM","title":"Social workers experiences with medical assistance in dying: Survey findings from Quebec, Canada","title-short":"Social workers experiences with medical assistance in dying","volume":"62","author":[{"family":"Bravo","given":"Gina"},{"family":"Delli Colli","given":"Nathalie"},{"family":"Dumont","given":"Isabelle"},{"family":"Bouthillier","given":"Marie-Eve"},{"family":"Rochette","given":"Marianne"},{"family":"Trottier","given":"Lise"}],"issued":{"date-parts":[["2023",5,28]]}}},{"id":86,"uris":["http://zotero.org/users/14650052/items/99D8KMWQ"],"itemData":{"id":86,"type":"article-journal","abstract":"Background: Legislative changes are resulting in assisted death as an option for people at the end of life. Although nurses experiences and perspectives are underrepresented within broader ethical discourses about assisted death, there is a small but significant body of literature examining nurses experiences of caring for people who request this option.nAim: To synthesize what has been learned about nurses experiences of caring for patients who request assisted death and to highlight what is morally at stake for nurses who undertake this type of care.nDesign: Qualitative meta-synthesis.nMethods: Six databases were searched: CINAHL, Medline, EMBASE, Joanna Briggs Institute, PsycINFO, and Web of Science. The search was completed on 22 October 2014 and updated in February 2016. Of 879 articles identified from the database searches, 16 articles were deemed relevant based on inclusion criteria. Following quality appraisal, 14 studies were retained for analysis and synthesis.nResults: The moral experience of the nurse is (1) defined by a profound sense of responsibility, (2) shaped by contextual forces that nurses navigate in everyday end-of-life care practice, and (3) sustained by intra-team moral and emotional support.nDiscussion: The findings of this synthesis support the view that nurses are moral agents who are deeply invested in the moral integrity of end-of-life care involving assisted death. The findings further demonstrate that to fully appreciate the ethics of assisted death from a nursing standpoint, it is necessary to understand the broader constraints on nurses moral agency that operate in everyday end-of-life care.nEthical considerations: Research ethics board approval was not required for this synthesis of previously published literature.nConclusion: In order to understand how to enact ethical practice in the area of assisted death, the moral experiences of nurses should be investigated and foregrounded.","container-title":"Nursing Ethics","DOI":"10.1177/0969733016679468","ISSN":"0969-7330","issue":"8","journalAbbreviation":"Nurs Ethics","language":"en","page":"955-972","source":"SAGE Journals","title":"Nurses moral experiences of assisted death: A meta-synthesis of qualitative research","title-short":"Nurses moral experiences of assisted death","volume":"25","author":[{"family":"Elmore","given":"James"},{"family":"Wright","given":"David Kenneth"},{"family":"Paradis","given":"Maude"}],"issued":{"date-parts":[["2018",12,1]]}}},{"id":271,"uris":["http://zotero.org/users/14650052/items/R7E2YAHS"],"itemData":{"id":271,"type":"article-journal","abstract":"Aim Describe the reported lived experiences of nurses who have participated at any stage of voluntary assisted dying (VAD), from the initial request to the end of life. Design A qualitative meta-synthesis. Data sources Databases searched were CINAHL, MEDLINE, Emcare, Scopus and PsycInfo. The search was undertaken in September 2021 with no date limitations. Qualitative studies were considered if published in English, reported primary data analysis of nurses' experiences who had been involved in VAD and reported direct quotes from nurses. Review methods Qualitative studies meeting the selection criteria were critically appraised, then an open card-sort method was applied. Quotes from nurses were organized to group similar experiences, constructing themes and metaphors across studies as a new understanding of nurses' experiences of VAD. Results Eight studies were included. Three major themes were constructed: An orderly procedure, reflecting the need for structure to feel adequately prepared; A beautiful death, reflecting the autonomy the patient exercised when choosing VAD facilitated an exceptionally positive death; and Psychological and emotional impact, where nurses recognized the emotional and ethical weight that they carried for themselves and the team when undertaking VAD. Conclusion Nurses may benefit from clear policy, supervision and communication training to support them as countries transition to providing VAD services. Policy provides nurses with confidence that they are undertaking the steps of VAD correctly and provides a layer of emotional protection. Communication training specific to VAD is necessary to prepare nurses to recognize their own emotional experiences when responding to the needs of the patient and their family. Impact VAD is increasingly becoming a legal option that nurses are encountering in their professional practice. Understanding nurses' experiences of being involved in VAD is required to support nurses in countries where VAD is becoming available to prepare professionally and psychologically.","container-title":"Journal of Advanced Nursing","DOI":"10.1111/jan.15324","ISSN":"1365-2648","issue":"10","language":"en","license":" 2022 The Authors. Journal of Advanced Nursing published by John Wiley & Sons Ltd.","note":"_eprint: https://onlinelibrary.wiley.com/doi/pdf/10.1111/jan.15324","page":"3101-3115","source":"Wiley Online Library","title":"Nurses' experiences of supporting patients requesting voluntary assisted dying: A qualitative meta-synthesis","title-short":"Nurses' experiences of supporting patients requesting voluntary assisted dying","volume":"78","author":[{"family":"Sandham","given":"Margaret"},{"family":"Carey","given":"Melissa"},{"family":"Hedgecock","given":"Emma"},{"family":"Jarden","given":"Rebecca"}],"issued":{"date-parts":[["2022"]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Antonacci et al., 2021; Bravo et al., 2023; Elmore et al., 2018; Sandham et al., 2022).

Research with junior doctors faces unique ethical challenges involving AD. Their ethical issues are due to their dependence on senior colleagues for career progression. The study claimed that there is a need for strong institutional support and policies to protect junior doctor who wish to exercise right to conscientious objection from ethical dilemmas and compromising their career ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"0oEpbNpO","properties":{"formattedCitation":"(McDougall et al., 2022)","plainCitation":"(McDougall et al., 2022)","noteIndex":0},"citationItems":[{"id":325,"uris":["http://zotero.org/users/14650052/items/CQL4R2PB"],"itemData":{"id":325,"type":"article-journal","abstract":"In jurisdictions where voluntary assisted dying (VAD) is legal, eligibility assessments, prescription and administration of a VAD substance are commonly performed by senior doctors. Junior doctors involvement is limited to a range of more peripheral aspects of patient care relating to VAD. In the Australian state of Victoria, where VAD has been legal since June 2019, all health professionals have a right under the legislation to conscientiously object to involvement in the VAD process, including provision of information about VAD. While this protection appears categorical and straightforward, conscientious objection to VAD-related care is ethically complex for junior doctors for reasons that are specific to this group of clinicians. For junior doctors wishing to exercise a conscientious objection to VAD, their dependence on their senior colleagues for career progression creates unique risks and burdens. In a context where senior colleagues are supportive of VAD, the junior doctors subordinate position in the medical hierarchy exposes them to potential significant harms: compromising their moral integrity by participating, or compromising their career progression by objecting. In jurisdictions intending to provide all health professionals with meaningful conscientious objection protection in relation to VAD, strong specific support for junior doctors is needed through local institutional policies and culture.","container-title":"Journal of Medical Ethics","DOI":"10.1136/medethics-2020-107125","ISSN":"0306-6800, 1473-4257","issue":"8","language":"en","license":" Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.. http://creativecommons.org/licenses/by-nc/4.0/This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.","note":"publisher: Institute of Medical Ethicsnsection: Original researchnPMID: 34127526","page":"517-521","source":"jme.bmj.com","title":"Junior doctors and conscientious objection to voluntary assisted dying: ethical complexity in practice","title-short":"Junior doctors and conscientious objection to voluntary assisted dying","volume":"48","author":[{"family":"McDougall","given":"Rosalind J."},{"family":"White","given":"Ben P."},{"family":"Ko","given":"Danielle"},{"family":"Keogh","given":"Louise"},{"family":"Willmott","given":"Lindy"}],"issued":{"date-parts":[["2022",8,1]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (McDougall et al., 2022). Physicians generally lack formal training on how to handle AD requests and often prefer to avoid addressing them ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"VSZCo0vj","properties":{"formattedCitation":"(Gamondi et al., 2019; Otte et al., 2017)","plainCitation":"(Gamondi et al., 2019; Otte et al., 2017)","noteIndex":0},"citationItems":[{"id":348,"uris":["http://zotero.org/users/14650052/items/MFRW26LZ"],"itemData":{"id":348,"type":"article-journal","abstract":"ObjectivesnAssisted suicide in Switzerland is mainly performed by right-to-die societies. Medical involvement is limited to the prescription of the drug and certification of eligibility. Palliative care has traditionally been perceived as generally opposed to assisted suicide, but little is known about palliative care physicians involvement in assisted suicide practices. This paper aims to describe their perspectives and involvement in assisted suicide practices.nMethodsnA qualitative interview study was conducted with 23 palliative care physicians across Switzerland. Thematic analysis was used to interpret data.nResultsnSwiss palliative care physicians regularly receive assisted suicide requests while none reported having received specific training in managing these requests. Participants reported being involved in assisted suicide decision making most were not willing to prescribe the lethal drug. After advising patients of the limits on their involvement in assisted suicide, the majority explored the origins of the patients request and offered alternatives. Many participants struggled to reconcile their understanding of palliative care principles with patients wishes to exercise their autonomy. The majority of participants had no direct contact with right-to-die societies, many desired better collaboration. A desire was voiced for a more structured debate on assisted suicide availability in hospitals and clearer legal and institutional frameworks.nConclusionsnThe Swiss model of assisted suicide gives palliative care physicians opportunities to develop roles which are compatible with each practitioners values, but may not correspond to patients expectations. Specific education for all palliative care professionals and more structured ways to manage communication about assisted suicide are warranted.","container-title":"BMJ Supportive & Palliative Care","DOI":"10.1136/bmjspcare-2016-001291","ISSN":"2045435X","issue":"1","language":"English","license":" 2019 Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2019. All rights reserved. No commercial use is permitted unless otherwise expressly granted.","note":"number-of-pages: e7npublisher-place: London, United Kingdomnpublisher: BMJ Publishing Group LTDnsection: Research","page":"e7","source":"ProQuest","title":"Responses to assisted suicide requests: an interview study with Swiss palliative care physicians","title-short":"Responses to assisted suicide requests","volume":"9","author":[{"family":"Gamondi","given":"Claudia"},{"family":"Borasio","given":"Gian Domenico"},{"family":"Oliver","given":"Pam"},{"family":"Preston","given":"Nancy"},{"family":"Payne","given":"Sheila"}],"issued":{"date-parts":[["2019",3]]}},"label":"page"},{"id":350,"uris":["http://zotero.org/users/14650052/items/R7VUAM9C"],"itemData":{"id":350,"type":"article-journal","abstract":"GPs usually care for their patients for annextended period of time, therefore, requests to not onlyndiscontinue a patient's treatment but to assist a patient in ansuicide are likely to create intensely stressful situations fornphysicians. However, in order to ensure the best patientncare possible, the competent communication about thenoption of physician assisted suicide (PAS) as well as thenassessment of the origin and sincerity of the request arenvery important. This is especially true, since patients'nrequests for PAS can also be an indicator for unmet needsnor concerns. Twenty-three qualitative semi-structuredninterviews were conducted to in-depth explore this multifaceted, complex topic while enabling GPs to expressnpossible difficulties when being asked for assistance. Thenanalysis of the gathered data shows three main themes whynGPs may find it difficult to professionally communicatenabout PAS: concerns for their own psychological wellbeing, conflicting personal values or their understanding ofntheir professional role. In the discussion part of this papernwe re-assess these different themes in order to ethicallyndiscuss and analyse how potential barriers to professionalncommunication concerning PAS could be overcome.","DOI":"10.1007/s11019-016-9744-z","journalAbbreviation":"Med Health Care and Philos","page":"249-256","title":"We need to talk! Barriers to GPs communication about the option of physician-assisted suicide and their ethical implications: results from a qualitative study.","volume":"20","author":[{"family":"Otte","given":"Ina","suffix":"C"},{"family":"Jung","given":"C"},{"family":"Elger","given":"Bernice"},{"family":"Bally","given":"Klaus"}],"issued":{"date-parts":[["2017"]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Gamondi et al., 2019; Otte et al., 2017). This gap in training and the absence of clear guidelines contribute to their discomfort in managing AD requests and raise concerns about how these requests are handled within the patient-physician relationship. They also reported a lack of clearly defined roles in AD for Swiss physicians who worked in a palliative care setting ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"g7i2ozkH","properties":{"formattedCitation":"(Gamondi et al., 2019)","plainCitation":"(Gamondi et al., 2019)","noteIndex":0},"citationItems":[{"id":348,"uris":["http://zotero.org/users/14650052/items/MFRW26LZ"],"itemData":{"id":348,"type":"article-journal","abstract":"ObjectivesnAssisted suicide in Switzerland is mainly performed by right-to-die societies. Medical involvement is limited to the prescription of the drug and certification of eligibility. Palliative care has traditionally been perceived as generally opposed to assisted suicide, but little is known about palliative care physicians involvement in assisted suicide practices. This paper aims to describe their perspectives and involvement in assisted suicide practices.nMethodsnA qualitative interview study was conducted with 23 palliative care physicians across Switzerland. Thematic analysis was used to interpret data.nResultsnSwiss palliative care physicians regularly receive assisted suicide requests while none reported having received specific training in managing these requests. Participants reported being involved in assisted suicide decision making most were not willing to prescribe the lethal drug. After advising patients of the limits on their involvement in assisted suicide, the majority explored the origins of the patients request and offered alternatives. Many participants struggled to reconcile their understanding of palliative care principles with patients wishes to exercise their autonomy. The majority of participants had no direct contact with right-to-die societies, many desired better collaboration. A desire was voiced for a more structured debate on assisted suicide availability in hospitals and clearer legal and institutional frameworks.nConclusionsnThe Swiss model of assisted suicide gives palliative care physicians opportunities to develop roles which are compatible with each practitioners values, but may not correspond to patients expectations. Specific education for all palliative care professionals and more structured ways to manage communication about assisted suicide are warranted.","container-title":"BMJ Supportive & Palliative Care","DOI":"10.1136/bmjspcare-2016-001291","ISSN":"2045435X","issue":"1","language":"English","license":" 2019 Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2019. All rights reserved. No commercial use is permitted unless otherwise expressly granted.","note":"number-of-pages: e7npublisher-place: London, United Kingdomnpublisher: BMJ Publishing Group LTDnsection: Research","page":"e7","source":"ProQuest","title":"Responses to assisted suicide requests: an interview study with Swiss palliative care physicians","title-short":"Responses to assisted suicide requests","volume":"9","author":[{"family":"Gamondi","given":"Claudia"},{"family":"Borasio","given":"Gian Domenico"},{"family":"Oliver","given":"Pam"},{"family":"Preston","given":"Nancy"},{"family":"Payne","given":"Sheila"}],"issued":{"date-parts":[["2019",3]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Gamondi et al., 2019). Their responses seemed to be largely shaped by personal or professional values and their experiences of AD. Their typical reaction was to discuss alternatives to AD while declining to prescribe the lethal drug. The physicians ambiguous role can result in ethical dilemmas. Although they believe in patient autonomy, many participants struggled to reconcile their understanding of palliative care principles with patients desire for autonomy and AD ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"BGBwEZvj","properties":{"formattedCitation":"(Gamondi et al., 2019)","plainCitation":"(Gamondi et al., 2019)","noteIndex":0},"citationItems":[{"id":348,"uris":["http://zotero.org/users/14650052/items/MFRW26LZ"],"itemData":{"id":348,"type":"article-journal","abstract":"ObjectivesnAssisted suicide in Switzerland is mainly performed by right-to-die societies. Medical involvement is limited to the prescription of the drug and certification of eligibility. Palliative care has traditionally been perceived as generally opposed to assisted suicide, but little is known about palliative care physicians involvement in assisted suicide practices. This paper aims to describe their perspectives and involvement in assisted suicide practices.nMethodsnA qualitative interview study was conducted with 23 palliative care physicians across Switzerland. Thematic analysis was used to interpret data.nResultsnSwiss palliative care physicians regularly receive assisted suicide requests while none reported having received specific training in managing these requests. Participants reported being involved in assisted suicide decision making most were not willing to prescribe the lethal drug. After advising patients of the limits on their involvement in assisted suicide, the majority explored the origins of the patients request and offered alternatives. Many participants struggled to reconcile their understanding of palliative care principles with patients wishes to exercise their autonomy. The majority of participants had no direct contact with right-to-die societies, many desired better collaboration. A desire was voiced for a more structured debate on assisted suicide availability in hospitals and clearer legal and institutional frameworks.nConclusionsnThe Swiss model of assisted suicide gives palliative care physicians opportunities to develop roles which are compatible with each practitioners values, but may not correspond to patients expectations. Specific education for all palliative care professionals and more structured ways to manage communication about assisted suicide are warranted.","container-title":"BMJ Supportive & Palliative Care","DOI":"10.1136/bmjspcare-2016-001291","ISSN":"2045435X","issue":"1","language":"English","license":" 2019 Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2019. All rights reserved. No commercial use is permitted unless otherwise expressly granted.","note":"number-of-pages: e7npublisher-place: London, United Kingdomnpublisher: BMJ Publishing Group LTDnsection: Research","page":"e7","source":"ProQuest","title":"Responses to assisted suicide requests: an interview study with Swiss palliative care physicians","title-short":"Responses to assisted suicide requests","volume":"9","author":[{"family":"Gamondi","given":"Claudia"},{"family":"Borasio","given":"Gian Domenico"},{"family":"Oliver","given":"Pam"},{"family":"Preston","given":"Nancy"},{"family":"Payne","given":"Sheila"}],"issued":{"date-parts":[["2019",3]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Gamondi et al., 2019). Thus, the existing support and policies are not clear, leaving physicians feeling ambiguous.

The nurses reflected their heavy emotions when engaging in discussion about AD, the care of the patient going through the AD process and the support of their family members ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"FOFVEzpp","properties":{"formattedCitation":"(Sandham et al., 2022)","plainCitation":"(Sandham et al., 2022)","noteIndex":0},"citationItems":[{"id":271,"uris":["http://zotero.org/users/14650052/items/R7E2YAHS"],"itemData":{"id":271,"type":"article-journal","abstract":"Aim Describe the reported lived experiences of nurses who have participated at any stage of voluntary assisted dying (VAD), from the initial request to the end of life. Design A qualitative meta-synthesis. Data sources Databases searched were CINAHL, MEDLINE, Emcare, Scopus and PsycInfo. The search was undertaken in September 2021 with no date limitations. Qualitative studies were considered if published in English, reported primary data analysis of nurses' experiences who had been involved in VAD and reported direct quotes from nurses. Review methods Qualitative studies meeting the selection criteria were critically appraised, then an open card-sort method was applied. Quotes from nurses were organized to group similar experiences, constructing themes and metaphors across studies as a new understanding of nurses' experiences of VAD. Results Eight studies were included. Three major themes were constructed: An orderly procedure, reflecting the need for structure to feel adequately prepared; A beautiful death, reflecting the autonomy the patient exercised when choosing VAD facilitated an exceptionally positive death; and Psychological and emotional impact, where nurses recognized the emotional and ethical weight that they carried for themselves and the team when undertaking VAD. Conclusion Nurses may benefit from clear policy, supervision and communication training to support them as countries transition to providing VAD services. Policy provides nurses with confidence that they are undertaking the steps of VAD correctly and provides a layer of emotional protection. Communication training specific to VAD is necessary to prepare nurses to recognize their own emotional experiences when responding to the needs of the patient and their family. Impact VAD is increasingly becoming a legal option that nurses are encountering in their professional practice. Understanding nurses' experiences of being involved in VAD is required to support nurses in countries where VAD is becoming available to prepare professionally and psychologically.","container-title":"Journal of Advanced Nursing","DOI":"10.1111/jan.15324","ISSN":"1365-2648","issue":"10","language":"en","license":" 2022 The Authors. Journal of Advanced Nursing published by John Wiley & Sons Ltd.","note":"_eprint: https://onlinelibrary.wiley.com/doi/pdf/10.1111/jan.15324","page":"3101-3115","source":"Wiley Online Library","title":"Nurses' experiences of supporting patients requesting voluntary assisted dying: A qualitative meta-synthesis","title-short":"Nurses' experiences of supporting patients requesting voluntary assisted dying","volume":"78","author":[{"family":"Sandham","given":"Margaret"},{"family":"Carey","given":"Melissa"},{"family":"Hedgecock","given":"Emma"},{"family":"Jarden","given":"Rebecca"}],"issued":{"date-parts":[["2022"]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Sandham et al., 2022). At this time, meaningful interactions, such as touch or physical presence, offered by colleagues were much valued. Those who receive and offer support to each other help create a smoother AD process. In contrast, those who were new to the team and still had barriers to getting along with the team reported having more complex emotion, as they lacking peer support ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"gnb6SS5S","properties":{"formattedCitation":"(Sandham et al., 2022)","plainCitation":"(Sandham et al., 2022)","noteIndex":0},"citationItems":[{"id":271,"uris":["http://zotero.org/users/14650052/items/R7E2YAHS"],"itemData":{"id":271,"type":"article-journal","abstract":"Aim Describe the reported lived experiences of nurses who have participated at any stage of voluntary assisted dying (VAD), from the initial request to the end of life. Design A qualitative meta-synthesis. Data sources Databases searched were CINAHL, MEDLINE, Emcare, Scopus and PsycInfo. The search was undertaken in September 2021 with no date limitations. Qualitative studies were considered if published in English, reported primary data analysis of nurses' experiences who had been involved in VAD and reported direct quotes from nurses. Review methods Qualitative studies meeting the selection criteria were critically appraised, then an open card-sort method was applied. Quotes from nurses were organized to group similar experiences, constructing themes and metaphors across studies as a new understanding of nurses' experiences of VAD. Results Eight studies were included. Three major themes were constructed: An orderly procedure, reflecting the need for structure to feel adequately prepared; A beautiful death, reflecting the autonomy the patient exercised when choosing VAD facilitated an exceptionally positive death; and Psychological and emotional impact, where nurses recognized the emotional and ethical weight that they carried for themselves and the team when undertaking VAD. Conclusion Nurses may benefit from clear policy, supervision and communication training to support them as countries transition to providing VAD services. Policy provides nurses with confidence that they are undertaking the steps of VAD correctly and provides a layer of emotional protection. Communication training specific to VAD is necessary to prepare nurses to recognize their own emotional experiences when responding to the needs of the patient and their family. Impact VAD is increasingly becoming a legal option that nurses are encountering in their professional practice. Understanding nurses' experiences of being involved in VAD is required to support nurses in countries where VAD is becoming available to prepare professionally and psychologically.","container-title":"Journal of Advanced Nursing","DOI":"10.1111/jan.15324","ISSN":"1365-2648","issue":"10","language":"en","license":" 2022 The Authors. Journal of Advanced Nursing published by John Wiley & Sons Ltd.","note":"_eprint: https://onlinelibrary.wiley.com/doi/pdf/10.1111/jan.15324","page":"3101-3115","source":"Wiley Online Library","title":"Nurses' experiences of supporting patients requesting voluntary assisted dying: A qualitative meta-synthesis","title-short":"Nurses' experiences of supporting patients requesting voluntary assisted dying","volume":"78","author":[{"family":"Sandham","given":"Margaret"},{"family":"Carey","given":"Melissa"},{"family":"Hedgecock","given":"Emma"},{"family":"Jarden","given":"Rebecca"}],"issued":{"date-parts":[["2022"]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Sandham et al., 2022). Sandhams (2022) study showed the importance of the availability of support in dealing with a critical situation, where little support is considered better than non-at all. Nurses in another study echoed similar sentiments ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"YmFS4AZZ","properties":{"formattedCitation":"(Antonacci et al., 2021; Elmore et al., 2018)","plainCitation":"(Antonacci et al., 2021; Elmore et al., 2018)","noteIndex":0},"citationItems":[{"id":74,"uris":["http://zotero.org/users/14650052/items/8VXWF4BJ"],"itemData":{"id":74,"type":"article-journal","abstract":"Background:With the legalization of medical assistance in dying (MAiD) in Canada, physicians and nurse practitioners now have another option within their scope of practice to consider alongside hospice palliative care (HPC) to support the patient and family regardless of their choice toward natural or medically assisted death. To elucidate insights and experiences with MAiD since its inception and to help adjust to this new end-of-life care environment, the membership of the Canadian Hospice Palliative Care Association (CHPCA) was surveyed.Methods:The CHPCA developed and distributed a 16-item survey to its membership in June 2017, one year following the legalization of MAiD. Data were arranged in Microsoft Excel and open-ended responses were analyzed thematically using NVivo 12 software.Results:From across Canada, 452 responses were received (response rate: 15%). The majority of individuals worked as nurses (n = 161, 33%), administrators (n = 79, 16%), volunteers (n = 76, 16%) and physicians (n = 56, 11%). Almost 75% (n = 320) of all respondents indicated that they had experienced a patient in their program who had requested MAiD. Participants expressed dissatisfaction with the current psychological and professional support being provided by their health care organization and Ministry of Health - during and after the MAiD procedure.Conclusion:The new complexities of MAiD present unique challenges to those working in the health-care field. There needs to be an increased focus on educating/training providers as without proper support, health-care workers will be unable to perform to their full potential/scope of practice while also providing patients with holistic and accessible care.","container-title":"Journal of Palliative Care","DOI":"10.1177/0825859719865548","ISSN":"0825-8597","issue":"3","journalAbbreviation":"J Palliat Care","language":"en","page":"151-156","source":"SAGE Journals","title":"Hospice Palliative Care (HPC) and Medical Assistance in Dying (MAiD): Results From a Canada-Wide Survey","title-short":"Hospice Palliative Care (HPC) and Medical Assistance in Dying (MAiD)","volume":"36","author":[{"family":"Antonacci","given":"Rebecca"},{"family":"Baxter","given":"Sharon"},{"family":"Henderson","given":"J. David"},{"family":"Mirza","given":"Raza M."},{"family":"Klinger","given":"Christopher A."}],"issued":{"date-parts":[["2021",7,1]]}}},{"id":86,"uris":["http://zotero.org/users/14650052/items/99D8KMWQ"],"itemData":{"id":86,"type":"article-journal","abstract":"Background: Legislative changes are resulting in assisted death as an option for people at the end of life. Although nurses experiences and perspectives are underrepresented within broader ethical discourses about assisted death, there is a small but significant body of literature examining nurses experiences of caring for people who request this option.nAim: To synthesize what has been learned about nurses experiences of caring for patients who request assisted death and to highlight what is morally at stake for nurses who undertake this type of care.nDesign: Qualitative meta-synthesis.nMethods: Six databases were searched: CINAHL, Medline, EMBASE, Joanna Briggs Institute, PsycINFO, and Web of Science. The search was completed on 22 October 2014 and updated in February 2016. Of 879 articles identified from the database searches, 16 articles were deemed relevant based on inclusion criteria. Following quality appraisal, 14 studies were retained for analysis and synthesis.nResults: The moral experience of the nurse is (1) defined by a profound sense of responsibility, (2) shaped by contextual forces that nurses navigate in everyday end-of-life care practice, and (3) sustained by intra-team moral and emotional support.nDiscussion: The findings of this synthesis support the view that nurses are moral agents who are deeply invested in the moral integrity of end-of-life care involving assisted death. The findings further demonstrate that to fully appreciate the ethics of assisted death from a nursing standpoint, it is necessary to understand the broader constraints on nurses moral agency that operate in everyday end-of-life care.nEthical considerations: Research ethics board approval was not required for this synthesis of previously published literature.nConclusion: In order to understand how to enact ethical practice in the area of assisted death, the moral experiences of nurses should be investigated and foregrounded.","container-title":"Nursing Ethics","DOI":"10.1177/0969733016679468","ISSN":"0969-7330","issue":"8","journalAbbreviation":"Nurs Ethics","language":"en","page":"955-972","source":"SAGE Journals","title":"Nurses moral experiences of assisted death: A meta-synthesis of qualitative research","title-short":"Nurses moral experiences of assisted death","volume":"25","author":[{"family":"Elmore","given":"James"},{"family":"Wright","given":"David Kenneth"},{"family":"Paradis","given":"Maude"}],"issued":{"date-parts":[["2018",12,1]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Antonacci et al., 2021; Elmore et al., 2018). They emphasised a lack of structured psychosocial support, including moderated debriefing sessions and trained counsellors to assist with resolving the complex emotional responses aftermath of AD (Antonacci et al., 2021) and acknowledges both moral dilemmas they faced (Elmore et al., 2018).

Social workers, also do not feel adequately supported by their work environments despite experiencing a high emotional charge while involving in AD, indicating a gap between emotional needs and available resources (Bravo et al., 2023). The same goes for physicians in hospice settings, who specifically emphasised the support tailored to address CO and disenfranchised grief, a form of grief that is defined as not openly acknowledged or validated within current support frameworks, usually happened on healthcare workers (Doka, 2002 as cited in Antonacci et al., 2021, p. 154). Studies from Switzerland illustrate a situation where a lack of formal training in communication relating to AD, along with anabsence of clear guidelines, leave palliative care physicians to act under their individualised ethical frameworks ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"330ntFWX","properties":{"formattedCitation":"(Gerson, Koksvik, et al., 2020)","plainCitation":"(Gerson, Koksvik, et al., 2020)","noteIndex":0},"citationItems":[{"id":268,"uris":["http://zotero.org/users/14650052/items/6Z65W9T5"],"itemData":{"id":268,"type":"article-journal","abstract":"ContextnA central approach of palliative care has been to provide holistic care for people who are dying, terminally ill, or facing life-limiting illnesses while neither hastening nor postponing death. Assisted dying laws allow eligible individuals to receive medically administered or self-administered medication from a health provider to end their life. The implementation of these laws in a growing number of jurisdictions therefore poses certain challenges for palliative care.nObjectivesnTo analyze the research literature about the relationship of assisted dying with palliative care, in countries where it is lawful.nMethodsnA five-stage scoping review process was adapted from the Joanna Briggs Institute. Data sources searched through October 2018 were MEDLINE, CINAHL, PsychINFO, SCOPUS, and ProQuest dissertations and theses, with additional material identified through hand searching. Research studies of any design were included, but editorials or opinion articles were excluded.nResultsnAfter reviewing 5778 references from searches, 105 were subject to full-text review. About 16 studies were included: from Belgium (n= 4), Canada (n= 1), Switzerland (n= 2), and the U.S. (n= 9). We found that the relationship between assisted dying and palliative care practices in these locations took varied and sometimes combined forms: supportive, neutral, coexisting, not mutually exclusive, integrated, synergistic, cooperative, collaborative, opposed, ambivalent, and conflicted.nConclusionnThe studies in this review cast only partial light on challenges faced by palliative care when assisted dying is legal. There is pressing need for more research on the involvement of palliative care in the developing practices of assisted dying, across a growing number of jurisdictions.","container-title":"Journal of Pain and Symptom Management","DOI":"10.1016/j.jpainsymman.2019.12.361","ISSN":"0885-3924","issue":"6","journalAbbreviation":"Journal of Pain and Symptom Management","page":"1287-1303.e1","source":"ScienceDirect","title":"The Relationship of Palliative Care With Assisted Dying Where Assisted Dying is Lawful: A Systematic Scoping Review of the Literature","title-short":"The Relationship of Palliative Care With Assisted Dying Where Assisted Dying is Lawful","volume":"59","author":[{"family":"Gerson","given":"Sheri Mila"},{"family":"Koksvik","given":"Gitte H."},{"family":"Richards","given":"Naomi"},{"family":"Materstvedt","given":"Lars Johan"},{"family":"Clark","given":"David"}],"issued":{"date-parts":[["2020",6,1]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Gerson, Koksvik, et al., 2020).

Another study conducted on chaplains experiences with patients requesting AD ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"xxGT7sb5","properties":{"formattedCitation":"(Carlson et al., 2005)","plainCitation":"(Carlson et al., 2005)","noteIndex":0},"citationItems":[{"id":258,"uris":["http://zotero.org/users/14650052/items/229BWI6M"],"itemData":{"id":258,"type":"article-journal","abstract":"Background: Oregons Death with Dignity Act (ODDA), which legalized physician-assistednsuicide (PAS) for terminally ill individuals, was enacted in 1997. Eighty-six percent of the 171npatients who have died by PAS were enrolled in hospice.nObjective: To survey hospice chaplains regarding their views on the ODDA and experiences working with patients who request PAS.nDesign: Single, anonymous, mailed survey.nSubjects: All chaplains affiliated with one of Oregons 50 hospices.nResults: Fifty of 77 hospice chaplains whom we identified (65%) returned the survey. Fortytwo percent of respondents opposed the ODDA and 40% supported it. Over half of respondents had, in the previous 3 years, worked with a patient who had made an explicit requestnfor assisted suicide. Conversation with patients around PAS focused on the role of faith andnspirituality in this decision, reasons for wanting hastened death, and family concerns or reactions to PAS. Chaplains did not feel that they had a strong influence on the patients decisions about PAS (mean score of 4 on a 010 scale), though three chaplains reported a patientnwho withdrew their request for PAS because of the chaplains involvement. Chaplains reported provision of a nonjudgmental presence helped the relationship with the patient.nConclusion: Oregon hospice chaplains are divided in their views on legalized PAS, but primarily see their role to deliver support to patients no matter what the patients final decisionnregarding PAS.","issue":"6","journalAbbreviation":"JOURNAL OF PALLIATIVE MEDICINE","language":"en","note":"DOI: 10.1089/jpm.2005.8.1160","page":"1160-1166","title":"Oregon Hospice Chaplains' Experiences with Patients Requesting Physician-Assisted Suicide","volume":"8","author":[{"family":"Carlson","given":"Bryant"},{"family":"Simopolous","given":"Nicole"},{"family":"Goy","given":"Elizabeth","suffix":"R."},{"family":"Jackson","given":"Ann"},{"family":"Ganzini","given":"Linda"}],"issued":{"date-parts":[["2005"]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Carlson et al., 2005) reported that chaplains in hospice have received extensive training trained extensively in providing emotional and spiritual support to patients. Chaplains generally support patients choices, no matter their opinion of support or oppose to AD ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"39tCWb7S","properties":{"formattedCitation":"(Gerson et al., 2019)","plainCitation":"(Gerson et al., 2019)","noteIndex":0},"citationItems":[{"id":269,"uris":["http://zotero.org/users/14650052/items/NP76J2W2"],"itemData":{"id":269,"type":"article-journal","abstract":"Laws allowing assisted suicide and euthanasia have been implemented in many locations around the world but some individuals suffering with terminal illness receiving palliative care services are hastening death or die by suicide without assistance. This systematic review aims to summarise evidence of palliative care professionals experiences of patients who died by suicide or hastened death in areas where assisted dying is legal and to understand when hastened death is considered to be a suicide.","container-title":"BMC Palliative Care","DOI":"10.1186/s12904-019-0451-4","ISSN":"1472-684X","issue":"75","journalAbbreviation":"BMC Palliat Care","language":"en","page":"1-13","source":"Springer Link","title":"When is hastened death considered suicide? A systematically conducted literature review about palliative care professionals experiences where assisted dying is legal","title-short":"When is hastened death considered suicide?","volume":"18","author":[{"family":"Gerson","given":"Sheri Mila"},{"family":"Bingley","given":"Amanda"},{"family":"Preston","given":"Nancy"},{"family":"Grinyer","given":"Anne"}],"issued":{"date-parts":[["2019",8,31]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Gerson et al., 2019). Chaplains are uniquely qualified to address spiritual religious and existential issues related to end of life ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"FBim5NJO","properties":{"formattedCitation":"(Carlson et al., 2005)","plainCitation":"(Carlson et al., 2005)","noteIndex":0},"citationItems":[{"id":258,"uris":["http://zotero.org/users/14650052/items/229BWI6M"],"itemData":{"id":258,"type":"article-journal","abstract":"Background: Oregons Death with Dignity Act (ODDA), which legalized physician-assistednsuicide (PAS) for terminally ill individuals, was enacted in 1997. Eighty-six percent of the 171npatients who have died by PAS were enrolled in hospice.nObjective: To survey hospice chaplains regarding their views on the ODDA and experiences working with patients who request PAS.nDesign: Single, anonymous, mailed survey.nSubjects: All chaplains affiliated with one of Oregons 50 hospices.nResults: Fifty of 77 hospice chaplains whom we identified (65%) returned the survey. Fortytwo percent of respondents opposed the ODDA and 40% supported it. Over half of respondents had, in the previous 3 years, worked with a patient who had made an explicit requestnfor assisted suicide. Conversation with patients around PAS focused on the role of faith andnspirituality in this decision, reasons for wanting hastened death, and family concerns or reactions to PAS. Chaplains did not feel that they had a strong influence on the patients decisions about PAS (mean score of 4 on a 010 scale), though three chaplains reported a patientnwho withdrew their request for PAS because of the chaplains involvement. Chaplains reported provision of a nonjudgmental presence helped the relationship with the patient.nConclusion: Oregon hospice chaplains are divided in their views on legalized PAS, but primarily see their role to deliver support to patients no matter what the patients final decisionnregarding PAS.","issue":"6","journalAbbreviation":"JOURNAL OF PALLIATIVE MEDICINE","language":"en","note":"DOI: 10.1089/jpm.2005.8.1160","page":"1160-1166","title":"Oregon Hospice Chaplains' Experiences with Patients Requesting Physician-Assisted Suicide","volume":"8","author":[{"family":"Carlson","given":"Bryant"},{"family":"Simopolous","given":"Nicole"},{"family":"Goy","given":"Elizabeth","suffix":"R."},{"family":"Jackson","given":"Ann"},{"family":"Ganzini","given":"Linda"}],"issued":{"date-parts":[["2005"]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Carlson et al., 2005). Chaplains require proper training and education to provide support to patients, such as a one-year postgraduate clinical pastoral education program or education endorsement by a faith community. In Oregon, hospice chaplains utilise their skills to help patients understand the role of faith and spirituality play in their decision for AD and explore the reasons behind the request for AD. However, existing research lacks detailed information on chaplains perspectives regarding the effectiveness of their support systems and their emotional experiences in providing spiritual care for patients undergoing AD requests. Current studies in similar settings, such as those chaplains working in intensive care units (ICU) ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"DzhlbD2J","properties":{"formattedCitation":"(McCurry et al., 2021)","plainCitation":"(McCurry et al., 2021)","noteIndex":0},"citationItems":[{"id":267,"uris":["http://zotero.org/users/14650052/items/JPMUGBCX"],"itemData":{"id":267,"type":"article-journal","abstract":"Background: The provision of spiritual care is a key component of high-quality patient-centered care, particularly in the intensive care unit (ICU). However, the integration of spiritual care into the care of patients in the ICU is variable, especially at the end of life, which may be due in part to poor or incomplete provider knowledge of the work of chaplains.Objective: To characterize the care and services provided by chaplains to patients in an ICU at the end of life and/or their families.Design: A retrospective chart review was performed to identify all patients admitted over a three-month period to an ICU who had visits with a chaplain and an ICU course that ended in death, discharge to a palliative care facility or discharge to hospice.Subjects/setting: Twenty-five chaplains at a U.S. medical center.Measurements: Qualitative analysis was performed using directed content analysis on the notes written by the chaplains.Results: Qualitative analyses of the chaplain notes revealed four broad themes regarding the activities of chaplains in the ICU with respect to patients and families. These were that chaplains provide comfort to patients and family facing the end of life, provide prayers with a variety of purposes, assist in supporting family members through complex medical decision making, and provide connections to appropriate resources.Conclusions: Chaplains contribute to the care of patients in the ICU through a wide range of activities that demonstrate the unique intermediary and collaborative role chaplains can play within the health care team at the end of life in the ICU.","container-title":"Palliative Medicine Reports","DOI":"10.1089/pmr.2021.0012","issue":"1","note":"publisher: Mary Ann Liebert, Inc., publishers","page":"280-286","source":"liebertpub.com (Atypon)","title":"Chaplain Care in the Intensive Care Unit at the End of Life: A Qualitative Analysis","title-short":"Chaplain Care in the Intensive Care Unit at the End of Life","volume":"2","author":[{"family":"McCurry","given":"Ian"},{"family":"Jennett","given":"Pauline"},{"family":"Oh","given":"Jimin"},{"family":"White","given":"Betty"},{"family":"DeLisser","given":"Horace M."}],"issued":{"date-parts":[["2021",12]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (McCurry et al., 2021), primarily focus on describing their roles in supporting patients, families and healthcare professionals, with less emphasis on the emotional experiences of chaplains involved in AD or other critical situations. Hence,no matter which roles NPHPs play, the availability and adequacy of support systems and resources are essential to address the emotional toll of their roles.

While specifically focusing on the Aotearoa AD literature, studies have examined NPHPs perceptions of the training resources available in Aotearoa. NPHPs participants gave positive reactions to the resources and training provided by the Ministry of Health (MoH) ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"oqzuSwkW","properties":{"formattedCitation":"(Dehkhoda et al., 2023; Snelling et al., 2023)","plainCitation":"(Dehkhoda et al., 2023; Snelling et al., 2023)","noteIndex":0},"citationItems":[{"id":356,"uris":["http://zotero.org/users/14650052/items/3TPVNK7I"],"itemData":{"id":356,"type":"article-journal","abstract":"AIM: To explore the importance of health workforce training, particularly in newly regulated healthcare practices such as assisted dying (AD). This study aims to analyse the socio-demographic factors associated with health professionals' completion of the e-learning module and attendance at the two webinars provided by the New Zealand Ministry of Health - Manat Hauora (MH) and whether completion of the e-learning module and webinars supported health professionals' understanding of the End of Life Choices Act 2019. METHOD: Secondary analysis of the MH workforce surveys conducted in July 2021. RESULTS: The study findings indicate that health professionals who are older, of Pkeh/European ethnicity and work in hospice settings are more likely to complete the e-learning module, while females are more likely to attend webinars. CONCLUSION: Despite low completion and attendance rates, the study highlights the positive association between training and health professionals' overall understanding of the Act. These results emphasise the need for enhancing training programmes to increase health professionals' knowledge and competence with AD. Furthermore, the research proposes focussing on healthcare practitioners in the early stages of their careers and not directly engaged in offering AD services, as well as Maori and Pasifika health practitioners.","container-title":"The New Zealand Medical Journal (Online)","issue":"1582","language":"English","license":"Copyright New Zealand Medical Association (NZMA) Sep 15, 2023","note":"number-of-pages: 52npublisher-place: Auckland, New Zealandnpublisher: Pasifika Medical Association Group (PMAG)nsection: ARTICLE","page":"52","source":"ProQuest","title":"Exploring the impact of e-learning modules and webinars on health professionals' understanding of the End of Life Choice Act 2019: a secondary analysis of Manat Hauora Ministry of Health workforce survey","title-short":"Exploring the impact of e-learning modules and webinars on health professionals' understanding of the End of Life Choice Act 2019","volume":"136","author":[{"family":"Dehkhoda","given":"Aida"},{"family":"Frey","given":"Rosemary"},{"family":"Carey","given":"Melissa"},{"family":"Jing","given":"Xuepeng"},{"family":"Robinson","given":"Jacqualine"},{"family":"Sundram","given":"Frederick"},{"family":"Hoeh","given":"Nicholas R."},{"family":"Bull","given":"Susan"},{"family":"Menkes","given":"David"},{"family":"Cheung","given":"Gary"}],"issued":{"date-parts":[["2023",9,15]]}}},{"id":97,"uris":["http://zotero.org/users/14650052/items/6RW5BWH5"],"itemData":{"id":97,"type":"article-journal","abstract":"In November 2021, assisted dying (AD) became lawful in Aotearoa New Zealand. A terminally ill person may now request, and receive, pharmacological assistance (self-administered or provided by a medical practitioner/nurse practitioner) to end their life, subject to specific legal criteria and processes. Exploring the experiences of health providers in the initial stage of the implementation of the End of Life Choice Act 2019 is vital to inform the ongoing development of safe and effective AD practice, policy and law.","container-title":"BMC Palliative Care","DOI":"10.1186/s12904-023-01222-4","ISSN":"1472-684X","issue":"1","journalAbbreviation":"BMC Palliative Care","page":"101","source":"BioMed Central","title":"Health care providers early experiences of assisted dying in Aotearoa New Zealand: an evolving clinical service","title-short":"Health care providers early experiences of assisted dying in Aotearoa New Zealand","volume":"22","author":[{"family":"Snelling","given":"Jeanne"},{"family":"Young","given":"Jessica"},{"family":"Beaumont","given":"Sophie"},{"family":"Diesfeld","given":"Kate"},{"family":"White","given":"Ben"},{"family":"Willmott","given":"Lindy"},{"family":"Robinson","given":"Jacqualine"},{"family":"Moeke-Maxwell","given":"Tess"}],"issued":{"date-parts":[["2023",7,22]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Dehkhoda et al., 2023; Snelling et al., 2023). However, they also raise concerns about how well AD providers were trained in specific legislation areas, especially in determining a patients capacity to make decisions and understand the outcome of a patients condition (Snelling et al., 2023). The study by Dehkhoda et al. (2023) found a positive link between training and understanding the Act, even though completion and attendance rates were low and the training resources were somewhat generic. The results underscore the significance of training in enhancing health professionals' knowledge and skills related to AD.

CO/IO

(how CO in IO feel, how not CO in IO feel)

Studies have explored the impact of conscientious objections (CO) and institutional objections (IO) on healthcare providers experiences, particularly in the context of AD ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"O9SrsnqP","properties":{"formattedCitation":"(Bouthillier & Opatrny, 2019; Denier et al., 2010; Fujioka et al., 2018; Snelling et al., 2023)","plainCitation":"(Bouthillier & Opatrny, 2019; Denier et al., 2010; Fujioka et al., 2018; Snelling et al., 2023)","noteIndex":0},"citationItems":[{"id":43,"uris":["http://zotero.org/users/14650052/items/9F9URVXP"],"itemData":{"id":43,"type":"article-journal","abstract":"Background:Under Quebecs Act respecting end-of-life care, physicians may refuse to provide medical aid in dying because of personal convictions, also called conscientious objections. Before legalisation, the results of our survey showed that the majority of physicians were in favour of medical aid in dying (76%), but one-third (28%) were not prepared to perform it. After 18months of legalisation, physicians were refusing far more frequently than the pre-Act survey had anticipated.Aim:To explore the conscientious objections stated by physicians so as to understand why some of them refuse to get involved in their patients medical aid in dying requests.Design/participants:An exploratory qualitative study based on semi-structured interviews with 22 physicians who expressed a refusal after they received a request for medical aid in dying. Thematic descriptive analysis was used to analyse physicians motives for their conscientious objections and the reasons behind it.Results:The majority of physicians who refused to participate did not oppose medical aid in dying. The reason most often cited is not based on moral and religious grounds. Rather, the emotional burden related to this act and the fear of psychological repercussions were the most expressed motivations for not participating in medical aid in dying.Conclusion:The originality of this research is based on what the actual perception is of doing medical aid in dying as opposed to merely a conceptual assent. Further explorations are required in order to support policy decisions such as access to better emotional supports for providers and interdisciplinary support.","container-title":"Palliative Medicine","DOI":"10.1177/0269216319861921","ISSN":"0269-2163","issue":"9","journalAbbreviation":"Palliat Med","language":"en","page":"1212-1220","source":"SAGE Journals","title":"A qualitative study of physicians conscientious objections to medical aid in dying","volume":"33","author":[{"family":"Bouthillier","given":"Marie-Eve"},{"family":"Opatrny","given":"Lucie"}],"issued":{"date-parts":[["2019",10,1]]}}},{"id":57,"uris":["http://zotero.org/users/14650052/items/SE2PXS34"],"itemData":{"id":57,"type":"article-journal","abstract":"The Belgian Act on Euthanasia came into force on 23 September 2002, making Belgium the second countryafter the Netherlandsto decriminalize euthanasia under certain due-care conditions. Since then, Belgian nurses have been increasingly involved in euthanasia care. In this paper, we report a qualitative study based on in-depth interviews with 18 nurses from Flanders (the Dutch-speaking part of Belgium) who have had experience in caring for patients requesting euthanasia since May 2002 (the approval of the Act). We found that the care process for patients requesting euthanasia is a complex and dynamic process, consisting of several stages, starting from the period preceding the euthanasia request and ending with the aftercare stage. When asked after the way in which they experience their involvement in the euthanasia care process, all nurses described it as a grave and difficult process, not only on an organizational and practical level, but also on an emotional level. Intense is the dominant feeling experienced by nurses. This is compounded by the presence of other feelings such as great concern and responsibility on the one hand, being content in truly helping the patient to die serenely, and doing everything in ones power to contribute to this; but also feeling unreal and ambivalent on the other hand, because death is arranged. Nurses feel a discrepancy, because although it is a nice death, which happens in dignity and with respect, it is also an unnatural death. The clinical ethical implications of these findings are discussed.","container-title":"Medicine, Health Care and Philosophy","DOI":"10.1007/s11019-009-9203-1","ISSN":"1572-8633","issue":"1","journalAbbreviation":"Med Health Care and Philos","language":"en","page":"41-48","source":"Springer Link","title":"Its intense, you know. Nurses experiences in caring for patients requesting euthanasia","volume":"13","author":[{"family":"Denier","given":"Yvonne"},{"family":"Dierckx de Casterl","given":"Bernadette"},{"family":"De Bal","given":"Nele"},{"family":"Gastmans","given":"Chris"}],"issued":{"date-parts":[["2010",2,1]]}}},{"id":65,"uris":["http://zotero.org/users/14650052/items/2KDC45VR",["http://zotero.org/users/14650052/items/2KDC45VR"]],"itemData":{"id":65,"type":"article-journal","abstract":"Research AimsnWith the growing interest in Medical Assistance in Dying (MAiD), understanding health care professionals' roles and experiences in handling requests is necessary to evaluate the quality, consistency, and efficacy of current practices. This scoping review sought to map the existing literature on health care providers' perspectives of their involvement in MAiD.nMethodsnA scoping review was conducted to address the following: 1) What are the roles of diverse health care professionals in the provision of MAiD? and 2) What professional challenges arise when confronted with MAiD requests? A literature search in electronic databases and gray literature sources was performed. Articles were screened, and a thematic content analysis synthesized key findings.nResultsnAfter evaluating 1715 citations and 148 full-text papers, 33 articles were included. Perspectives of nurses (n=10), physicians (n=7), mental health providers (n=7), pharmacists (n=4), social workers (n=3), and medical examiners (n=1) were explored. Professional roles included consulting/supporting patients and/or other staff members with requests, assessing eligibility, administering/dispensing the lethal drugs, providing aftercare to bereaved relatives, and regulatory oversight. Challenges included lack of clear guidelines/protocols, role ambiguity, evaluating capacity/consent, conscientious objection, and lack of interprofessional collaboration.nConclusionnEvidence from various jurisdictions highlighted a need for clear guidelines and protocols that define each profession's role, scope of practice, and legal boundaries for MAiD. Comprehensive models of care that incorporate multidisciplinary teams alongside improved clinician education may be effective to support MAiD implementation. Little is known about health care providers' perspectives in handling requests, especially outside physician practice and nursing.","container-title":"Journal of Pain and Symptom Management","DOI":"10.1016/j.jpainsymman.2018.02.011","ISSN":"0885-3924","issue":"6","journalAbbreviation":"Journal of Pain and Symptom Management","page":"1564-1576.e9","source":"ScienceDirect","title":"Implementation of Medical Assistance in Dying: A Scoping Review of Health Care Providers' Perspectives","title-short":"Implementation of Medical Assistance in Dying","volume":"55","author":[{"family":"Fujioka","given":"Jamie K."},{"family":"Mirza","given":"Raza M."},{"family":"McDonald","given":"P. Lynn"},{"family":"Klinger","given":"Christopher A."}],"issued":{"date-parts":[["2018",6,1]]}}},{"id":97,"uris":["http://zotero.org/users/14650052/items/6RW5BWH5"],"itemData":{"id":97,"type":"article-journal","abstract":"In November 2021, assisted dying (AD) became lawful in Aotearoa New Zealand. A terminally ill person may now request, and receive, pharmacological assistance (self-administered or provided by a medical practitioner/nurse practitioner) to end their life, subject to specific legal criteria and processes. Exploring the experiences of health providers in the initial stage of the implementation of the End of Life Choice Act 2019 is vital to inform the ongoing development of safe and effective AD practice, policy and law.","container-title":"BMC Palliative Care","DOI":"10.1186/s12904-023-01222-4","ISSN":"1472-684X","issue":"1","journalAbbreviation":"BMC Palliative Care","page":"101","source":"BioMed Central","title":"Health care providers early experiences of assisted dying in Aotearoa New Zealand: an evolving clinical service","title-short":"Health care providers early experiences of assisted dying in Aotearoa New Zealand","volume":"22","author":[{"family":"Snelling","given":"Jeanne"},{"family":"Young","given":"Jessica"},{"family":"Beaumont","given":"Sophie"},{"family":"Diesfeld","given":"Kate"},{"family":"White","given":"Ben"},{"family":"Willmott","given":"Lindy"},{"family":"Robinson","given":"Jacqualine"},{"family":"Moeke-Maxwell","given":"Tess"}],"issued":{"date-parts":[["2023",7,22]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Bouthillier & Opatrny, 2019; Denier et al., 2010; Fujioka et al., 2018; Snelling et al., 2023). CO refer to when professional refuses to provide AD based on moral or conscientious reasons, or it can occur in those who initially opposed to AD, but since its legalisation, help with aspects of care related to AD without directly participating in the procedure; while IO refers to institutions declining to offer AD services despite individual willingness (Snelling et al., 2023). Snelling and colleagues (2023) identified four main groups of healthcare professionals regarding AD. Conscientious objectors are those who oppose AD on moral grounds and do not participate in its procedures. Reluctant AD facilitators initially opposed AD, but since its legalisation, help with aspects of care related to AD without directly participating in the procedure. AD participators support AD and are actively involved in providing the service. Lastly, non-participator allies support AD but do not engage in its provision due to factors like institutional restrictions or legal constraints. However, those who are CO are obliged to inform patients or supervisors of their CO's decision, and when patients request AD information can give basic information and refer them to other providers. For example, although NPHPs are not executing AD, they co-operated with AD providers in supplying clinical information upon requested ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"LjigRdmp","properties":{"formattedCitation":"(Bruce & Beuthin, 2020; Snelling et al., 2023)","plainCitation":"(Bruce & Beuthin, 2020; Snelling et al., 2023)","noteIndex":0},"citationItems":[{"id":272,"uris":["http://zotero.org/users/14650052/items/PE8LHP4Y"],"itemData":{"id":272,"type":"article-journal","abstract":"BackgroundNurses witness pain and distress up close and consequently experience their own suffering. A narrative study of Canadian nurses participating in medical assistance in dying found nurses previous witnessing of unresolved end-of-life suffering has shaped their acceptance of medical assistance in dying. Little is known about the impact of participating in medically assisted dying on nurses suffering.PurposeTo explore how nurses overall experience of suffering is shaped by participating in medical assistance in dying.MethodsQualitative secondary analysis using narrative inquiry and thematic analysis.ResultsNurses narratives are chronologically organized addressing experiences of suffering before medical assistance in dying was a legal option and after its implementation. An overarching narrative before the availability of medical assistance in dying is (1) a culture of nurses taken-for-granted suffering: feeling terrible. After medical assistance in dying, two key narratives describe (2) transformational feelings of a beautiful death and (3) residual discomfort. Nurses found their suffering transformed when participating in medical assistance in dying; end-of-life care was satisfying and gratifying. And yet, unanswered questions due to worries of becoming desensitized and ongoing deeper questioning remain.ConclusionsParticipating in medical assistance in dying has positively impacted nurses and starkly contrasts their previous experiences caring for those with unbearable suffering. Further research is needed to explore becoming desensitized and long-term emotional impact for nurses.","container-title":"Canadian Journal of Nursing Research","DOI":"10.1177/0844562119856234","ISSN":"0844-5621","issue":"4","journalAbbreviation":"Can J Nurs Res","language":"en","note":"publisher: SAGE Publications Inc","page":"268-277","source":"SAGE Journals","title":"Medically Assisted Dying in Canada: Beautiful Death Is Transforming Nurses Experiences of Suffering","title-short":"Medically Assisted Dying in Canada","volume":"52","author":[{"family":"Bruce","given":"Anne"},{"family":"Beuthin","given":"Rosanne"}],"issued":{"date-parts":[["2020",12,1]]}}},{"id":97,"uris":["http://zotero.org/users/14650052/items/6RW5BWH5"],"itemData":{"id":97,"type":"article-journal","abstract":"In November 2021, assisted dying (AD) became lawful in Aotearoa New Zealand. A terminally ill person may now request, and receive, pharmacological assistance (self-administered or provided by a medical practitioner/nurse practitioner) to end their life, subject to specific legal criteria and processes. Exploring the experiences of health providers in the initial stage of the implementation of the End of Life Choice Act 2019 is vital to inform the ongoing development of safe and effective AD practice, policy and law.","container-title":"BMC Palliative Care","DOI":"10.1186/s12904-023-01222-4","ISSN":"1472-684X","issue":"1","journalAbbreviation":"BMC Palliative Care","page":"101","source":"BioMed Central","title":"Health care providers early experiences of assisted dying in Aotearoa New Zealand: an evolving clinical service","title-short":"Health care providers early experiences of assisted dying in Aotearoa New Zealand","volume":"22","author":[{"family":"Snelling","given":"Jeanne"},{"family":"Young","given":"Jessica"},{"family":"Beaumont","given":"Sophie"},{"family":"Diesfeld","given":"Kate"},{"family":"White","given":"Ben"},{"family":"Willmott","given":"Lindy"},{"family":"Robinson","given":"Jacqualine"},{"family":"Moeke-Maxwell","given":"Tess"}],"issued":{"date-parts":[["2023",7,22]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Bruce & Beuthin, 2020; Snelling et al., 2023).

Moral distress is frequently discussed as a results of CO/IO ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"V9Das5ev","properties":{"formattedCitation":"(Close, Willmott, et al., 2023; Heilman & Trothen, 2020; Knox & Wagg, 2023)","plainCitation":"(Close, Willmott, et al., 2023; Heilman & Trothen, 2020; Knox & Wagg, 2023)","noteIndex":0},"citationItems":[{"id":309,"uris":["http://zotero.org/users/14650052/items/RL8NVZ6C"],"itemData":{"id":309,"type":"article-journal","abstract":"Victoria was the first Australian state to legalize voluntary assisted dying (elsewhere known as physician-assisted suicide and euthanasia). Some institutions indicated they would not participate in voluntary assisted dying. The Victorian government issued policy approaches for institutions to consider","container-title":"Journal of Bioethical Inquiry","DOI":"10.1007/s11673-023-10271-6","ISSN":"1872-4353","issue":"3","journalAbbreviation":"Bioethical Inquiry","language":"en","page":"467-484","source":"Springer Link","title":"Institutional Objection to Voluntary Assisted Dying in Victoria, Australia: An Analysis of Publicly Available Policies","title-short":"Institutional Objection to Voluntary Assisted Dying in Victoria, Australia","volume":"20","author":[{"family":"Close","given":"Eliana"},{"family":"Willmott","given":"Lindy"},{"family":"Keogh","given":"Louise"},{"family":"White","given":"Ben P."}],"issued":{"date-parts":[["2023",9,1]]}}},{"id":312,"uris":["http://zotero.org/users/14650052/items/22FG3NJP"],"itemData":{"id":312,"type":"article-journal","abstract":"Conscientious objection has become a divisive topic in recent bioethics publications. Discussion has tended to frame the issue in terms of the rights of the healthcare professional versus the rights of the patient. However, a rights-based approach neglects the relational nature of conscience, and the impact that violating ones conscience has on the care one provides. Using medical assistance in dying as a case study, we suggest that what has been lacking in the discussion of conscientious objection thus far is a recognition and prioritising of the relational nature of ethical decision-making in healthcare and the negative consequences of moral distress that occur when healthcare professionals find themselves in situations in which they feel they cannot provide what they consider to be excellent care. We propose that policies that respect the relational conscience could benefit our healthcare institutions by minimising the negative impact of moral distress, improving communication among team members and fostering a culture of ethical awareness. Constructive responses to moral distress including relational cultivation of moral resilience are urged.","container-title":"Journal of Medical Ethics","DOI":"10.1136/medethics-2019-105855","ISSN":"0306-6800, 1473-4257","issue":"2","language":"en","license":" Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.","note":"publisher: Institute of Medical Ethicsnsection: Extended essaynPMID: 31811013","page":"123-127","source":"jme.bmj.com","title":"Conscientious objection and moral distress: a relational ethics case study of MAiD in Canada","title-short":"Conscientious objection and moral distress","volume":"46","author":[{"family":"Heilman","given":"Mary Kathleen Deutscher"},{"family":"Trothen","given":"Tracy J."}],"issued":{"date-parts":[["2020",2,1]]}}},{"id":337,"uris":["http://zotero.org/users/14650052/items/BDRBKVPY"],"itemData":{"id":337,"type":"article-journal","abstract":"Since the legalization of medical assistance in dying (MAiD) in Canada in 2016, volitional non-participation in MAiD on the part of some healthcare institutions has revealed ethical uncertainties, potential access problems, and policy gaps. The problem has remained much neglected in the literature base, with no comprehensive studies on the subject so far. We analyzed print media articles and grey literature on institutional objections to and non-participation in MAiD. Thematic analyses were performed on all data to better understand the diverse stakeholder arguments and positions that characterize this important public health debate. Our search yielded 89 relevant media articles and 22 legislative, policy, and other relevant documents published since 2016 in the English language. We identified four main themes about institutional refusals to participate in MAiD, articulated as the following questions: (1) Who has the right to conscience? (2) Can MAiD be considered a palliative practice? (3) Are there imbalances across diverse stakeholder rights and burdens? and (4) Where are the gaps being felt in MAiD service implementation? Stakeholder views about institutional conscience with respect to MAiD are varied, complex, and evolving. In the absence of substantial systematic evidence, public domain materials constitute a key resource for understanding the implications for service access and determining the relevance of this contentious issue for future MAiD research and policy.","container-title":"Healthcare","DOI":"10.3390/healthcare11162305","ISSN":"2227-9032","issue":"16","language":"en","license":"http://creativecommons.org/licenses/by/3.0/","note":"number: 16npublisher: Multidisciplinary Digital Publishing Institute","page":"2305","source":"www.mdpi.com","title":"Institutional Resistance to Medical Assistance in Dying in Canada: Arguments and Realities Emerging in the Public Domain","title-short":"Institutional Resistance to Medical Assistance in Dying in Canada","volume":"11","author":[{"family":"Knox","given":"Michelle"},{"family":"Wagg","given":"Adrian"}],"issued":{"date-parts":[["2023",1]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Close, Willmott, et al., 2023; Heilman & Trothen, 2020; Knox & Wagg, 2023), and is recognised as a significant factor impacting the mental health of NPHPs (Heilman & Trothen, 2020). It is defined as the feeling of being forced to do what feels like the wrong thing in the situation ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"1bUxbCAk","properties":{"formattedCitation":"(Berlinger, 2016, p. 33)","plainCitation":"(Berlinger, 2016, p. 33)","noteIndex":0},"citationItems":[{"id":364,"uris":["http://zotero.org/users/14650052/items/6QE89WB2"],"itemData":{"id":364,"type":"article-journal","container-title":"The Hastings Center Report","DOI":"10.1002/hast.547","ISSN":"0093-0334","issue":"2","journalAbbreviation":"Hastings Cent Rep","language":"eng","note":"PMID: 27120283","page":"32-34","source":"PubMed","title":"When Policy Produces Moral Distress: Reclaiming Conscience","title-short":"When Policy Produces Moral Distress","volume":"46","author":[{"family":"Berlinger","given":"Nancy"}],"issued":{"date-parts":[["2016"]]}},"locator":"33","label":"page"}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Berlinger, 2016, p. 33). This phenomenon affects nurses and other healthcare providers across various practice areas and reflects challenges in enacting their moral agency due to various factors such as conflicts with other providers excessive workloads, and difficulties in end-of-life care decision making ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"PtftDzV9","properties":{"formattedCitation":"(Musto et al., 2015)","plainCitation":"(Musto et al., 2015)","noteIndex":0},"citationItems":[{"id":359,"uris":["http://zotero.org/users/14650052/items/SYFWETWJ"],"itemData":{"id":359,"type":"article-journal","abstract":"Background:The concept of moral distress has been the subject of nursing research for the past 30 years. Recently, there has been a call to move from developing an understanding of the concept to developing interventions to help ameliorate the experience. At the same time, the use of the term moral distress has been critiqued for a lack of clarity about the concepts that underpin the experience.Discussion:Some researchers suggest that a closer examination of how socio-political structures influence healthcare delivery will move moral distress from being seen as located in the individual to an experience that is also located in broader healthcare structures. Informed by new thinking in relational ethics, we draw on research findings from neuroscience and attachment literature to examine the reciprocal relationship between structures and agents and frame the experience of moral distress.Conclusion:We posit moral distress as a form of relational trauma and subsequently point to the need to better understand how nurses as moral agents are influenced byand influencethe complex socio-political structures they inhabit. In so doing, we identify this reciprocity as a framework for interventions.","container-title":"Nursing Ethics","DOI":"10.1177/0969733014534879","ISSN":"0969-7330","issue":"1","journalAbbreviation":"Nurs Ethics","language":"en","note":"publisher: SAGE Publications Ltd","page":"91-102","source":"SAGE Journals","title":"Toward interventions to address moral distress: Navigating structure and agency","title-short":"Toward interventions to address moral distress","volume":"22","author":[{"family":"Musto","given":"Lynn C"},{"family":"Rodney","given":"Patricia A"},{"family":"Vanderheide","given":"Rebecca"}],"issued":{"date-parts":[["2015",2,1]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Musto et al., 2015).

NPHPs often experience moral distress when they are unable to provide care that align with their ethical standards (Heilman & Trothen, 2020). Junior doctors, too, encounter similar ethical challenges, particularly when confronted with CO related to AD. Their subordinate position in the healthcare hierarchy can force them to choose between compromising their moral integrity or their career progression, which leads them involved in ethical dilemmas ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"2EMvel2H","properties":{"formattedCitation":"(McDougall et al., 2022)","plainCitation":"(McDougall et al., 2022)","noteIndex":0},"citationItems":[{"id":325,"uris":["http://zotero.org/users/14650052/items/CQL4R2PB"],"itemData":{"id":325,"type":"article-journal","abstract":"In jurisdictions where voluntary assisted dying (VAD) is legal, eligibility assessments, prescription and administration of a VAD substance are commonly performed by senior doctors. Junior doctors involvement is limited to a range of more peripheral aspects of patient care relating to VAD. In the Australian state of Victoria, where VAD has been legal since June 2019, all health professionals have a right under the legislation to conscientiously object to involvement in the VAD process, including provision of information about VAD. While this protection appears categorical and straightforward, conscientious objection to VAD-related care is ethically complex for junior doctors for reasons that are specific to this group of clinicians. For junior doctors wishing to exercise a conscientious objection to VAD, their dependence on their senior colleagues for career progression creates unique risks and burdens. In a context where senior colleagues are supportive of VAD, the junior doctors subordinate position in the medical hierarchy exposes them to potential significant harms: compromising their moral integrity by participating, or compromising their career progression by objecting. In jurisdictions intending to provide all health professionals with meaningful conscientious objection protection in relation to VAD, strong specific support for junior doctors is needed through local institutional policies and culture.","container-title":"Journal of Medical Ethics","DOI":"10.1136/medethics-2020-107125","ISSN":"0306-6800, 1473-4257","issue":"8","language":"en","license":" Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.. http://creativecommons.org/licenses/by-nc/4.0/This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.","note":"publisher: Institute of Medical Ethicsnsection: Original researchnPMID: 34127526","page":"517-521","source":"jme.bmj.com","title":"Junior doctors and conscientious objection to voluntary assisted dying: ethical complexity in practice","title-short":"Junior doctors and conscientious objection to voluntary assisted dying","volume":"48","author":[{"family":"McDougall","given":"Rosalind J."},{"family":"White","given":"Ben P."},{"family":"Ko","given":"Danielle"},{"family":"Keogh","given":"Louise"},{"family":"Willmott","given":"Lindy"}],"issued":{"date-parts":[["2022",8,1]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (McDougall et al., 2022).

The impact of moral distress on healthcare providers includes potential moral disengagement, which can erode relationships within healthcare teams and negatively affect the quality and safety of patient and family care (Musto et al., 2015). Empirical data also suggest that moral distress can lead to moral residuea progressive, cumulative impact of repeated moral distress incidents ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"kBitlxK9","properties":{"formattedCitation":"(Hamric, 2012; Musto et al., 2015)","plainCitation":"(Hamric, 2012; Musto et al., 2015)","noteIndex":0},"citationItems":[{"id":363,"uris":["http://zotero.org/users/14650052/items/LG2WE2I5"],"itemData":{"id":363,"type":"article-journal","DOI":"10.1007/s10730-012-9177-x","journalAbbreviation":"HEC Forum","page":"39-49","title":"Empirical Research on Moral Distress: Issues, Challenges, and Opportunities.","volume":"24","author":[{"family":"Hamric","given":"A. B."}],"issued":{"date-parts":[["2012"]]}}},{"id":359,"uris":["http://zotero.org/users/14650052/items/SYFWETWJ"],"itemData":{"id":359,"type":"article-journal","abstract":"Background:The concept of moral distress has been the subject of nursing research for the past 30 years. Recently, there has been a call to move from developing an understanding of the concept to developing interventions to help ameliorate the experience. At the same time, the use of the term moral distress has been critiqued for a lack of clarity about the concepts that underpin the experience.Discussion:Some researchers suggest that a closer examination of how socio-political structures influence healthcare delivery will move moral distress from being seen as located in the individual to an experience that is also located in broader healthcare structures. Informed by new thinking in relational ethics, we draw on research findings from neuroscience and attachment literature to examine the reciprocal relationship between structures and agents and frame the experience of moral distress.Conclusion:We posit moral distress as a form of relational trauma and subsequently point to the need to better understand how nurses as moral agents are influenced byand influencethe complex socio-political structures they inhabit. In so doing, we identify this reciprocity as a framework for interventions.","container-title":"Nursing Ethics","DOI":"10.1177/0969733014534879","ISSN":"0969-7330","issue":"1","journalAbbreviation":"Nurs Ethics","language":"en","note":"publisher: SAGE Publications Ltd","page":"91-102","source":"SAGE Journals","title":"Toward interventions to address moral distress: Navigating structure and agency","title-short":"Toward interventions to address moral distress","volume":"22","author":[{"family":"Musto","given":"Lynn C"},{"family":"Rodney","given":"Patricia A"},{"family":"Vanderheide","given":"Rebecca"}],"issued":{"date-parts":[["2015",2,1]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Hamric, 2012; Musto et al., 2015). As a result, there is increasing attention to the physiological and psychological effects of moral distress, including potential attrition from the practice area or profession (Heilman & Trothen, 2020; McDougall et al., 2022).

Emerging research on motivations for participating or not participating in AD highlights personal values, professional identity, and organisation context as key factors for CO ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"FPJnF4ba","properties":{"formattedCitation":"(Brown et al., 2021; Oliphant & Frolic, 2021)","plainCitation":"(Brown et al., 2021; Oliphant & Frolic, 2021)","noteIndex":0},"citationItems":[{"id":339,"uris":["http://zotero.org/users/14650052/items/4KQN6C2W"],"itemData":{"id":339,"type":"article-journal","abstract":"Access to medical assistance in dying (MAID) is influenced by legislation, health care providers (HCPs), the number of patient requests, and the patients locations. This research explored the factors that influenced HCPs nonparticipation in formal MAID processes and their needs to support this emerging practice area. Using an interpretive description methodology, we interviewed 17 physicians and 18 nurse practitioners who identified as non-participators in formal MAID processes. Nonparticipation was influenced by their (a) previous personal and professional experiences, (b) comfort with death, (c) conceptualization of duty, (d) preferred end-of-life care approaches, (e) faith or spirituality beliefs, (f) self-accountability, (g) consideration of emotional labor, and (h) future emotional impact. They identified a need for clear care pathways and safe passage. Two separate yet overlapping concepts were identified, conscientious objection to and nonparticipation in MAID, and we discussed options to support the social contract of care between HCPs and patients.","container-title":"Qualitative Health Research","DOI":"10.1177/10497323211008843","ISSN":"1049-7323","issue":"10","journalAbbreviation":"Qual Health Res","language":"en","note":"publisher: SAGE Publications Inc","page":"1786-1800","source":"SAGE Journals","title":"What Is Right for Me, Is Not Necessarily Right for You: The Endogenous Factors Influencing Nonparticipation in Medical Assistance in Dying","title-short":"What Is Right for Me, Is Not Necessarily Right for You","volume":"31","author":[{"family":"Brown","given":"Janine"},{"family":"Goodridge","given":"Donna"},{"family":"Thorpe","given":"Lilian"},{"family":"Crizzle","given":"Alexander"}],"issued":{"date-parts":[["2021",8,1]]}}},{"id":341,"uris":["http://zotero.org/users/14650052/items/225WC8W4"],"itemData":{"id":341,"type":"article-journal","abstract":"The availability of willing providers of medical assistance in dying (MAiD) in Canada has been an issue since a Canadian Supreme Court decision and the subsequent passing of federal legislation, Bill C14, decriminalised MAiD in 2016. Following this legislation, Hamilton Health Sciences (HHS) in Ontario, Canada, created a team to support access to MAiD for patients. This research used a qualitative, mixed methods approach to data collection, obtaining the narratives of providers and supporters of MAiD practice at HHS. This study occurred at the outset of MAiD practice in 2016, and 1 year later, once MAiD practice was established. Our study reveals that professional identity and values, personal identity and values, experience with death and dying, and organisation context are the most significant contributors to conscientious participation for MAiD providers and supporters. The stories of study participants were used to create a model that provides a framework for values clarification around MAiD practice, and can be used to explore beliefs and reasoning around participation in MAiD across the moral spectrum. This research addresses a significant gap in the literature by advancing our understanding of factors that influence participation in taboo clinical practices. It may be applied practically to help promote reflective practice regarding complex and controversial areas of medicine, to improve interprofessional engagement in MAiD practice and promote the conditions necessary to support moral diversity in our institutions.","container-title":"Journal of Medical Ethics","DOI":"10.1136/medethics-2019-105758","ISSN":"0306-6800, 1473-4257","issue":"1","language":"en","license":" Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.","note":"publisher: Institute of Medical Ethicsnsection: Extended essaynPMID: 32371593","page":"51-58","source":"jme.bmj.com","title":"Becoming a medical assistance in dying (MAiD) provider: an exploration of the conditions that produce conscientious participation","title-short":"Becoming a medical assistance in dying (MAiD) provider","volume":"47","author":[{"family":"Oliphant","given":"Allyson"},{"family":"Frolic","given":"Andrea Nadine"}],"issued":{"date-parts":[["2021",1,1]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Brown et al., 2021; Oliphant & Frolic, 2021). Fujioka et al. (2018) observed that ethical and moral objections pose a challenge to NPHPs emotional well-being, evidenced by the study conducted on palliative care nurses in Belgium ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"7UhBoAtK","properties":{"formattedCitation":"(de Casterluc0u233{} et al., 2006)","plainCitation":"(de Casterl et al., 2006)","noteIndex":0},"citationItems":[{"id":274,"uris":["http://zotero.org/users/14650052/items/GI35V9IA","http://zotero.org/users/14650052/items/6MZDY7R2"],"itemData":{"id":274,"type":"article-journal","issue":"4","journalAbbreviation":"Journal of medical ethics","title":"Nurses views on their involvement in euthanasia: a qualitative study in Flanders (Belgium)","volume":"32","author":[{"family":"Casterl","given":"B. Dierckx","non-dropping-particle":"de","dropping-particle":"de"},{"family":"Verpoort","given":"C."},{"family":"Bal","given":"N.","non-dropping-particle":"de"},{"family":"Gastmans","given":"C."}],"issued":{"date-parts":[["2006"]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (de Casterl et al., 2006). Nurses tend to set aside their personal beliefs about AD to meet the patient's needs, which gradually impacting their emotional well-being. Not to mention, NPHPs with CO may also lose their job. When pharmacists object to CO, they may refuse to prescribe lethal medications to patients, which risks their jobs in the long term period (Fujioka et al., 2018).

Conversely, Bouthillier and Opatrny (2019) argue that CO is often used to avoid participating in AD for reasons beyond ethical or moral objections. They argue that the majority of participants were not genuine conscientious objectors ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"qtbdDpS5","properties":{"formattedCitation":"(Bouthillier & Opatrny, 2019)","plainCitation":"(Bouthillier & Opatrny, 2019)","noteIndex":0},"citationItems":[{"id":43,"uris":["http://zotero.org/users/14650052/items/9F9URVXP"],"itemData":{"id":43,"type":"article-journal","abstract":"Background:Under Quebecs Act respecting end-of-life care, physicians may refuse to provide medical aid in dying because of personal convictions, also called conscientious objections. Before legalisation, the results of our survey showed that the majority of physicians were in favour of medical aid in dying (76%), but one-third (28%) were not prepared to perform it. After 18months of legalisation, physicians were refusing far more frequently than the pre-Act survey had anticipated.Aim:To explore the conscientious objections stated by physicians so as to understand why some of them refuse to get involved in their patients medical aid in dying requests.Design/participants:An exploratory qualitative study based on semi-structured interviews with 22 physicians who expressed a refusal after they received a request for medical aid in dying. Thematic descriptive analysis was used to analyse physicians motives for their conscientious objections and the reasons behind it.Results:The majority of physicians who refused to participate did not oppose medical aid in dying. The reason most often cited is not based on moral and religious grounds. Rather, the emotional burden related to this act and the fear of psychological repercussions were the most expressed motivations for not participating in medical aid in dying.Conclusion:The originality of this research is based on what the actual perception is of doing medical aid in dying as opposed to merely a conceptual assent. Further explorations are required in order to support policy decisions such as access to better emotional supports for providers and interdisciplinary support.","container-title":"Palliative Medicine","DOI":"10.1177/0269216319861921","ISSN":"0269-2163","issue":"9","journalAbbreviation":"Palliat Med","language":"en","page":"1212-1220","source":"SAGE Journals","title":"A qualitative study of physicians conscientious objections to medical aid in dying","volume":"33","author":[{"family":"Bouthillier","given":"Marie-Eve"},{"family":"Opatrny","given":"Lucie"}],"issued":{"date-parts":[["2019",10,1]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Bouthillier & Opatrny, 2019). Following the definition of CO (refusals based on moral convictions), 13 over 22 participants reported that their opposition to AD was beyond moral objections, often cited various reasons. They seemed to use the term CO to cover up their emotional and professional vulnerabilities ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"v7Jv9bjm","properties":{"formattedCitation":"(Bouthillier & Opatrny, 2019)","plainCitation":"(Bouthillier & Opatrny, 2019)","noteIndex":0},"citationItems":[{"id":43,"uris":["http://zotero.org/users/14650052/items/9F9URVXP"],"itemData":{"id":43,"type":"article-journal","abstract":"Background:Under Quebecs Act respecting end-of-life care, physicians may refuse to provide medical aid in dying because of personal convictions, also called conscientious objections. Before legalisation, the results of our survey showed that the majority of physicians were in favour of medical aid in dying (76%), but one-third (28%) were not prepared to perform it. After 18months of legalisation, physicians were refusing far more frequently than the pre-Act survey had anticipated.Aim:To explore the conscientious objections stated by physicians so as to understand why some of them refuse to get involved in their patients medical aid in dying requests.Design/participants:An exploratory qualitative study based on semi-structured interviews with 22 physicians who expressed a refusal after they received a request for medical aid in dying. Thematic descriptive analysis was used to analyse physicians motives for their conscientious objections and the reasons behind it.Results:The majority of physicians who refused to participate did not oppose medical aid in dying. The reason most often cited is not based on moral and religious grounds. Rather, the emotional burden related to this act and the fear of psychological repercussions were the most expressed motivations for not participating in medical aid in dying.Conclusion:The originality of this research is based on what the actual perception is of doing medical aid in dying as opposed to merely a conceptual assent. Further explorations are required in order to support policy decisions such as access to better emotional supports for providers and interdisciplinary support.","container-title":"Palliative Medicine","DOI":"10.1177/0269216319861921","ISSN":"0269-2163","issue":"9","journalAbbreviation":"Palliat Med","language":"en","page":"1212-1220","source":"SAGE Journals","title":"A qualitative study of physicians conscientious objections to medical aid in dying","volume":"33","author":[{"family":"Bouthillier","given":"Marie-Eve"},{"family":"Opatrny","given":"Lucie"}],"issued":{"date-parts":[["2019",10,1]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Bouthillier & Opatrny, 2019). They found that emotional burden and fear of psychological impact often drive physicians reluctance from engaging with AD. The emotional toll of participating in AD can lead to significant psychological stress, highlighting the need for better emotional support systems for NPHPs ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"FFNJ42Bj","properties":{"formattedCitation":"(Bouthillier & Opatrny, 2019)","plainCitation":"(Bouthillier & Opatrny, 2019)","noteIndex":0},"citationItems":[{"id":43,"uris":["http://zotero.org/users/14650052/items/9F9URVXP"],"itemData":{"id":43,"type":"article-journal","abstract":"Background:Under Quebecs Act respecting end-of-life care, physicians may refuse to provide medical aid in dying because of personal convictions, also called conscientious objections. Before legalisation, the results of our survey showed that the majority of physicians were in favour of medical aid in dying (76%), but one-third (28%) were not prepared to perform it. After 18months of legalisation, physicians were refusing far more frequently than the pre-Act survey had anticipated.Aim:To explore the conscientious objections stated by physicians so as to understand why some of them refuse to get involved in their patients medical aid in dying requests.Design/participants:An exploratory qualitative study based on semi-structured interviews with 22 physicians who expressed a refusal after they received a request for medical aid in dying. Thematic descriptive analysis was used to analyse physicians motives for their conscientious objections and the reasons behind it.Results:The majority of physicians who refused to participate did not oppose medical aid in dying. The reason most often cited is not based on moral and religious grounds. Rather, the emotional burden related to this act and the fear of psychological repercussions were the most expressed motivations for not participating in medical aid in dying.Conclusion:The originality of this research is based on what the actual perception is of doing medical aid in dying as opposed to merely a conceptual assent. Further explorations are required in order to support policy decisions such as access to better emotional supports for providers and interdisciplinary support.","container-title":"Palliative Medicine","DOI":"10.1177/0269216319861921","ISSN":"0269-2163","issue":"9","journalAbbreviation":"Palliat Med","language":"en","page":"1212-1220","source":"SAGE Journals","title":"A qualitative study of physicians conscientious objections to medical aid in dying","volume":"33","author":[{"family":"Bouthillier","given":"Marie-Eve"},{"family":"Opatrny","given":"Lucie"}],"issued":{"date-parts":[["2019",10,1]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Bouthillier & Opatrny, 2019). Another reason could be the nurses expressed that they felt more comfortable when chose to be conscientious objectors. Even though they had a difficult time caring for patients on the day of their planned death, as compared to execution, they are more comfortable in providing care for patients, but not others job ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"LYVH1zsy","properties":{"formattedCitation":"(Beuthin et al., 2018)","plainCitation":"(Beuthin et al., 2018)","noteIndex":0},"citationItems":[{"id":70,"uris":["http://zotero.org/users/14650052/items/Y4HWYM4Q",["http://zotero.org/users/14650052/items/Y4HWYM4Q"]],"itemData":{"id":70,"type":"article-journal","abstract":"Medical assistance in dying (MAiD) represents a historic change in Canadian society and the provision of end-of-life care. In this descriptive narrative inquiry, 17 nurses were interviewed during the first 6 months of assisted dying becoming a legal option for patients in Canada. Nurses experiences of either providing care for a patient who had chosen MAiD, or declining to participate in MAiD, were explored. Findings describe three themes and eight storylines of the impact of MAiD on nurses view of the profession, clinical practice, and personally. While most nurses perceived MAiD as an extension of the profession and their nursing practice, a small number also expressed moral distress as they grappled with assisted dying. Narratives illustrated an ongoing sensemaking process and spectrum of emotions. These findings offer insight and provide direction for nurses and managers in this new clinical and legal reality. Further research is needed to understand more fully the moral distress of some nurses, as well as the importance of communicating openly and nonjudgmentally with patients, families, and the health-care team.","container-title":"Nursing Forum","DOI":"10.1111/nuf.12280","ISSN":"1744-6198","issue":"4","language":"en","license":" 2018 The Authors. Nursing Forum published by Wiley Periodicals, Inc.","page":"511-520","source":"Wiley Online Library","title":"Medical assistance in dying (MAiD): Canadian nurses experiences","title-short":"Medical assistance in dying (MAiD)","volume":"53","author":[{"family":"Beuthin","given":"Rosanne"},{"family":"Bruce","given":"Anne"},{"family":"Scaia","given":"Margaret"}],"issued":{"date-parts":[["2018"]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Beuthin et al., 2018). Besides that, van Marwijk et al. (2007) also highlighted many physicians stated their decision for CO was due to adverse psychological concerns about the high intensity of AD procedures. NPHPs would consider different CO angles, including the societal acceptability of AD, organisation practices, and individual sensitivity while considering involving in AD ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"V9TbGwDo","properties":{"formattedCitation":"(van Marwijk et al., 2007)","plainCitation":"(van Marwijk et al., 2007)","noteIndex":0},"citationItems":[{"id":99,"uris":["http://zotero.org/users/14650052/items/XACTX6Q9"],"itemData":{"id":99,"type":"article-journal","abstract":"Background : There is only limited knowledge about the emotional impact that performing euthanasia has on primary care physicians (PCPs) in the Netherlands. Objective : To obtain more insight into the emotional impact on PCPs of performing euthanasia or assisted suicide, and to tailor the educational needs of vocational PCP trainees accordingly. Methods : Qualitative research, consisting of four focus group studies. The setting was primary care in the Netherlands; 22 PCPs participated, in four groups (older males, older females, younger males and a group with interest with regard to euthanasia). Results : Various phases with different emotions were distinguished: before (tension), during (loss) and after (relief) the event. Although it is a very rare occurrence, euthanasia has a major impact on PCPs. Their relationship with the patient, their loneliness, the role of the family, and pressure from society are the main issues that emerged. Making sufficient emotional space and time available to take leave adequately from a patient is important for PCPs. Conclusions : Many PCPs stressed that young physicians should form their own opinions about euthanasia and other end-of-life decisions early on in their career. We recommend that these issues are officially included in the vocational training programme for general practice. Palliative Medicine 2007; 21: 609614","container-title":"Palliative Medicine","DOI":"10.1177/0269216307082475","ISSN":"0269-2163","issue":"7","journalAbbreviation":"Palliat Med","language":"en","page":"609-614","source":"SAGE Journals","title":"Impact of euthanasia on primary care physicians in the Netherlands","volume":"21","author":[{"family":"Marwijk","given":"Harm","non-dropping-particle":"van"},{"family":"Haverkate","given":"Ilinka"},{"family":"Royen","given":"Paul","non-dropping-particle":"van"},{"family":"The","given":"Anne-Mei"}],"issued":{"date-parts":[["2007",10,1]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (van Marwijk et al., 2007).

In addition, working with colleagues or in an institution that does not support assisted dying affected physicians emotionally ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"cqRozC2N","properties":{"formattedCitation":"(Shaw et al., 2018)","plainCitation":"(Shaw et al., 2018)","noteIndex":0},"citationItems":[{"id":378,"uris":["http://zotero.org/users/14650052/items/FMRPNLKP"],"itemData":{"id":378,"type":"article-journal","abstract":"ObjectivenTo explore the experiences of the first cohort of physicians to offer medical assistance in dying (MAID) in British Columbia.nnDesignnQualitative study using semistructured, one-on-one interviews.nnSettingnBritish Columbia.nnParticipantsnEight physicians who offered MAID in British Columbia in 2016.nnMethodsnThe physicians were interviewed by telephone or by e-mail between 4 and 6 months after MAID was made legal in Canada, with follow-up in January 2017. Interviews were audiorecorded, transcribed, and analyzed through qualitative thematic analysis.nnMain findingsnParticipants believed that MAID was rewarding and satisfying work. They explained that some of the structural and emotional challenges related to providing MAID included the following: the refusal of faith-based institutions to provide information about MAID to patients, as well as their refusal to allow assessments or deaths to occur on site; having to deny MAID to patients who did not qualify for it; disagreements with colleagues who did not support the provision of MAID; dealing with the grief of family and friends who were present at the death; and feeling like they were always on call. While a few participants thought that the legislative restrictions of Bill C-14 were appropriate in the beginning when MAID was first available in Canada, most would like to see changes to the legislation to make it more aligned with the intent of the Carter decision, including broadening the eligibility criteria to include mature minors and people with advanced psychiatric diagnoses, having the ability to honour advance directives, and removing the requirement of death being in the reasonably foreseeable future for patients with grievous and irremediable conditions.nnConclusionnPhysicians in this study explained that providing MAID is rewarding work; however, there are many challenges that complicate their ability to offer MAID to patients. The current MAID legislation in Canada should be updated to better serve the needs of patients.","container-title":"Canadian Family Physician","ISSN":"0008-350X","issue":"9","journalAbbreviation":"Can Fam Physician","note":"PMID: 30209113nPMCID: PMC6135115","page":"394-399","source":"PubMed Central","title":"Providing medical assistance in dying","volume":"64","author":[{"family":"Shaw","given":"Jessica"},{"family":"Wiebe","given":"Ellen"},{"family":"Nuhn","given":"Amelia"},{"family":"Holmes","given":"Sheila"},{"family":"Kelly","given":"Michaela"},{"family":"Just","given":"Alanna"}],"issued":{"date-parts":[["2018",9]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Shaw et al., 2018).Some physicians in Canada, where advance requests are not legal, felt distressed for having to decline requests from patients who had met the eligibility requirements for assisted dying, but had lost decision-making capacity during the reflection period ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"VK883DG9","properties":{"formattedCitation":"(Shaw et al., 2018)","plainCitation":"(Shaw et al., 2018)","noteIndex":0},"citationItems":[{"id":378,"uris":["http://zotero.org/users/14650052/items/FMRPNLKP"],"itemData":{"id":378,"type":"article-journal","abstract":"ObjectivenTo explore the experiences of the first cohort of physicians to offer medical assistance in dying (MAID) in British Columbia.nnDesignnQualitative study using semistructured, one-on-one interviews.nnSettingnBritish Columbia.nnParticipantsnEight physicians who offered MAID in British Columbia in 2016.nnMethodsnThe physicians were interviewed by telephone or by e-mail between 4 and 6 months after MAID was made legal in Canada, with follow-up in January 2017. Interviews were audiorecorded, transcribed, and analyzed through qualitative thematic analysis.nnMain findingsnParticipants believed that MAID was rewarding and satisfying work. They explained that some of the structural and emotional challenges related to providing MAID included the following: the refusal of faith-based institutions to provide information about MAID to patients, as well as their refusal to allow assessments or deaths to occur on site; having to deny MAID to patients who did not qualify for it; disagreements with colleagues who did not support the provision of MAID; dealing with the grief of family and friends who were present at the death; and feeling like they were always on call. While a few participants thought that the legislative restrictions of Bill C-14 were appropriate in the beginning when MAID was first available in Canada, most would like to see changes to the legislation to make it more aligned with the intent of the Carter decision, including broadening the eligibility criteria to include mature minors and people with advanced psychiatric diagnoses, having the ability to honour advance directives, and removing the requirement of death being in the reasonably foreseeable future for patients with grievous and irremediable conditions.nnConclusionnPhysicians in this study explained that providing MAID is rewarding work; however, there are many challenges that complicate their ability to offer MAID to patients. The current MAID legislation in Canada should be updated to better serve the needs of patients.","container-title":"Canadian Family Physician","ISSN":"0008-350X","issue":"9","journalAbbreviation":"Can Fam Physician","note":"PMID: 30209113nPMCID: PMC6135115","page":"394-399","source":"PubMed Central","title":"Providing medical assistance in dying","volume":"64","author":[{"family":"Shaw","given":"Jessica"},{"family":"Wiebe","given":"Ellen"},{"family":"Nuhn","given":"Amelia"},{"family":"Holmes","given":"Sheila"},{"family":"Kelly","given":"Michaela"},{"family":"Just","given":"Alanna"}],"issued":{"date-parts":[["2018",9]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Shaw et al., 2018).

Followed by IO, some organisations, mainly hospices, opted out of AD services in Aotearoa. NPHPs who worked in the IO organisations continued to provide consultation about AD. Hospice healthcare workers indicated that they were relatively suitable to facilitate AD consultation, but they worked in an IO organisation, which ironically impacts their role in facilitating a quality AD conversation (Snelling et al., 2023).

Research has demonstrated that IO causes a range of harm to patients ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"eOkOoljr","properties":{"formattedCitation":"(White et al., 2021, 2023)","plainCitation":"(White et al., 2021, 2023)","noteIndex":0},"citationItems":[{"id":308,"uris":["http://zotero.org/users/14650052/items/GSAWJTA9"],"itemData":{"id":308,"type":"article-journal","abstract":"Voluntary assisted dying is being considered by parliaments and law reform bodies across Australia. Although individual conscientious objection is routinely considered in these deliberations, an institutions desire to object to providing voluntary assisted dying has received very little attention. After briefly considering the concept of institutional objection in voluntary assisted dying, this article examines the available (albeit limited) Australian evidence on this practice. Institutional objection is happening in Victoria (where voluntary assisted dying is lawful) and is likely to occur in other Australian states. The article proposes that regulation is needed and presents three models for parliaments and law reformers to consider. The first is conscientious absolutism, which grants institutions unrestricted ability to object to voluntary assisted dying. The second is a compromise or reasonable accommodation model, which aims to accommodate both institutional objection and a persons wish to access voluntary assisted dying. Different balances can be struck; we propose a model that prioritises a patients interests. The third model is non-toleration, which would refuse to allow an institution to object at all. While there can be debate about the optimal model, the issue of institutional objection to voluntary assisted dying must be addressed.","journalAbbreviation":"University of New South Wales Law Journal Forum","page":"1-19","title":"Legislative options to address institutional objections to voluntary assisted dying in Australia.","volume":"3","author":[{"family":"White","given":"Ben P."},{"family":"Willmott","given":"Lindy"},{"family":"Eliana","given":"Close"},{"family":"Jocelyn","given":"Downie"}],"issued":{"date-parts":[["2021"]]}}},{"id":331,"uris":["http://zotero.org/users/14650052/items/4F9HPU87"],"itemData":{"id":331,"type":"article-journal","issue":"22","journalAbbreviation":"BMC Medical Ethics","page":"1-12","title":"The impact on patients of objections by institutions to assisted dying: a qualitative study of family caregivers perceptions","volume":"24","author":[{"family":"White","given":"Ben P."},{"family":"Jeanneret","given":"Ruthie"},{"family":"Close","given":"Eliana"},{"family":"Willmott","given":"Lindy"}],"issued":{"date-parts":[["2023"]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (White et al., 2021, 2023). In some cases, IO prevented patients from accessing healthcare, especially when there is no alternative provider was available or when transferring to a hospital were physically unbearable or logistically impossible ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"UsScnGhG","properties":{"formattedCitation":"(Variath et al., 2020)","plainCitation":"(Variath et al., 2020)","noteIndex":0},"citationItems":[{"id":335,"uris":["http://zotero.org/users/14650052/items/9HTGAZZB"],"itemData":{"id":335,"type":"article-journal","abstract":"Background:Family members and healthcare providers play an integral role in a persons assisted dying journey. Their own needs during the assisted dying journey are often, however, unrecognized and underrepresented in policies and guidelines. Circumstances under which people choose assisted dying, and relational contexts such as the sociopolitical environment, may influence the experiences of family members and healthcare providers.Ethical considerations:Ethics approval was not required to conduct this review.Aim:This scoping review aims to identify the relational influences on the experiences of family members and healthcare providers of adults who underwent assisted dying and of those unable to access assisted dying due to the loss of capacity to consent.Methods:A literature search was conducted in four databases, including MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature (CINAHL) and PsycINFO. The search retrieved 12,074 articles, a number narrowed down to 172 articles for full-text screening. Thirty-six articles met the established inclusion criteria. A feminist relational framework guided the data analysis.Results:Five key themes on the influences of family members and healthcare providers experiences throughout the assisted dying process were synthesized from the data. They include (1) relationships as central to beginning the process, (2) social and political influences on decision making, (3) complex roles and responsibilities of family members and healthcare providers, (4) a unique experience of death, and (5) varying experiences following death.Conclusion:The feminist relational lens, used to guide analysis, shed light on the effect of the sociopolitical influences and the relationships among patients, families, and healthcare providers on each others experiences. Addressing the needs of the family members and healthcare providers is vital to improving the assisted dying process. Including families and healthcare providers needs within institutional policies and enhancing collaboration and communication among those involved could improve the overall experience.","container-title":"Nursing Ethics","DOI":"10.1177/0969733020921493","ISSN":"0969-7330","issue":"7","journalAbbreviation":"Nurs Ethics","language":"en","note":"publisher: SAGE Publications Ltd","page":"1501-1516","source":"SAGE Journals","title":"Relational influences on experiences with assisted dying: A scoping review","title-short":"Relational influences on experiences with assisted dying","volume":"27","author":[{"family":"Variath","given":"Caroline"},{"family":"Peter","given":"Elizabeth"},{"family":"Cranley","given":"Lisa"},{"family":"Godkin","given":"Dianne"},{"family":"Just","given":"Danielle"}],"issued":{"date-parts":[["2020",11,1]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Variath et al., 2020). Physicians reported they had failed patients who endured prolonged deaths due to forced transfers ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"HIAzyPRI","properties":{"formattedCitation":"(Close, Jeanneret, et al., 2023)","plainCitation":"(Close, Jeanneret, et al., 2023)","noteIndex":0},"citationItems":[{"id":329,"uris":["http://zotero.org/users/14650052/items/2AWZ945J"],"itemData":{"id":329,"type":"article-journal","abstract":"Background In June 2016, Canada legalized medical assistance in dying (MAiD). From the outset, some healthcare institutions (including faith-based and non-faith-based hospitals, hospices, and residential aged care facilities) have refused to allow aspects of MAiD onsite, resulting in patient transfers for MAiD assessments and provision. There have been media reports highlighting the negative consequences of these institutional objections, however, very little research has examined their nature and impact.nMethods This study reports on findings from 48 semi-structured qualitative interviews conducted with MAiD assessors and providers, MAiD team members (working to coordinate care and lead MAiD programs in institutions and health authorities), and family caregivers on their experiences with institutional objection. Participants were recruited from the Canadian provinces of British Columbia, Ontario, and Nova Scotia. Data were analyzed using inductive thematic analysis.nResults Themes identified were: (1) basis for institutional objection (with objections commonly rooted in religious values and a particular philosophy of palliative care); (2) scope of objection (demonstrating a wide range of practices objected to); (3) lack of transparency regarding institutional position; (4) impacts on patients; (5) impacts on health practitioners; and (6) catalysts for change. Participants reported that many institutions objections had softened over time, lessening barriers to MAiD access and adverse impacts on patients and health practitioners. Participants attributed this positive change to a range of catalysts including advocacy by health practitioners and family members, policymaking by local health authorities, education, and relationship building. Nevertheless, some institutions, particularly faith-based ones, retained strong objections to MAiD, resulting in forced transfers and negative emotional and psychological impacts on patients, family members, and health practitioners.nConclusions This paper adds to the limited evidence base about the impacts of institutional objection and can inform practical and regulatory solutions in Canada and abroad. Reform is needed to minimize the negative impacts on patients, their caregivers, and health practitioners involved in MAiD practice.","container-title":"BMC Medical Ethics","DOI":"10.1186/s12910-023-00950-9","ISSN":"1472-6939","issue":"1","journalAbbreviation":"BMC Med Ethics","language":"en","page":"71","source":"DOI.org (Crossref)","title":"A qualitative study of experiences of institutional objection to medical assistance in dying in Canada: ongoing challenges and catalysts for change","title-short":"A qualitative study of experiences of institutional objection to medical assistance in dying in Canada","volume":"24","author":[{"family":"Close","given":"Eliana"},{"family":"Jeanneret","given":"Ruthie"},{"family":"Downie","given":"Jocelyn"},{"family":"Willmott","given":"Lindy"},{"family":"White","given":"Ben P"}],"issued":{"date-parts":[["2023",9,21]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Close, Jeanneret, et al., 2023). NPHPs involved in these transfers experienced significant emotional distress, including frustration, anger, and moral distress. Another physician also reported feelings of being stigmatised and outraged as their patient faced a series of mandatory assessment and transfers ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"sOWpxLcV","properties":{"formattedCitation":"(Close, Jeanneret, et al., 2023)","plainCitation":"(Close, Jeanneret, et al., 2023)","noteIndex":0},"citationItems":[{"id":329,"uris":["http://zotero.org/users/14650052/items/2AWZ945J"],"itemData":{"id":329,"type":"article-journal","abstract":"Background In June 2016, Canada legalized medical assistance in dying (MAiD). From the outset, some healthcare institutions (including faith-based and non-faith-based hospitals, hospices, and residential aged care facilities) have refused to allow aspects of MAiD onsite, resulting in patient transfers for MAiD assessments and provision. There have been media reports highlighting the negative consequences of these institutional objections, however, very little research has examined their nature and impact.nMethods This study reports on findings from 48 semi-structured qualitative interviews conducted with MAiD assessors and providers, MAiD team members (working to coordinate care and lead MAiD programs in institutions and health authorities), and family caregivers on their experiences with institutional objection. Participants were recruited from the Canadian provinces of British Columbia, Ontario, and Nova Scotia. Data were analyzed using inductive thematic analysis.nResults Themes identified were: (1) basis for institutional objection (with objections commonly rooted in religious values and a particular philosophy of palliative care); (2) scope of objection (demonstrating a wide range of practices objected to); (3) lack of transparency regarding institutional position; (4) impacts on patients; (5) impacts on health practitioners; and (6) catalysts for change. Participants reported that many institutions objections had softened over time, lessening barriers to MAiD access and adverse impacts on patients and health practitioners. Participants attributed this positive change to a range of catalysts including advocacy by health practitioners and family members, policymaking by local health authorities, education, and relationship building. Nevertheless, some institutions, particularly faith-based ones, retained strong objections to MAiD, resulting in forced transfers and negative emotional and psychological impacts on patients, family members, and health practitioners.nConclusions This paper adds to the limited evidence base about the impacts of institutional objection and can inform practical and regulatory solutions in Canada and abroad. Reform is needed to minimize the negative impacts on patients, their caregivers, and health practitioners involved in MAiD practice.","container-title":"BMC Medical Ethics","DOI":"10.1186/s12910-023-00950-9","ISSN":"1472-6939","issue":"1","journalAbbreviation":"BMC Med Ethics","language":"en","page":"71","source":"DOI.org (Crossref)","title":"A qualitative study of experiences of institutional objection to medical assistance in dying in Canada: ongoing challenges and catalysts for change","title-short":"A qualitative study of experiences of institutional objection to medical assistance in dying in Canada","volume":"24","author":[{"family":"Close","given":"Eliana"},{"family":"Jeanneret","given":"Ruthie"},{"family":"Downie","given":"Jocelyn"},{"family":"Willmott","given":"Lindy"},{"family":"White","given":"Ben P"}],"issued":{"date-parts":[["2023",9,21]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Close, Jeanneret, et al., 2023). Additional stress arose from threats and complaints to authorities, including their professional regulatory bodies and the police, although these complaints did not result in sanctions. As a result, NPHPs who are in an IO organisation experience moral distress due to being forced to participate because they believe these transfers are not in the interests of patients ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"5C6Mh9qT","properties":{"formattedCitation":"(Close, Jeanneret, et al., 2023)","plainCitation":"(Close, Jeanneret, et al., 2023)","noteIndex":0},"citationItems":[{"id":329,"uris":["http://zotero.org/users/14650052/items/2AWZ945J"],"itemData":{"id":329,"type":"article-journal","abstract":"Background In June 2016, Canada legalized medical assistance in dying (MAiD). From the outset, some healthcare institutions (including faith-based and non-faith-based hospitals, hospices, and residential aged care facilities) have refused to allow aspects of MAiD onsite, resulting in patient transfers for MAiD assessments and provision. There have been media reports highlighting the negative consequences of these institutional objections, however, very little research has examined their nature and impact.nMethods This study reports on findings from 48 semi-structured qualitative interviews conducted with MAiD assessors and providers, MAiD team members (working to coordinate care and lead MAiD programs in institutions and health authorities), and family caregivers on their experiences with institutional objection. Participants were recruited from the Canadian provinces of British Columbia, Ontario, and Nova Scotia. Data were analyzed using inductive thematic analysis.nResults Themes identified were: (1) basis for institutional objection (with objections commonly rooted in religious values and a particular philosophy of palliative care); (2) scope of objection (demonstrating a wide range of practices objected to); (3) lack of transparency regarding institutional position; (4) impacts on patients; (5) impacts on health practitioners; and (6) catalysts for change. Participants reported that many institutions objections had softened over time, lessening barriers to MAiD access and adverse impacts on patients and health practitioners. Participants attributed this positive change to a range of catalysts including advocacy by health practitioners and family members, policymaking by local health authorities, education, and relationship building. Nevertheless, some institutions, particularly faith-based ones, retained strong objections to MAiD, resulting in forced transfers and negative emotional and psychological impacts on patients, family members, and health practitioners.nConclusions This paper adds to the limited evidence base about the impacts of institutional objection and can inform practical and regulatory solutions in Canada and abroad. Reform is needed to minimize the negative impacts on patients, their caregivers, and health practitioners involved in MAiD practice.","container-title":"BMC Medical Ethics","DOI":"10.1186/s12910-023-00950-9","ISSN":"1472-6939","issue":"1","journalAbbreviation":"BMC Med Ethics","language":"en","page":"71","source":"DOI.org (Crossref)","title":"A qualitative study of experiences of institutional objection to medical assistance in dying in Canada: ongoing challenges and catalysts for change","title-short":"A qualitative study of experiences of institutional objection to medical assistance in dying in Canada","volume":"24","author":[{"family":"Close","given":"Eliana"},{"family":"Jeanneret","given":"Ruthie"},{"family":"Downie","given":"Jocelyn"},{"family":"Willmott","given":"Lindy"},{"family":"White","given":"Ben P"}],"issued":{"date-parts":[["2023",9,21]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Close, Jeanneret, et al., 2023). The conflicting views within healthcare organisation affect providers' willingness to participate in AD and expose them to a greater risk of moral distress and emotional burnout ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"B82yp3EA","properties":{"formattedCitation":"(Heilman & Trothen, 2020; Knox & Wagg, 2023)","plainCitation":"(Heilman & Trothen, 2020; Knox & Wagg, 2023)","noteIndex":0},"citationItems":[{"id":312,"uris":["http://zotero.org/users/14650052/items/22FG3NJP"],"itemData":{"id":312,"type":"article-journal","abstract":"Conscientious objection has become a divisive topic in recent bioethics publications. Discussion has tended to frame the issue in terms of the rights of the healthcare professional versus the rights of the patient. However, a rights-based approach neglects the relational nature of conscience, and the impact that violating ones conscience has on the care one provides. Using medical assistance in dying as a case study, we suggest that what has been lacking in the discussion of conscientious objection thus far is a recognition and prioritising of the relational nature of ethical decision-making in healthcare and the negative consequences of moral distress that occur when healthcare professionals find themselves in situations in which they feel they cannot provide what they consider to be excellent care. We propose that policies that respect the relational conscience could benefit our healthcare institutions by minimising the negative impact of moral distress, improving communication among team members and fostering a culture of ethical awareness. Constructive responses to moral distress including relational cultivation of moral resilience are urged.","container-title":"Journal of Medical Ethics","DOI":"10.1136/medethics-2019-105855","ISSN":"0306-6800, 1473-4257","issue":"2","language":"en","license":" Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.","note":"publisher: Institute of Medical Ethicsnsection: Extended essaynPMID: 31811013","page":"123-127","source":"jme.bmj.com","title":"Conscientious objection and moral distress: a relational ethics case study of MAiD in Canada","title-short":"Conscientious objection and moral distress","volume":"46","author":[{"family":"Heilman","given":"Mary Kathleen Deutscher"},{"family":"Trothen","given":"Tracy J."}],"issued":{"date-parts":[["2020",2,1]]}}},{"id":337,"uris":["http://zotero.org/users/14650052/items/BDRBKVPY"],"itemData":{"id":337,"type":"article-journal","abstract":"Since the legalization of medical assistance in dying (MAiD) in Canada in 2016, volitional non-participation in MAiD on the part of some healthcare institutions has revealed ethical uncertainties, potential access problems, and policy gaps. The problem has remained much neglected in the literature base, with no comprehensive studies on the subject so far. We analyzed print media articles and grey literature on institutional objections to and non-participation in MAiD. Thematic analyses were performed on all data to better understand the diverse stakeholder arguments and positions that characterize this important public health debate. Our search yielded 89 relevant media articles and 22 legislative, policy, and other relevant documents published since 2016 in the English language. We identified four main themes about institutional refusals to participate in MAiD, articulated as the following questions: (1) Who has the right to conscience? (2) Can MAiD be considered a palliative practice? (3) Are there imbalances across diverse stakeholder rights and burdens? and (4) Where are the gaps being felt in MAiD service implementation? Stakeholder views about institutional conscience with respect to MAiD are varied, complex, and evolving. In the absence of substantial systematic evidence, public domain materials constitute a key resource for understanding the implications for service access and determining the relevance of this contentious issue for future MAiD research and policy.","container-title":"Healthcare","DOI":"10.3390/healthcare11162305","ISSN":"2227-9032","issue":"16","language":"en","license":"http://creativecommons.org/licenses/by/3.0/","note":"number: 16npublisher: Multidisciplinary Digital Publishing Institute","page":"2305","source":"www.mdpi.com","title":"Institutional Resistance to Medical Assistance in Dying in Canada: Arguments and Realities Emerging in the Public Domain","title-short":"Institutional Resistance to Medical Assistance in Dying in Canada","volume":"11","author":[{"family":"Knox","given":"Michelle"},{"family":"Wagg","given":"Adrian"}],"issued":{"date-parts":[["2023",1]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Heilman & Trothen, 2020; Knox & Wagg, 2023).

CO or IO not only affect the quality of care provided to patients but also has a considerable impact on the emotional and professional, including moral distress, burnout, and feelings of failure among NPHPs. These issues highlight the need for enhanced emotional support systems for NPHPs.

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Assisted dying (AD)

Non-provider health professionals (NPHPs)

MethodologyThis study explores the lived experiences, particularly of NPHPs emotional experiences when who are providing care for patients undergoing the AD process. I used a qualitative approach, informed by interpretivism, grounded in phenomenology to analyse semi-structured interviews with NPHPs. In this chapter, I consider the relevance of interpretive phenomenology to my research aim. The interpretive phenomenology was chosen as it enables the research to explore how NPHPs perception of their lived experience contributes to emotional experience when involved in AD. To recap, the research questions guiding my study are: What are the emotional experiences of NPHPs involved in AD? and from the perspectives of NPHPs What impacts these experiences?. This study used existing data provided collected by my supervisors, who were the interviewers., and I was responsible for checking transcripts and analysing the data. In this chapter, I consider the relevance of interpretive phenomenology to my research aim. I also discuss describe the process of recruiting participants and interviewing as well as describe discuss how I use reflexive thematic analysis as a guide to analyse the dataset. Lastly, I outlined the ethical considerations for this study.

Qualitative Research MethodologyQualitative research primarily focuses on understanding individual and collective human experiences by delving into their personal and social significance ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"BfTp5EgM","properties":{"formattedCitation":"(Hesse-Biber & Leavy, 2006)","plainCitation":"(Hesse-Biber & Leavy, 2006)","noteIndex":0},"citationItems":[{"id":133,"uris":["http://zotero.org/users/local/Nb00G2jp/items/72QGYBHW"],"uri":["http://zotero.org/users/local/Nb00G2jp/items/72QGYBHW"],"itemData":{"id":133,"type":"book","title":"The Practice of Qualitative Research","publisher":"SAGE","number-of-pages":"424","source":"Google Books","abstract":"The Practice of Qualitative Research provides students with a "hands-on" introduction to qualitative research methods through the use of in-depth examples and out-of-class exercises. Rather than separating theory from methods and presenting students with a laundry list of methods as so many texts do, authors Sharlene Nagy Hesse-Biber and Patricia Leavy provide readers with a holistic approach to research by tightly linking theory and methods throughout the book. The authors cover all the key mainstream qualitative methods, as well as a number of more unconventional ones such as oral history, visual and unobtrusive methods, and present an overview of mixed-methods approaches. As part of their discussion of the ethical issues underpinning all social research, the authors raise important issues concerning the problems and prospects novice researchers confront in researching human subjects. The Practice of Qualitative Research is designed for advanced undergraduate and graduate students studying qualitative research in the social sciences-especially Sociology, Women's Studies, Psychology, Anthropology, and Communications. The book presents a feminist research perspective and follows the interpretivist approach to qualitative methods, making it is an invaluable text for any course in which these are core components. The candid wisdom and tips from leading researchers will help students with the day-to-day process of completing a successful research project. Book jacket.","ISBN":"978-0-7619-2826-3","language":"en","author":[{"family":"Hesse-Biber","given":"Sharlene Nagy"},{"family":"Leavy","given":"Patricia"}],"issued":{"date-parts":[["2006"]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Hesse-Biber & Leavy, 2006). Unlike quantitative methodologies, that emphasise rigidity and objectivity for testing hypotheses or theories, qualitative descriptive studies aim to provide a comprehensive and accurate portrayal of events or phenomena, including their meanings from the participants perspectives ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"ekR8Fbku","properties":{"formattedCitation":"(Ayres, 2007)","plainCitation":"(Ayres, 2007)","noteIndex":0},"citationItems":[{"id":128,"uris":["http://zotero.org/users/local/Nb00G2jp/items/CUCZFTZI"],"uri":["http://zotero.org/users/local/Nb00G2jp/items/CUCZFTZI"],"itemData":{"id":128,"type":"article-journal","title":"Qualitative Research ProposalsPart I: Posing the Problem","container-title":"Journal of Wound Ostomy & Continence Nursing","page":"30","volume":"34","issue":"1","source":"journals.lww.com","abstract":"An abstract is unavailable.","ISSN":"1071-5754","shortTitle":"Qualitative Research ProposalsPart I","language":"en-US","author":[{"family":"Ayres","given":"Lioness"}],"issued":{"date-parts":[["2007",2]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Ayres, 2007). Through in-depth exploration, researchers develop narratives rich in data, detail, and description. Within the qualitative umbrella, various approaches exist, including ethnography, case studies, phenomenology, grounded theory, and narrative analysis, commonly employed in health, nursing, and psychological research. Approaches such as phenomenology or grounded theoryThese approaches push researchers to delve deeper into participants experiences and interpret beyond literal words ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"UmLriP67","properties":{"formattedCitation":"(Sandelowski, 2000)","plainCitation":"(Sandelowski, 2000)","noteIndex":0},"citationItems":[{"id":135,"uris":["http://zotero.org/users/local/Nb00G2jp/items/ZG34QCV4"],"uri":["http://zotero.org/users/local/Nb00G2jp/items/ZG34QCV4"],"itemData":{"id":135,"type":"article-journal","title":"Whatever happened to qualitative description?","container-title":"Research in Nursing & Health","page":"334-340","volume":"23","issue":"4","source":"Wiley Online Library","abstract":"The general view of descriptive research as a lower level form of inquiry has influenced some researchers conducting qualitative research to claim methods they are really not using and not to claim the method they are using: namely, qualitative description. Qualitative descriptive studies have as their goal a comprehensive summary of events in the everyday terms of those events. Researchers conducting qualitative descriptive studies stay close to their data and to the surface of words and events. Qualitative descriptive designs typically are an eclectic but reasonable combination of sampling, and data collection, analysis, and re-presentation techniques. Qualitative descriptive study is the method of choice when straight descriptions of phenomena are desired. 2000 John Wiley & Sons, Res Nurs Health 23:334340, 2000.","DOI":"10.1002/1098-240X(200008)23:4<334::AID-NUR9>3.0.CO;2-G","ISSN":"1098-240X","language":"en","author":[{"family":"Sandelowski","given":"Margarete"}],"issued":{"date-parts":[["2000"]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Sandelowski, 2000). Within the qualitative umbrella, various approaches exist, including ethnography, case studies, phenomenology, grounded theory, and narrative analysis, commonly employed in health, nursing, and psychological research. These methods prioritise linguistic over numeric data and meaning-based rather than statistical analysis ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"gUf2lIcS","properties":{"formattedCitation":"(Denzin & Lincoln, 2008)","plainCitation":"(Denzin & Lincoln, 2008)","dontUpdate":true,"noteIndex":0},"citationItems":[{"id":130,"uris":["http://zotero.org/users/local/Nb00G2jp/items/AHAG622R"],"uri":["http://zotero.org/users/local/Nb00G2jp/items/AHAG622R"],"itemData":{"id":130,"type":"book","title":"Collecting and Interpreting Qualitative Materials. Third Edition","publisher":"SAGE Publications","source":"ERIC","abstract":"This book is the third volume of the paperback versions of "The SAGE Handbook of Qualitative Research, Third Edition." This portion of the handbook considers the tasks of collecting, analyzing, and interpreting empirical materials, and comprises the Handbook's Parts IV ("Methods of Collecting and Analyzing Empirical Materials") and V ("The Art and Practices of Interpretation, Evaluation, and Presentation"). "Collecting and Interpreting Qualitative Materials, Third Edition" introduces the researcher to basic methods of gathering, analyzing and interpreting qualitative empirical materials. Part I moves from interviewing to observing, to the use of artifacts, documents and records from the past; to visual, and autoethnographic methods. It then takes up analysis methods, including computer-assisted methodologies, as well as strategies for analyzing talk and text. This Third Edition contains a new Reader's Guide prepared by the editors that helps students and researchers navigate through the chapters, locating the different methodologies, methods, techniques, issues, and theories relevant to their work. It presents an abbreviated Glossary of terms that offer students and researchers a ready resource to help decode the language of qualitative research. The book offers recommended Readings that provide readers with additional sources on specific topic areas linked to their research. This text is designed for graduate students taking classes in social research methods and qualitative methods as well as researchers throughout the social sciences and in some fields within the humanities. An introductory chapter, "The Discipline and Practice of Qualitative Research," by editors Norman K. Denzin and Yvonna S. Lincoln, begins the book. Part I, Methods of Collecting and Analyzing Empirical Materials, contains chapters: (2) Narrative Inquiry: Multiple Lenses, Approaches, Voices (Susan E. Chase); (3) Arts-Based Inquiry: Performing Revolutionary Pedagogy (Susan Finley); (4) The Interview: From Neutral Stance to Political Involvement (Andrea Fontana and James H. Frey); (5) Recontextualizing Observation: Ethnography, Pedagogy, and the Prospects for a Progressive Political Agenda (Michael V. Angrosino); (6) What's New Visually? (Douglas Harper); (7) Autoethnography: Making the Personal Political (Stacy Holman Jones); (8) The Methods, Politics, and Ethics of Representation in Online Ethnography (Annette N. Markham); (9) Analytic Perspectives (Paul Atkinson and Sara Delamont); (10) Foucault's Methodologies: Archeaology and Genealogy (James Joseph Scheurich and Kathryn Bell McKenzie); (11) Analyzing Talk and Text (Anssi Perakyla); and (12) Focus Groups: Strategic Articulations of Pedagogy, Politics, and Inquiry (George Kamberelis and Greg Dimitriadis). Part II, The Art and Practices of Interpretation, Evaluation, and Representation, contains chapters: (13) Relativism, Criteria, and Politics (John K. Smith and Phil Hodkinson); (14) Emancipatory Discourses and the Ethics and Politics of Interpretation (Norman K. Denzin); (15) Writing: A Method of Inquiry (Laurel Richardson and Elizabeth Adams St. Pierre); (16) Poetics for a Planet: Discourse on Some Problems of Being-in-Place (Ivan Brady); (17) Cultural Poesis: The Generativity of Emergent Things (Kathleen Stewart); (18) "Aria in Time of War:" Investigative Poetry and the Politics of Witnessing (Stephen J. Hartnett and Jeremy D. Engels); and (19) Qualitative Evaluation and Changing Social Policy (Ernest R. House). 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A qualitative research methodology was considered appropriate for this study. The nature of qualitative research provides an ability to gather information about patterns of human behaviour or experiences that can be difficult to quantify ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"19V0huIe","properties":{"formattedCitation":"(Tenny et al., 2022)","plainCitation":"(Tenny et al., 2022)","noteIndex":0},"citationItems":[{"id":137,"uris":["http://zotero.org/users/local/Nb00G2jp/items/HVJMSK44"],"uri":["http://zotero.org/users/local/Nb00G2jp/items/HVJMSK44"],"itemData":{"id":137,"type":"chapter","title":"Qualitative Study","container-title":"StatPearls","publisher":"StatPearls Publishing","publisher-place":"Treasure Island (FL)","source":"PubMed","event-place":"Treasure Island (FL)","abstract":"Qualitative research is a type of research that explores and provides deeper insights into real-world problems. Instead of collecting numerical data points or intervening or introducing treatments just like in quantitative research, qualitative research helps generate hypothenar to further investigate and understand quantitative data. Qualitative research gathers participants' experiences, perceptions, and behavior. It answers the hows and whys instead of how many or how much. It could be structured as a standalone study, purely relying on qualitative data, or part of mixed-methods research that combines qualitative and quantitative data. This review introduces the readers to some basic concepts, definitions, terminology, and applications of qualitative research. Qualitative research, at its core, asks open-ended questions whose answers are not easily put into numbers, such as "how" and "why." Due to the open-ended nature of the research questions, qualitative research design is often not linear like quantitative design. One of the strengths of qualitative research is its ability to explain processes and patterns of human behavior that can be difficult to quantify. Phenomena such as experiences, attitudes, and behaviors can be complex to capture accurately and quantitatively. In contrast, a qualitative approach allows participants themselves to explain how, why, or what they were thinking, feeling, and experiencing at a particular time or during an event of interest. Quantifying qualitative data certainly is possible, but at its core, qualitative data is looking for themes and patterns that can be difficult to quantify, and it is essential to ensure that the context and narrative of qualitative work are not lost by trying to quantify something that is not meant to be quantified. However, while qualitative research is sometimes placed in opposition to quantitative research, where they are necessarily opposites and therefore "compete" against each other and the philosophical paradigms associated with each other, qualitative and quantitative work are neither necessarily opposites, nor are they incompatible. While qualitative and quantitative approaches are different, they are not necessarily opposites and certainly not mutually exclusive. For instance, qualitative research can help expand and deepen understanding of data or results obtained from quantitative analysis. For example, say a quantitative analysis has determined a correlation between length of stay and level of patient satisfaction, but why does this correlation exist? This dual-focus scenario shows one way in which qualitative and quantitative research could be integrated.","URL":"http://www.ncbi.nlm.nih.gov/books/NBK470395/","call-number":"NBK470395","note":"PMID: 29262162","language":"eng","author":[{"family":"Tenny","given":"Steven"},{"family":"Brannan","given":"Janelle M."},{"family":"Brannan","given":"Grace D."}],"issued":{"date-parts":[["2022"]]},"accessed":{"date-parts":[["2024",5,29]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Tenny et al., 2022). It can, therefore, provide valuable insights into the subjective experiences of NPHPs perspectives. Different qualitative approaches employ diverse data collection and analysis methods, providing researchers with a pathway to understanding participants' experiences. Data sources in this study may encompass interview transcripts, video recordings, and reflective diaries documenting participants' and reseachermy experiences and reflections ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"6gcIxuPh","properties":{"formattedCitation":"(Saldana, 2011)","plainCitation":"(Saldana, 2011)","noteIndex":0},"citationItems":[{"id":140,"uris":["http://zotero.org/users/local/Nb00G2jp/items/AFIZPCLK"],"uri":["http://zotero.org/users/local/Nb00G2jp/items/AFIZPCLK"],"itemData":{"id":140,"type":"book","title":"Fundamentals of research: Understanding qualitative research","publisher":"Oxford University Press","publisher-place":"NY","event-place":"NY","URL":"https://nibmehub.com/opac-service/pdf/read/Fundamentals%20of%20Qualitative%20Research.pdf","author":[{"family":"Saldana","given":"J"}],"issued":{"date-parts":[["2011"]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Saldana, 2011).

Paradigm: InterpretivismInterpretivism is being positioned as an opposition to positivism or and has been labelled as anti-positivism ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"TowKva44","properties":{"formattedCitation":"(Clark et al., 2021)","plainCitation":"(Clark et al., 2021)","noteIndex":0},"citationItems":[{"id":106,"uris":["http://zotero.org/users/local/Nb00G2jp/items/C83UFATE"],"uri":["http://zotero.org/users/local/Nb00G2jp/items/C83UFATE"],"itemData":{"id":106,"type":"book","title":"Bryman's Social Research Methods","publisher":"Oxford University Press","number-of-pages":"705","source":"Google Books","abstract":"Clear, comprehensive, and trusted, Bryman's Social Research Methods has supported over a quarter of a million students through their research methods course and research project. Spanning theory and practice and covering quantitative, qualitative, and mixed methods, this bestselling text offers unrivalled coverage of the whole research process. The authors have worked closely with lecturers and students in thoroughly updating the sixth edition to reflect the current social science landscape, and carefully streamlining content to make it relevant and appealing to today's students. As a result, the text's comprehensive coverage - which includes many new examples and additional material on areas such as social media research and big data - is now even clearer, more focused, and easier to navigate. In addition to many new examples of published research, this edition features the insights of a panel of recent graduates from their experiences of researching a variety of fascinating topics, including attitudes towards the LGBT+ community on social media, the experiences of Pakistani Muslim single mothers, and the impact of screen time on sleep. 'Learn from experience' boxes in every chapter contain their candid reflections on the successes and challenges of their projects, and their advice for student researchers. Digital formats and resources Bryman's Social Research Methods is available for students and institutions to purchase in a variety of formats, and is supported by extensive online resources. The e-book offers a mobile experience and convenient access, with learning resources embedded and hyperlinked throughout to offer self-assessment activities and extra support: www.oxfordtextbooks.co.uk/ebooks The student resources, accessible both online and via the e-book, include: - Over 300 multiple choice questions - A 'Research process in practice' simulation - Student researcher's toolkit - Answers to the end-of-chapter questions, including audio commentary from the authors - A flashcard glossary - Data analysis software tutorials covering SPSS, Nvivo, R, and Stata - Guidance on using Excel in data analysis - 'Learn from experience' videos, expanding on the graduate insights provided in the book The book's teaching resources, accessible online to adopting lecturers, include: - PowerPoint slides for every chapter - 250 test bank questions - 25 seminar outlines - 75 exam- or coursework-based questions - Figures and tables from the book","URL":"https://books.google.co.nz/books?hl=en&lr=&id=QJg5EAAAQBAJ&oi=fnd&pg=PP1&dq=Bryman.A+(2008)+3rd+Ed.+Social+Research+Methods,+Oxford+University+Press,+London+UK&ots=5mImqoSU3x&sig=aix-iHtrRlDKkfPJzLaWyPG93Ek#v=onepage&q&f=false","ISBN":"978-0-19-879605-3","note":"Google-Books-ID: QJg5EAAAQBAJ","language":"en","author":[{"family":"Clark","given":"Tom"},{"family":"Foster","given":"Liam"},{"family":"Bryman","given":"Alan"},{"family":"Sloan","given":"Luke"}],"issued":{"date-parts":[["2021"]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Clark et al., 2021). Interpretivism traces back to the 18th century, attributed to philosopher Giambattista Vico, who challenged Descartes views of. Vico argued for a differentiatingion between natural and social realms, emphasising the influence of social structures and experiences on our perceptions of reality and truth ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"mbM6Tx9v","properties":{"formattedCitation":"(Ryan, 2018)","plainCitation":"(Ryan, 2018)","noteIndex":0},"citationItems":[{"id":143,"uris":["http://zotero.org/users/local/Nb00G2jp/items/IQYAYTLF"],"uri":["http://zotero.org/users/local/Nb00G2jp/items/IQYAYTLF"],"itemData":{"id":143,"type":"article-journal","title":"Introduction to Positivism, Interpretivism and Critical Theory","page":"41-49","volume":"25","issue":"4","journalAbbreviation":"Nurse Researcher","author":[{"family":"Ryan","given":"Gemma"}],"issued":{"date-parts":[["2018"]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Ryan, 2018). According to interpretivism, truth and knowledge are subjective, shaped by cultural and historical contexts, as well asand influenced by individuals experiences and interpretations. Researchers cannot fully detach themselves from their values and beliefs, which inevitably impacts data collection, interpretation, and analysis (Bunnis & Kelly, 2010; Ryan, 2018). Studies conducted from an interpretivist perspective would consider how the researchers thoughts, feelings, opinions and experiences might influence what is observed and recorded (Bunnis & Kelly, 2010).

Interpretivism's ontology sees reality as subjective, meaning that individuals create their own versions of reality based on their perceptions and interpretations (Bunniss & Kelly, 2010). Epistemologically, interpretivism emphasises that reality and knowledge are constructed through language and social interactions ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"TQQjfDzh","properties":{"formattedCitation":"(Bunniss & Kelly, 2010)","plainCitation":"(Bunniss & Kelly, 2010)","noteIndex":0},"citationItems":[{"id":141,"uris":["http://zotero.org/users/local/Nb00G2jp/items/R7TN3CVG"],"uri":["http://zotero.org/users/local/Nb00G2jp/items/R7TN3CVG"],"itemData":{"id":141,"type":"article-journal","title":"Research paradigms in medical education research","container-title":"Medical Education","page":"358-366","volume":"44","issue":"4","source":"Wiley Online Library","abstract":"Medical Education 2010: 44: 358366 Context The growing popularity of less familiar methodologies in medical education research, and the use of related data collection methods, has made it timely to revisit some basic assumptions regarding knowledge and evidence. Methods This paper outlines four major research paradigms and examines the methodological questions that underpin the development of knowledge through medical education research. Discussion This paper explores the rationale behind different research designs, and shows how the underlying research philosophy of a study can directly influence what is captured and reported. It also explores the interpretivist perspective in some depth to show how less familiar paradigm perspectives can provide useful insights to the complex questions generated by modern healthcare practice. Conclusions This paper concludes that the quality of research is defined by the integrity and transparency of the research philosophy and methods, rather than the superiority of any one paradigm. By demonstrating that different methodological approaches deliberately include and exclude different types of data, this paper highlights how competing knowledge philosophies have practical implications for the findings of a study.","DOI":"10.1111/j.1365-2923.2009.03611.x","ISSN":"1365-2923","language":"en","author":[{"family":"Bunniss","given":"Suzanne"},{"family":"Kelly","given":"Diane R"}],"issued":{"date-parts":[["2010"]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Bunniss & Kelly, 2010). Therefore, interpretivism can have multiple and diverse interpretations of reality. There is no singular or correct way of knowing.

Design: PhenomenologyThe following is section is a brief introduction to the background of phenomenology. There are different versions of the story of its development ref. This version presents a better structural flow of how different elements evolve and develop into the phenomenology that I woudrawing onld am apply in this studyHeideggerian interpretive phenomenology. A brief introduction to the background of phenomenology provides the reader with a sense of reliability of the paradigm Phenomenology, originating from Johann Heinrickh Lambert in 1764, is a philosophical approach that focuses on understanding phenomena as they appear to us, without judgment or preconceptions ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"pMdMCSKd","properties":{"formattedCitation":"(Rashid et al., 2021)","plainCitation":"(Rashid et al., 2021)","noteIndex":0},"citationItems":[{"id":114,"uris":["http://zotero.org/users/local/Nb00G2jp/items/ACVE8NI8"],"uri":["http://zotero.org/users/local/Nb00G2jp/items/ACVE8NI8"],"itemData":{"id":114,"type":"article-journal","title":"Alfred Schutz's Perspective in Phenomenology Approach: Concepts, Characteristics, Methods and Examples","container-title":"International Journal of Educational Research & Social Sciences","page":"190-201","ISSN":"2774-5406","author":[{"family":"Rashid","given":"Ruslan"},{"family":"Djafar","given":"Hilman"},{"family":"Santoso","given":"Budi"}],"issued":{"date-parts":[["2021"]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Rashid et al., 2021). While Lambert laid its initial foundations, Edmund Husserl is widely regarded as the father of modern phenomenology due to his extensive philosophical inquiries ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"NYv0EIza","properties":{"formattedCitation":"(Gelvan, 1970)","plainCitation":"(Gelvan, 1970)","noteIndex":0},"citationItems":[{"id":126,"uris":["http://zotero.org/users/local/Nb00G2jp/items/CSKQ4FZX"],"uri":["http://zotero.org/users/local/Nb00G2jp/items/CSKQ4FZX"],"itemData":{"id":126,"type":"book","title":"A Commentary on Heidegger's "Being and Time"","publisher":"Harper & Row Publisher","publisher-place":"New York, N.Y","event-place":"New York, N.Y","author":[{"family":"Gelvan","given":"Michael"}],"issued":{"date-parts":[["1970"]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Gelvan, 1970). Alfred Schutz is credited with making phenomenology concepts more accessible and applicable, especially in social science research (Rashid et al., 2021). Max Webers theory of social action served as a precursor to phenomenological perspective (and symbolic interactionism). Webers concept of verstehen (understand) aligns with phenomenologys emphasis on grasping the subjective meaning behind human actions. For Weber, social action is inherently meaningful and involves interpretation and deliberate behaviour (Rashid et al., 2021).

Husserl then critiqued existing scientific knowledge for being detached from everyday experiences and offered phenomenology as a way to bridge this gap .ref. He emphasised the importance of being open-minded and experiencing reality directly through the senses. Husserl's phenomenological concept, influenced by Weber's verstehen, underscores emphasises the idea that reality should be understood rather than explained. Schutz expanded on Husserls ideas by highlighting the significance of understanding actions and interactions for social existence ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"FOWv0SQG","properties":{"formattedCitation":"(Clark et al., 2021)","plainCitation":"(Clark et al., 2021)","noteIndex":0},"citationItems":[{"id":106,"uris":["http://zotero.org/users/local/Nb00G2jp/items/C83UFATE"],"uri":["http://zotero.org/users/local/Nb00G2jp/items/C83UFATE"],"itemData":{"id":106,"type":"book","title":"Bryman's Social Research Methods","publisher":"Oxford University Press","number-of-pages":"705","source":"Google Books","abstract":"Clear, comprehensive, and trusted, Bryman's Social Research Methods has supported over a quarter of a million students through their research methods course and research project. Spanning theory and practice and covering quantitative, qualitative, and mixed methods, this bestselling text offers unrivalled coverage of the whole research process. The authors have worked closely with lecturers and students in thoroughly updating the sixth edition to reflect the current social science landscape, and carefully streamlining content to make it relevant and appealing to today's students. As a result, the text's comprehensive coverage - which includes many new examples and additional material on areas such as social media research and big data - is now even clearer, more focused, and easier to navigate. In addition to many new examples of published research, this edition features the insights of a panel of recent graduates from their experiences of researching a variety of fascinating topics, including attitudes towards the LGBT+ community on social media, the experiences of Pakistani Muslim single mothers, and the impact of screen time on sleep. 'Learn from experience' boxes in every chapter contain their candid reflections on the successes and challenges of their projects, and their advice for student researchers. Digital formats and resources Bryman's Social Research Methods is available for students and institutions to purchase in a variety of formats, and is supported by extensive online resources. The e-book offers a mobile experience and convenient access, with learning resources embedded and hyperlinked throughout to offer self-assessment activities and extra support: www.oxfordtextbooks.co.uk/ebooks The student resources, accessible both online and via the e-book, include: - Over 300 multiple choice questions - A 'Research process in practice' simulation - Student researcher's toolkit - Answers to the end-of-chapter questions, including audio commentary from the authors - A flashcard glossary - Data analysis software tutorials covering SPSS, Nvivo, R, and Stata - Guidance on using Excel in data analysis - 'Learn from experience' videos, expanding on the graduate insights provided in the book The book's teaching resources, accessible online to adopting lecturers, include: - PowerPoint slides for every chapter - 250 test bank questions - 25 seminar outlines - 75 exam- or coursework-based questions - Figures and tables from the book","URL":"https://books.google.co.nz/books?hl=en&lr=&id=QJg5EAAAQBAJ&oi=fnd&pg=PP1&dq=Bryman.A+(2008)+3rd+Ed.+Social+Research+Methods,+Oxford+University+Press,+London+UK&ots=5mImqoSU3x&sig=aix-iHtrRlDKkfPJzLaWyPG93Ek#v=onepage&q&f=false","ISBN":"978-0-19-879605-3","note":"Google-Books-ID: QJg5EAAAQBAJ","language":"en","author":[{"family":"Clark","given":"Tom"},{"family":"Foster","given":"Liam"},{"family":"Bryman","given":"Alan"},{"family":"Sloan","given":"Luke"}],"issued":{"date-parts":[["2021"]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Clark et al., 2021). He emphasised the role of consciousness and social relationships in shaping individuals experiences. Later on, besides Husserl and Schutz, phenomenology was further developed by thinkers like Morleau-Ponty, Martin Heidegger and others, all sharing a common belief in the possibility of understanding true reality and desire to break through barriers that obscure individuals to see the true reality (Lubis, 2004 as cited in ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"rRikXsHe","properties":{"formattedCitation":"(Rashid et al., 2021)","plainCitation":"(Rashid et al., 2021)","dontUpdate":true,"noteIndex":0},"citationItems":[{"id":114,"uris":["http://zotero.org/users/local/Nb00G2jp/items/ACVE8NI8"],"uri":["http://zotero.org/users/local/Nb00G2jp/items/ACVE8NI8"],"itemData":{"id":114,"type":"article-journal","title":"Alfred Schutz's Perspective in Phenomenology Approach: Concepts, Characteristics, Methods and Examples","container-title":"International Journal of Educational Research & Social Sciences","page":"190-201","ISSN":"2774-5406","author":[{"family":"Rashid","given":"Ruslan"},{"family":"Djafar","given":"Hilman"},{"family":"Santoso","given":"Budi"}],"issued":{"date-parts":[["2021"]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} Rashid et al., 2021).

Building upon the foundation of phenomenology laid out by thinkers like Husserl and Schutz, the exploration of subjective experience and the pursuit of understanding reality were deepened. The contributions of Husserl and Heidegger, two pivotal figures whose works significantly influenced the course of phenomenology, included the descriptive school derived from Husserls work and the interpretive school following Heideggers hermeneutic philosophy (Mapp, 2008). Phenomenology, initially conceived as a descriptive approach, was also known as Husserlian phenomenology ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"IKfLmLWj","properties":{"formattedCitation":"(Mapp, 2008)","plainCitation":"(Mapp, 2008)","dontUpdate":true,"noteIndex":0},"citationItems":[{"id":55,"uris":["http://zotero.org/users/local/Nb00G2jp/items/88Q75R8W"],"uri":["http://zotero.org/users/local/Nb00G2jp/items/88Q75R8W"],"itemData":{"id":55,"type":"article-journal","title":"Understanding phenomenology: the lived experience","container-title":"British Journal of Midwifery","page":"308-311","volume":"16","issue":"5","source":"magonlinelibrary.com (Atypon)","abstract":"This article details the use of Phenomenology as a research method which is to fully describe a person's lived experience of an event or experience. It stresses that only those that have experienced phenomena can communicate them to the outside world. It therefore provides an understanding of an experience from those who have lived it. The two schools of phenomenology which are described are utilized in both midwifery and nursing research. These are Husserlian and Heideggerian (Hermeneutics) phenomenology. The main focus in this article, however, is on the Husserlian approach, its background, data collection, data analysis methods and its application to midwifery research.","DOI":"10.12968/bjom.2008.16.5.29192","ISSN":"0969-4900","shortTitle":"Understanding phenomenology","author":[{"family":"Mapp","given":"Taniya"}],"issued":{"date-parts":[["2008",5]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Mapp, 2008; ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"cgmyNuUj","properties":{"formattedCitation":"(Moran, 1999)","plainCitation":"(Moran, 1999)","dontUpdate":true,"noteIndex":0},"citationItems":[{"id":58,"uris":["http://zotero.org/users/local/Nb00G2jp/items/D7NGWQ9M"],"uri":["http://zotero.org/users/local/Nb00G2jp/items/D7NGWQ9M"],"itemData":{"id":58,"type":"book","title":"Introduction to Phenomenology","publisher":"Routledge","publisher-place":"London","number-of-pages":"592","event-place":"London","abstract":"Introduction to Phenomenology is an outstanding and comprehensive guide to phenomenology. Dermot Moran lucidly examines the contributions of phenomenology's nine seminal thinkers: Brentano, Husserl, Heidegger, Gadamer, Arendt, Levinas, Sartre, Merleau-Ponty and Derrida.Written in a clear and engaging style, Introduction to Phenomenology charts the course of the phenomenological movement from its origins in Husserl to its transformation by Derrida. It describes the thought of Heidegger and Sartre, phenomonology's most famous thinkers, and introduces and assesses the distinctive use of phenomonology by some of its lesser known exponents, such as Levinas, Arendt and Gadamer. Throughout the book, the enormous influence of phenomenology on the course of twentieth-century philosophy is thoroughly explored.This is an indispensible introduction for all unfamiliar with this much talked about but little understood school of thought. Technical terms are explained throughout and jargon is avoided. Introduction to Phenomenology will be of interest to all students seeking a reliable introduction to a key movement in European thought.","URL":"https://www.drghazi.net/media/drghazi/365.pdf","ISBN":"978-0-203-19663-2","note":"DOI: 10.4324/9780203196632","author":[{"family":"Moran","given":"Dermot"}],"issued":{"date-parts":[["1999",12,23]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} Moran, 1999). This approach introduced the "bracketing" practice, where researchers suspend their own preconceptions, sebeliefs, or biases to prevent them from influencing their interpretation of respondents' experiences. This necessitates the researcher to set aside personal beliefs while focusing on describing participants' experiences. Contrary to Husserlian phenomenology, Heideggerian phenomenology suggests that researchers interpret collected data through their own experiences and knowledge. In my study, I specifically focused on Heideggerian interpretive phenomenology (and hermeneutics) as the basis for qualitative research methodology, which is explained further in the following section.

Heideggerian Interpretive PhenomenologyThe foundation of Heideggerian interpretive phenomenology lies in the concept of Dasein. It is a German word meaning existence, or as Heidegger would sayis translated to, being-there ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"I5axrb21","properties":{"formattedCitation":"(Schacht, 1972)","plainCitation":"(Schacht, 1972)","noteIndex":0},"citationItems":[{"id":196,"uris":["http://zotero.org/users/local/Nb00G2jp/items/DIRWBXLY"],"uri":["http://zotero.org/users/local/Nb00G2jp/items/DIRWBXLY"],"itemData":{"id":196,"type":"article-journal","title":"Husserlian and Heideggerian phenomenology","page":"293-314","volume":"23","issue":"5","journalAbbreviation":"Philosophical Studies: An International Journal for Philosophy in the Analytic Tradition","author":[{"family":"Schacht","given":"R"}],"issued":{"date-parts":[["1972"]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Schacht, 1972). or it cannot be simply understood by the single word meaning. Heidegger writes of Dasein as Being-in-the-world. It, which emphasises the interconnectedness of human beings with their surroundings. It highlights that humans and the environment should be interpreted as one entity instead of the Cartesian dualism of subject and object (Heidegger, 1927).

Heideggerian phenomenology proposesd that everyday phenomena are mostly hidden, covered in multiple layers of forgetfulness (Heidegger, 1927a as cited in ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"C9TqATEw","properties":{"formattedCitation":"(Frechette et al., 2020)","plainCitation":"(Frechette et al., 2020)","dontUpdate":true,"noteIndex":0},"citationItems":[{"id":41,"uris":["http://zotero.org/users/local/Nb00G2jp/items/KJY9T6HR"],"uri":["http://zotero.org/users/local/Nb00G2jp/items/KJY9T6HR"],"itemData":{"id":41,"type":"article-journal","title":"Capturing Lived Experience: Methodological Considerations for Interpretive Phenomenological Inquiry","container-title":"International Journal of Qualitative Methods","page":"1-12","volume":"19","source":"SAGE Journals","abstract":"Interpretive phenomenology presents a unique methodology for inquiring into lived experience, yet few scholarly articles provide methodological guidelines for researchers, and many studies lack coherence with the methodologys philosophical foundations. This article contributes to filling these gaps in qualitative research by examining the following question: What are the key methodological and philosophical considerations of leading an interpretive phenomenological study? An exploration of interpretive phenomenologys foundations, including Heideggerian philosophy and Benners applications in health care, will show how the philosophical tradition can guide research methodology. The interpretive phenomenological concepts of Dasein, lived experience, existentialia, authenticity are at the core of the discussion while relevant methodological concerns include research paradigm, researchers stance, objective and research question, sampling and recruitment, data collection, and data analysis. A study of pediatric intensive care unit nurses lived experience of a major hospital transformation project will illustrate these research considerations. This methodological article is innovative in that it explicitly describes the ties between the operational elements of an interpretive phenomenological study and the philosophical tradition. This endeavor is particularly warranted, as the essence of phenomenology is to bring to light what is taken for granted, and yet phenomenological research paradoxically makes frequent assumptions concerning the philosophical underpinnings.","DOI":"10.1177/1609406920907254","ISSN":"1609-4069","shortTitle":"Capturing Lived Experience","language":"en","author":[{"family":"Frechette","given":"Julie"},{"family":"Bitzas","given":"Vasiliki"},{"family":"Aubry","given":"Monique"},{"family":"Kilpatrick","given":"Kelley"},{"family":"Lavoie-Tremblay","given":"Mlanie"}],"issued":{"date-parts":[["2020",1,1]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} Frechette et al., 2020). Being-in-the-world is to bring the underlying or hiddenness that often occurs in our everyday existence back to the consciousness state through existentialia (the equiprimordial elements of the structure of existence) like mood (Heidegger, 1927a as cited in ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"MnkhPRZ5","properties":{"formattedCitation":"(Frechette et al., 2020)","plainCitation":"(Frechette et al., 2020)","dontUpdate":true,"noteIndex":0},"citationItems":[{"id":41,"uris":["http://zotero.org/users/local/Nb00G2jp/items/KJY9T6HR"],"uri":["http://zotero.org/users/local/Nb00G2jp/items/KJY9T6HR"],"itemData":{"id":41,"type":"article-journal","title":"Capturing Lived Experience: Methodological Considerations for Interpretive Phenomenological Inquiry","container-title":"International Journal of Qualitative Methods","page":"1-12","volume":"19","source":"SAGE Journals","abstract":"Interpretive phenomenology presents a unique methodology for inquiring into lived experience, yet few scholarly articles provide methodological guidelines for researchers, and many studies lack coherence with the methodologys philosophical foundations. This article contributes to filling these gaps in qualitative research by examining the following question: What are the key methodological and philosophical considerations of leading an interpretive phenomenological study? An exploration of interpretive phenomenologys foundations, including Heideggerian philosophy and Benners applications in health care, will show how the philosophical tradition can guide research methodology. The interpretive phenomenological concepts of Dasein, lived experience, existentialia, authenticity are at the core of the discussion while relevant methodological concerns include research paradigm, researchers stance, objective and research question, sampling and recruitment, data collection, and data analysis. A study of pediatric intensive care unit nurses lived experience of a major hospital transformation project will illustrate these research considerations. This methodological article is innovative in that it explicitly describes the ties between the operational elements of an interpretive phenomenological study and the philosophical tradition. This endeavor is particularly warranted, as the essence of phenomenology is to bring to light what is taken for granted, and yet phenomenological research paradoxically makes frequent assumptions concerning the philosophical underpinnings.","DOI":"10.1177/1609406920907254","ISSN":"1609-4069","shortTitle":"Capturing Lived Experience","language":"en","author":[{"family":"Frechette","given":"Julie"},{"family":"Bitzas","given":"Vasiliki"},{"family":"Aubry","given":"Monique"},{"family":"Kilpatrick","given":"Kelley"},{"family":"Lavoie-Tremblay","given":"Mlanie"}],"issued":{"date-parts":[["2020",1,1]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} Frechette et al., 2020). By that means, Heidegger intends to suggests that an individual exists in the world in a way that uncovers or discloses a phenomenon to understand other entities and themselves (Heidegger, 1927 as cited in ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"31MjPltl","properties":{"formattedCitation":"(Frechette et al., 2020)","plainCitation":"(Frechette et al., 2020)","dontUpdate":true,"noteIndex":0},"citationItems":[{"id":41,"uris":["http://zotero.org/users/local/Nb00G2jp/items/KJY9T6HR"],"uri":["http://zotero.org/users/local/Nb00G2jp/items/KJY9T6HR"],"itemData":{"id":41,"type":"article-journal","title":"Capturing Lived Experience: Methodological Considerations for Interpretive Phenomenological Inquiry","container-title":"International Journal of Qualitative Methods","page":"1-12","volume":"19","source":"SAGE Journals","abstract":"Interpretive phenomenology presents a unique methodology for inquiring into lived experience, yet few scholarly articles provide methodological guidelines for researchers, and many studies lack coherence with the methodologys philosophical foundations. This article contributes to filling these gaps in qualitative research by examining the following question: What are the key methodological and philosophical considerations of leading an interpretive phenomenological study? An exploration of interpretive phenomenologys foundations, including Heideggerian philosophy and Benners applications in health care, will show how the philosophical tradition can guide research methodology. The interpretive phenomenological concepts of Dasein, lived experience, existentialia, authenticity are at the core of the discussion while relevant methodological concerns include research paradigm, researchers stance, objective and research question, sampling and recruitment, data collection, and data analysis. A study of pediatric intensive care unit nurses lived experience of a major hospital transformation project will illustrate these research considerations. This methodological article is innovative in that it explicitly describes the ties between the operational elements of an interpretive phenomenological study and the philosophical tradition. This endeavor is particularly warranted, as the essence of phenomenology is to bring to light what is taken for granted, and yet phenomenological research paradoxically makes frequent assumptions concerning the philosophical underpinnings.","DOI":"10.1177/1609406920907254","ISSN":"1609-4069","shortTitle":"Capturing Lived Experience","language":"en","author":[{"family":"Frechette","given":"Julie"},{"family":"Bitzas","given":"Vasiliki"},{"family":"Aubry","given":"Monique"},{"family":"Kilpatrick","given":"Kelley"},{"family":"Lavoie-Tremblay","given":"Mlanie"}],"issued":{"date-parts":[["2020",1,1]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} Frechette et al., 2020). The use of uncover or disclose can be interpreted as an individual using existing knowledge to discover everyday life and the world.

Heideggerian interpretive phenomenology also consists of limitations that have been criticised by other reviewers or authors refs. This phenomenology, specifically focused on the individual level, has been criticised for not considering the social dimension. However, as we know from Heideggers concept that, humans and the environment are merely a contingent and therefore it. It is would be impossible for Heideggerian to interpret the individual level experience? without considering the social dimension. This leads to another concept - authenticity versus inauthenticity. Living in a social world would mean that we are be easily influenced by others, such as aligning ourselves/behaviour? with perceived social norms. Being authentic to yourself is important. It involves being true to oneself, embracing a disclosed, open self, and standing firmly within the social framework. While being inauthentic occurs when individuals disown their true selves and conform to societal norms, allowing the majority to obscure their identity (Heidegger, 1927a as cited in ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"ewbasZ60","properties":{"formattedCitation":"(Frechette et al., 2020)","plainCitation":"(Frechette et al., 2020)","dontUpdate":true,"noteIndex":0},"citationItems":[{"id":41,"uris":["http://zotero.org/users/local/Nb00G2jp/items/KJY9T6HR"],"uri":["http://zotero.org/users/local/Nb00G2jp/items/KJY9T6HR"],"itemData":{"id":41,"type":"article-journal","title":"Capturing Lived Experience: Methodological Considerations for Interpretive Phenomenological Inquiry","container-title":"International Journal of Qualitative Methods","page":"1-12","volume":"19","source":"SAGE Journals","abstract":"Interpretive phenomenology presents a unique methodology for inquiring into lived experience, yet few scholarly articles provide methodological guidelines for researchers, and many studies lack coherence with the methodologys philosophical foundations. This article contributes to filling these gaps in qualitative research by examining the following question: What are the key methodological and philosophical considerations of leading an interpretive phenomenological study? An exploration of interpretive phenomenologys foundations, including Heideggerian philosophy and Benners applications in health care, will show how the philosophical tradition can guide research methodology. The interpretive phenomenological concepts of Dasein, lived experience, existentialia, authenticity are at the core of the discussion while relevant methodological concerns include research paradigm, researchers stance, objective and research question, sampling and recruitment, data collection, and data analysis. A study of pediatric intensive care unit nurses lived experience of a major hospital transformation project will illustrate these research considerations. This methodological article is innovative in that it explicitly describes the ties between the operational elements of an interpretive phenomenological study and the philosophical tradition. This endeavor is particularly warranted, as the essence of phenomenology is to bring to light what is taken for granted, and yet phenomenological research paradoxically makes frequent assumptions concerning the philosophical underpinnings.","DOI":"10.1177/1609406920907254","ISSN":"1609-4069","shortTitle":"Capturing Lived Experience","language":"en","author":[{"family":"Frechette","given":"Julie"},{"family":"Bitzas","given":"Vasiliki"},{"family":"Aubry","given":"Monique"},{"family":"Kilpatrick","given":"Kelley"},{"family":"Lavoie-Tremblay","given":"Mlanie"}],"issued":{"date-parts":[["2020",1,1]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} Frechette et al., 2020). (link to emotion work?)

Fundamentally, for interpretive phenomenological research, hermeneutics plays a crucial role. Hermeneutics emphasises the interpretation of meaning in lived experience from a text, artefact or other sources of significance ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"T2UYhUHk","properties":{"formattedCitation":"(Polit & Beck, 2008)","plainCitation":"(Polit & Beck, 2008)","noteIndex":0},"citationItems":[{"id":69,"uris":["http://zotero.org/users/local/Nb00G2jp/items/SKHLJ3PP"],"uri":["http://zotero.org/users/local/Nb00G2jp/items/SKHLJ3PP"],"itemData":{"id":69,"type":"book","title":"Nursing Research: Generating and Assessing Evidence for Nursing Practice","publisher":"Lippincott Williams & Wilkins","number-of-pages":"840","source":"Google Books","abstract":"Thoroughly revised to emphasize the link between research and evidence-based practice, this Eighth Edition presents methods and tools for generating and assessing evidence for nursing practice. This edition offers more guidance on evaluating and critiquing research evidence. Other revisions include more in-depth coverage of both qualitative and quantitative research and a new chapter on developing and testing new instruments. Note: The for-sale Student Resource guide to accompany the text is now fully revised to meet emerging graduate course needs. New features include a free CD-ROM called the "Toolkit," which includes copious application exercises, samples of systematic reviews, and full critiques of two of the eight studies in the text. Please note that this is sold separately: Student Resource Manual with Toolkit, ISBN: 978-0-7817-7052-1.","URL":"https://books.google.co.nz/books?hl=en&lr=&id=Ej3wstotgkQC&oi=fnd&pg=PA1&ots=wiJBCO8xxl&sig=tZJhtmUuHR9B-pwZmiSUpTgxdC0&redir_esc=y#v=onepage&q&f=false","ISBN":"978-0-7817-9468-8","note":"Google-Books-ID: Ej3wstotgkQC","shortTitle":"Nursing Research","language":"en","author":[{"family":"Polit","given":"Denise F."},{"family":"Beck","given":"Cheryl Tatano"}],"issued":{"date-parts":[["2008"]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Polit & Beck, 2008) and contribute to how history, culture and language shape fundamental aspects of the human world (Mason & May, 2019). Interpretive phenomenology and hermeneutics are often used interchangeably, although hermeneutics has a narrower focus on the interpretive process (Frechette et al., 2020). It offers researchers a method for exploring lived experience, suggesting a back-and-forth movement from part to the whole, with meaning shaped by what matters to us (Taylor, 1991 as cited in ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"U6lTTnxr","properties":{"formattedCitation":"(Frechette et al., 2020)","plainCitation":"(Frechette et al., 2020)","dontUpdate":true,"noteIndex":0},"citationItems":[{"id":41,"uris":["http://zotero.org/users/local/Nb00G2jp/items/KJY9T6HR"],"uri":["http://zotero.org/users/local/Nb00G2jp/items/KJY9T6HR"],"itemData":{"id":41,"type":"article-journal","title":"Capturing Lived Experience: Methodological Considerations for Interpretive Phenomenological Inquiry","container-title":"International Journal of Qualitative Methods","page":"1-12","volume":"19","source":"SAGE Journals","abstract":"Interpretive phenomenology presents a unique methodology for inquiring into lived experience, yet few scholarly articles provide methodological guidelines for researchers, and many studies lack coherence with the methodologys philosophical foundations. This article contributes to filling these gaps in qualitative research by examining the following question: What are the key methodological and philosophical considerations of leading an interpretive phenomenological study? An exploration of interpretive phenomenologys foundations, including Heideggerian philosophy and Benners applications in health care, will show how the philosophical tradition can guide research methodology. The interpretive phenomenological concepts of Dasein, lived experience, existentialia, authenticity are at the core of the discussion while relevant methodological concerns include research paradigm, researchers stance, objective and research question, sampling and recruitment, data collection, and data analysis. A study of pediatric intensive care unit nurses lived experience of a major hospital transformation project will illustrate these research considerations. This methodological article is innovative in that it explicitly describes the ties between the operational elements of an interpretive phenomenological study and the philosophical tradition. This endeavor is particularly warranted, as the essence of phenomenology is to bring to light what is taken for granted, and yet phenomenological research paradoxically makes frequent assumptions concerning the philosophical underpinnings.","DOI":"10.1177/1609406920907254","ISSN":"1609-4069","shortTitle":"Capturing Lived Experience","language":"en","author":[{"family":"Frechette","given":"Julie"},{"family":"Bitzas","given":"Vasiliki"},{"family":"Aubry","given":"Monique"},{"family":"Kilpatrick","given":"Kelley"},{"family":"Lavoie-Tremblay","given":"Mlanie"}],"issued":{"date-parts":[["2020",1,1]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} Frechette et al., 2020).

In addition to hermeneutics, these philosophical underpinnings of interpretive phenomenology contribute significantly to enriching research methodology by acknowledging the role of presuppositions in shaping our interpretations of phenomena.

The Relevance of Heideggerian Interpretive Phenomenology to My StudyHeideggerian interpretive phenomenology (HIP) provides a framework that can helps me explore the subjective experiences of NPHPs involved in AD. Its nature of philosophy provides a flexible-based approach to exploring experience. It allows me to delve into each NPHPs experience to examine how their experiences contribute to emotional experience and how individual differences in interpreting experience relate to AD. Unlike Husserlian phenomenologys concept of bracketing, HIPit allows me to keep reflect on? my perspectives, beliefs, and cultural background and see my prior understanding and previous knowledge (fore-structure) to help with interpret my dataation.

Besides that, in contrast to positivism, interpretivism provides a better foundation for me to delve into eachevery participating NPHPs insights and understand how every each NPHPs interprets and perceives AD affects how they experience emotions when involved in the AD process. Interpretivism highlights the researcher's reflexivity in jointly constructing knowledge with participants, which is crucial for critically interpreting the data. This also aligns with the data analysis approach (e.g., Reflexive Thematic Analysis) that I would am usinguse in the study.

Compared to other methodologies like such as survey design or grounded theory, phenomenology provides a relatively direct method for researchers to understand the lived experience and acknowledge the diversity of interpretations within the individual, contributing to an interesting comprehension of this studys findings.

As previously mentioned, Heidegger suggested existentialia as a tool to bring back the unnoticed phenomenon into everyday life ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"Dh71BpzD","properties":{"formattedCitation":"(Gelvan, 1970)","plainCitation":"(Gelvan, 1970)","noteIndex":0},"citationItems":[{"id":126,"uris":["http://zotero.org/users/local/Nb00G2jp/items/CSKQ4FZX"],"uri":["http://zotero.org/users/local/Nb00G2jp/items/CSKQ4FZX"],"itemData":{"id":126,"type":"book","title":"A Commentary on Heidegger's "Being and Time"","publisher":"Harper & Row Publisher","publisher-place":"New York, N.Y","event-place":"New York, N.Y","author":[{"family":"Gelvan","given":"Michael"}],"issued":{"date-parts":[["1970"]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Gelvan, 1970; Heidegger, 1927a as cited in ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"dYYDY0mR","properties":{"formattedCitation":"(Frechette et al., 2020)","plainCitation":"(Frechette et al., 2020)","dontUpdate":true,"noteIndex":0},"citationItems":[{"id":41,"uris":["http://zotero.org/users/local/Nb00G2jp/items/KJY9T6HR"],"uri":["http://zotero.org/users/local/Nb00G2jp/items/KJY9T6HR"],"itemData":{"id":41,"type":"article-journal","title":"Capturing Lived Experience: Methodological Considerations for Interpretive Phenomenological Inquiry","container-title":"International Journal of Qualitative Methods","page":"1-12","volume":"19","source":"SAGE Journals","abstract":"Interpretive phenomenology presents a unique methodology for inquiring into lived experience, yet few scholarly articles provide methodological guidelines for researchers, and many studies lack coherence with the methodologys philosophical foundations. This article contributes to filling these gaps in qualitative research by examining the following question: What are the key methodological and philosophical considerations of leading an interpretive phenomenological study? An exploration of interpretive phenomenologys foundations, including Heideggerian philosophy and Benners applications in health care, will show how the philosophical tradition can guide research methodology. The interpretive phenomenological concepts of Dasein, lived experience, existentialia, authenticity are at the core of the discussion while relevant methodological concerns include research paradigm, researchers stance, objective and research question, sampling and recruitment, data collection, and data analysis. A study of pediatric intensive care unit nurses lived experience of a major hospital transformation project will illustrate these research considerations. This methodological article is innovative in that it explicitly describes the ties between the operational elements of an interpretive phenomenological study and the philosophical tradition. This endeavor is particularly warranted, as the essence of phenomenology is to bring to light what is taken for granted, and yet phenomenological research paradoxically makes frequent assumptions concerning the philosophical underpinnings.","DOI":"10.1177/1609406920907254","ISSN":"1609-4069","shortTitle":"Capturing Lived Experience","language":"en","author":[{"family":"Frechette","given":"Julie"},{"family":"Bitzas","given":"Vasiliki"},{"family":"Aubry","given":"Monique"},{"family":"Kilpatrick","given":"Kelley"},{"family":"Lavoie-Tremblay","given":"Mlanie"}],"issued":{"date-parts":[["2020",1,1]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} Frechette et al., 2020). These are the elements that exist within each individual. In addition to mood, it also includes understanding, discourse, and everydayness. This tool can also serve as a framework to explore and understand the subjective experiences of NPHPs involved in AD.

Befindlichkeitor MoodAccording to Heidegger, mood is a crucial aspect of being-in-the-world. It means considers howthat emotions like anxiety, sadness, or relief could influence NPHPs perspectives on AD and influence, their interactions with patients and colleagues, and shape their overall experience of being-in-the-world. Understanding how these moods impact decision-making and caregiving becomes essential for comprehending the lived experiences of these professionals ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"QAsYTkDR","properties":{"formattedCitation":"(Sharma et al., 2009)","plainCitation":"(Sharma et al., 2009)","noteIndex":0},"citationItems":[{"id":123,"uris":["http://zotero.org/users/local/Nb00G2jp/items/P287EPD6"],"uri":["http://zotero.org/users/local/Nb00G2jp/items/P287EPD6"],"itemData":{"id":123,"type":"article-journal","title":"Practicing the Awareness of Embodiment in Qualitative Health Research: Methodological Reflections","page":"1642-1650","volume":"19","issue":"11","DOI":"10.1177/1049732309350684","author":[{"family":"Sharma","given":"Sonya"},{"family":"Reimer-Kirkham","given":"Sheryl"},{"family":"Cochrane","given":"Marie"}],"issued":{"date-parts":[["2009"]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Sharma et al., 2009). For instance, we could understand the considerations that were involved in their NPHPs decision-making and explore how different levels of involvement in AD contribute to their interpretation of experiences.

Heidegger highlighted that our bodily sensations and emotions can offer insight into human experience (Frechette et al., 2020). Despite this study exploring emotional experiences, tThis study largely relies on participants descriptions of their experiences. I acknowledge a limitation in not exploring their bodily sensations (physiological response) to gain an in-depth understanding of their experiences. However, in this study, I would apply theory () to support that physiological response is not necessary to examine emotional experiences. In sum, Heidegger's concept of mood adds confidence to the study where its phenomenology is able to provide understanding in exploring emotional experienceUnderstandingUnderstanding serves as a foundation for interpretation, shaping how we perceive and make sense of experiences ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"1tUAkAJv","properties":{"formattedCitation":"(Gelvan, 1970)","plainCitation":"(Gelvan, 1970)","noteIndex":0},"citationItems":[{"id":126,"uris":["http://zotero.org/users/local/Nb00G2jp/items/CSKQ4FZX"],"uri":["http://zotero.org/users/local/Nb00G2jp/items/CSKQ4FZX"],"itemData":{"id":126,"type":"book","title":"A Commentary on Heidegger's "Being and Time"","publisher":"Harper & Row Publisher","publisher-place":"New York, N.Y","event-place":"New York, N.Y","author":[{"family":"Gelvan","given":"Michael"}],"issued":{"date-parts":[["1970"]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Gelvan, 1970). This foundation, also known as fore-structure, is built upon existing knowledge and guides our interpretation process by allowing us to recognise possibilities within the experience. We could draw upon our pre-existing knowledge to articulate the experience that has been presented at the moment.

Without interpretation, understanding is not complete (Gelvan, 1970, p91). Interpretation involves bringing what is already presented in the world and further revealing its true nature. We would first understand the case before becoming capable of having the possibility to interpret the case (Gelvan, 1970). For instance, I would need to review the literature to understand topics relevant to AD and health professionals before interpreting the data to analyse their emotional experiences.

DiscourseDiscourse, shaped by language and everyday communication, reveals how phenomena are understood and expressed (Heidegger, 1927a, as cited in Frechette et al., 2020). It can manifest authentically through silence, poetry or self-reflection, which goes beyond everyday speech. It can also occur in inauthentic ways, as seen in gossip and small talk, which include a wider broader range of phenomena or topics. NPHPs have to engage in various conversations with patients, families, and colleagues, as well as within the societal discourse surrounding end-of-life care. These different forms of discourse could impact how they communicate their experiences during interviews, which researchers must be aware of. For instance, researchers can identify the content, whether it is from their own thoughts or by adopting what others say. (but after identifying the authenticity, how does this content affect your data? like what does authenticity contribute to data findings)

Everydayness

The concept of everydayness in being-in-the-world includes the potential for fallenness. Fallenness is characterised by inauthentic forms such as idle talk, ambiguity, and curiosity. It leads to a loss of self-awareness due to immersion in these forms of inauthenticity and receiving messages from other words ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"m0CNMjAB","properties":{"formattedCitation":"(Gelvan, 1970)","plainCitation":"(Gelvan, 1970)","noteIndex":0},"citationItems":[{"id":126,"uris":["http://zotero.org/users/local/Nb00G2jp/items/CSKQ4FZX"],"uri":["http://zotero.org/users/local/Nb00G2jp/items/CSKQ4FZX"],"itemData":{"id":126,"type":"book","title":"A Commentary on Heidegger's "Being and Time"","publisher":"Harper & Row Publisher","publisher-place":"New York, N.Y","event-place":"New York, N.Y","author":[{"family":"Gelvan","given":"Michael"}],"issued":{"date-parts":[["1970"]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Gelvan, 1970). Individuals, or NPHPs in our case, may grapple with moral ambiguity, ethical dilemmas, and societal pressures, which may prompt them to engage in inauthentic forms of communication. This could involve experiencing ambiguity or accepting things at face value. It is important to recognise that researchers are also susceptible to these challenges. Researchers need to confront their own biases, assumptions and societal influence, which could possibly affect how researchers they understand and interpret the phenomena of the study (Heidegger, 1927a, as cited in Frechette et al., 2020). MethodThe study is part of a bigger Health Research Council-funded study. I greatly appreciate my supervisors, Dr Aida Dehkhoda and Dr Jessica Young, who provided me with the existing dataset for my thesis research. My supervisors (interviewers) were responsible for recruiting participants and conducting interviews. Although I was not involved in data collection, I (researchers) was responsible for checking interview transcripts, which helped me to familiarise myself with the interviews.

Participants

Health professionals from different professional and age groups, ethnicities, geographical locations, social backgrounds, health and disability, genders, and sexual orientations were invited to participate to ensure the diversity of data collected to represent a wide range of groups. Ten participants were involved in this study. Of themthese NPHPs, nine identified as female and one as male. They ten participating NPHPs worked in a combination of primary care (n=2), secondary care (n=2), community care (n=5), and aged residential care (n=1) sectors. Among them were palliative care nurses (n=4), assisted dying support workers and advisors (n=2), spiritual care coordinators (n=1), community occupational therapists (n=1) and end-of-life doulas (n=1). Six of them were Pkeh, and others were non-New Zealanders (e.g., Dutch, British, and others European) but practising in New Zealand at the time of conducting interviews. Only one participant explicitly expressed conscientious objection to not providing AD (n=1); other participants were either not qualified (n=5) or had other reasons for not providing AD (n=4). Their age ranged from 32 to 66.

RecruitmentHealth organisations, medical press, community groups, and professional bodies, such as Health New Zealand, Nurse Practitioners New Zealand, NZ Doctor, Hospice NZ, Palliative Care Nurses NZ, Assisted Dying Research Network and the Pasifika Medical Association Group, were approached to recruit participants. They were invited to share the study recruitment flyer with their members and on social media. Recruitment was also supplemented by snowballing from participants. Interested participants could find study information, survey links, and researcher contact information on the study flyers or advertisements. Interested participants could either fill out the survey form or contact my supervisors directly via phone call or email as a screening process to ensure a diverse group of participants was recruited.

Procedure and data collectionThe data was collected through interviews with a single participant, a lead interviewer and an observer who asked supplementary questions. The interview time and meeting platform were arranged between the participants and the interviewers based on the participants' convenience. The researchers all participants were sent participants a participant information sheet and consent form via email (see Appendix X) before the interview. These documents participant information sheet and consent form were used to obtain participants agreement to participate in the study, ensure they knew what the study involved, the usage of the information, and convey rights regarding their participation.

At the beginning of the interview, the participant and the interviewers had a casual conversation to ensure that the participant felt comfortable, had a chance to asked any questions about the interview and study they might have had, and offered the option of karakia. Semi-structured interviews were conducted online through Microsoft Teams with an interview guide. The interview guide included open-ended questions and prompts to elicit the participants deeply subjective and personalised responses. Semi-structured interview guides offered flexibility in asking the question, which was determined by the participants responses. The limitation of semi-structured interviews is that the flexible nature of asking questions may result in interviewers skipping important questions as conversations may not follow a defined format. To address this issue, interviewers carefully tracked the questions and ensured all essential questions were covered before concluding the interview.

Some of the interview questions relevant to my research questions were: Can you tell us about your experience with AD? When your patient was going through the AD process, how could you talk about your role with others or colleagues, and how did they respond? Did you have any conflicted feelings about your patients applying for AD or AD in general, and if so, how did you work through them? What kind of support or resources are currently accessible to you? Questions framed in the context were to gain the inner experiences of the NPHPs. Before ending the interview, the interviewers asked the participants if there were aspects related to AD that they thought were relevant but had not yet been asked or mentioned. Then, the interviewers thanked the participants for their time and insights. All participants received a $50 voucher as a token of appreciation.

Each interview lasted between 60 to 90 minutes. The interviews were audio-recorded and transcribed using the built-in function of Microsoft Teams. A research assistant and I checked the transcripts. Participants were offered to review their transcripts and edit, remove, or provide additional information within 14 days. The interviewers de-identified and imported the participants' details to NVivo for data analysis, which is a software for analysing text-based information for qualitative research.

Data AnalysisIn my study, I utilised the reflexive thematic analysis (TA) by Braun and Clarke (2019, 2021a, 2021b) to analyse the interview transcripts. Reflexive TA, widely utilised in counselling and psychotherapy research, aims to identify recurring patterns or themes across cases. Reflexive TA is a theoretically flexible method for identifying, analysing and interpreting themes within a qualitative dataset (Braun & Clarke, 2021a). The approach conceptualises themes as patterns of shared meaning within their contextual settings, acknowledges multiple realities and values researcher subjectivity. TA approaches encompass both inductive (data-driven) and deductive (theory-driven) coding approaches, capturing both explicit (semantic) and implicit (latent) meanings, with the potential for some flexibility in theoretical framing ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"Lj1s8xTe","properties":{"formattedCitation":"(Braun & Clarke, 2021a)","plainCitation":"(Braun & Clarke, 2021a)","noteIndex":0},"citationItems":[{"id":92,"uris":["http://zotero.org/users/local/Nb00G2jp/items/IWA5BPHP"],"uri":["http://zotero.org/users/local/Nb00G2jp/items/IWA5BPHP"],"itemData":{"id":92,"type":"article-journal","title":"Can I use TA? Should I use TA? Should I not use TA? Comparing reflexive thematic analysis and other pattern-based qualitative analytic approaches","container-title":"Counselling and Psychotherapy Research","page":"37-47","volume":"21","issue":"1","source":"Wiley Online Library","abstract":"Thematic analysis methods, including the reflexive approach we have developed, are widely used in counselling and psychotherapy research, as are other approaches that seek to develop patterns (themes, categories) across cases. Without a thorough grounding in the conceptual foundations of a wide variety of across-case analytic approaches, and qualitative research more broadlysomething rarely offered in counselling trainingit can be difficult to understand how these differ, where they overlap, and which might be appropriate for a particular research project. Our aim in this paper is to support researchers in counselling and psychotherapy to select an appropriate across-case approach for their research, and to justify their choice, by discussing conceptual and procedural differences and similarities between reflexive thematic analysis (TA) and four other across-case approaches. Three of these are also widely used in counselling and psychotherapy researchqualitative content analysis, interpretative phenomenological analysis and grounded theory. The fourthdiscourse analysisis less widely used but importantly exemplifies the critical qualitative research tradition. We contextualise our comparative approach by highlighting the diversity within TA. TA is best thought of as a spectrum of methodsfrom types that prioritise coding accuracy and reliability to reflexive approaches like ours that emphasise the inescapable subjectivity of data interpretation. Although reflexive TA provides the point of comparison for our discussion of other across-case approaches, our aim is not to promote reflexive TA as best. Rather, we encourage the knowing selection and use of analytic methods and methodologies in counselling and psychotherapy research.","DOI":"10.1002/capr.12360","ISSN":"1746-1405","shortTitle":"Can I use TA?","language":"en","author":[{"family":"Braun","given":"Virginia"},{"family":"Clarke","given":"Victoria"}],"issued":{"date-parts":[["2021"]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Braun & Clarke, 2021a). 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In this reflexive commentary, we look back at some of the unspoken assumptions that informed how we wrote our 2006 paper. We connect some of these un-identified assumptions, and developments in the method over the years, with some conceptual mismatches and confusions we see in published TA studies. In order to facilitate better TA practice, we reflect on how our thinking has evolved and in some cases sedimented since the publication of our 2006 paper, and clarify and revise some of the ways we phrased or conceptualised TA, and the elements of, and processes around, a method we now prefer to call reflexive TA.","DOI":"10.1080/2159676X.2019.1628806","ISSN":"2159-676X","author":[{"family":"Braun","given":"Virginia"},{"family":"Clarke","given":"Victoria"}],"issued":{"date-parts":[["2019",8,8]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Braun & Clarke, 2019).

In conducting reflexive TA, the researchers position and contribution are necessary, unavoidable, and integral to the process. The researcher and their subjectivity are viewed as conscious and active tools to be utilised ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"fuy98N8w","properties":{"formattedCitation":"(Braun et al., 2016)","plainCitation":"(Braun et al., 2016)","noteIndex":0},"citationItems":[{"id":94,"uris":["http://zotero.org/users/local/Nb00G2jp/items/6MM9BITV"],"uri":["http://zotero.org/users/local/Nb00G2jp/items/6MM9BITV"],"itemData":{"id":94,"type":"chapter","title":"Using thematic analysis in sport and exercise research","container-title":"Routledge Handbook of Qualitative Research in Sport and Exercise","publisher":"Routledge","abstract":"Thematic analysis (TA) is one of a cluster of analytic approaches you can use, if you want to nidentify patterns of meaning across a qualitative dataset. The widely used version of TA we outline in this chapter is fairly unique in the canon of qualitative analytic approaches in that it just noffers the researcher analytic tools to make sense of data. It is not tied to a particular theoretical nframework, and it does not come with methodological stipulations about, for example, how to nsample, or collect data. This gives the researcher great flexibility in how they use TA. Alongside nthe fact that TA is a relatively accessible qualitative analytic technique, these features make it an nexcellent and robust method for beginner qualitative researchers, for those wishing to do fairly ndescriptive work, for those working in teams across disciplinary contexts, or with researchers nof mixed (qualitative) experience, and for those wanting to produce research for public consumption (e.g., policy-or practice-oriented research). That said TA also provides a tool that noffers the potential for nuanced, complex, interpretative analysis. 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The widely used version of TA we outline in this chapter is fairly unique in the canon of qualitative analytic approaches in that it just noffers the researcher analytic tools to make sense of data. It is not tied to a particular theoretical nframework, and it does not come with methodological stipulations about, for example, how to nsample, or collect data. This gives the researcher great flexibility in how they use TA. Alongside nthe fact that TA is a relatively accessible qualitative analytic technique, these features make it an nexcellent and robust method for beginner qualitative researchers, for those wishing to do fairly ndescriptive work, for those working in teams across disciplinary contexts, or with researchers nof mixed (qualitative) experience, and for those wanting to produce research for public consumption (e.g., policy-or practice-oriented research). That said TA also provides a tool that noffers the potential for nuanced, complex, interpretative analysis. 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How Does Reflexive TA Fit My Study?Reflexive TA was chosen to align with the research question and philosophical underpinning. It facilitateds tthe exploration of participants voices and lived experiences, particularly in how they describe their subjective emotional experiences and nuanced perspectives. It allowed me to explore semantic and latent meaning articulated by the NPHPs by following a six-phase process (Braun & Clarke, 2019, 2021a, 2021b) as a guide to analyse the data.

Six-Phase of TA

(Braun & Clarke, 2019, 2021a, 2021b)

(changes needed, after conducting analysis, especially the part started with I)

Phase 1: Data Familiarisation. This is the first step in the analysis and involves two sub-steps. Firstly, as suggested in the literature, I familiarised myself with every interview data I had through transcription ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"ZljqbKf9","properties":{"formattedCitation":"(Riessman, 2005)","plainCitation":"(Riessman, 2005)","noteIndex":0},"citationItems":[{"id":149,"uris":["http://zotero.org/users/local/Nb00G2jp/items/AT6B4H75"],"uri":["http://zotero.org/users/local/Nb00G2jp/items/AT6B4H75"],"itemData":{"id":149,"type":"chapter","title":"Narrative Analysis","container-title":"Narrative, Memory, and Everyday Life","publisher":"University of Huddersfield","publisher-place":"Huddersfield","page":"1-7","event-place":"Huddersfield","author":[{"family":"Riessman","given":"Catherine Kohler"}],"issued":{"date-parts":[["2005"]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Riessman, 2005). I have watched each interview video, read the transcript at least three times and highlighted some text that inspired and interested me. I roughly wrote a short, simple sentence about why I felt inspired, noting some key points and facial expressions with the timestamp. These notes can be understood as casual observations about the data rather than as systematic code (Braun & Clarke, 2019, 2021a, 2021b). Once I felt more familiar with and remembered most of the content, I moved on to the next sub-step, critical engagement with the data. I reviewed the simple note I made during the familiarising stage. I engaged critically and reflexively asking myself questions like how and why to consider how the participants lived experiences contribute to their emotional experience. Familiarising seemed a simple step, but it took me one whole day for each participant.

Phase 2: Data Coding. This coding process involved reading each data item closely, tagging all text segments, labelling and organising relevant data to my research question, and allocating them a brief description (codes). (give example when actually doing data analysis) A code serves as a succinct label to capture and communicate the significant analytical concept within the data to the researcher. Codes can be categorised into four domains of TA, ranging from descriptive (summarising the semantic content of the data excerpts) to more interpretive (reflecting analytical insights), inductive (data-driven) to deductive (theory-driven), experiential to critical and realist to constructionist depending on the research questions. Braun and Clarke encourage the researchers to remember these domains, especially during coding. The awareness of the researchers subjective position and these domains is essential for crafting high-quality, cohesive, and evidentially supported analysis during the later write-up phase. One of the helpful tricks Braun and Clarke recommended is reviewing and coding the data in a different order, such as from the end to the beginning. It helped me remain freshly engaged with the data and prevent glazing over, which can easily happen when looking at the data repeatedly.

Phase 3: Generating Initial Themes. The codes that have identified a single idea can be clustered together when there is some shared meaning. Braun and Clarke mentioned that a theme captures the patterning of meaning across the dataset (2021a, p.76). A theme is not the summary of the topic but more of a central organising concept (p.80), which can capture the core point or pattern of a dataset and contain multiple facets or even not a single idea. I made a table to organise the participants responses according to the codes I identified at the previous stage. I compared their responses and codes and grouped those with similar patterns to themes. This table was just a draft with rough details, but the goal was to generate plausible themes that have the potential to be promoted to be the core theme used in the write-up phase. I grouped the themes based on my understanding and integrated my knowledge and background. An explanation of why I grouped this way would be provided in the findings section.

Phase 4: Developing and Reviewing Themes. This phase provides an opportunity to check the themes to see if there fit with the coded data and adjust the themes to ensure there can describe the full story of the relevant data. The reviewing process ensures that no crucial data is missed. In the checking process, I discarded some of the themes and split them into more specific themes. I discovered that some themes could combine to produce a new theme. I felt that this was quite a challenging stage where I had to let go of some of the themes that I had identified and felt unsure where I would miss out on important details. However, it is the process that I would have to go through to finalise the theme for the dataset. I had to be conscious about my research question during the process. Braun and Clarke mentioned that if a central organising concept can be identified in the process, it is relatively easy to determine whether some aspect of the data is part of a theme. I found that it worked for some of the themes, but honestly speaking, I did not manage to find central organising concept for all my themes. Then, I shared my themes with my supervisors and discussed my analysis, which gave me some insights and jumped out of the frames. Remember to keep an open mind and not to set a rigid structure for your themes too early. This phase often involves a recursive review and revision process to shape the themes. The Braun and Clarke recommended using a thematic map to develop TA, as it would be helpful to determine the relationships between themes and shape an overall structure and organisation for the analysis. I found it was ineffective for me, as I am not a map person, so I stick with the table I made at the previous stage to develop the findings. In sum, I have ensured that the identified themes are coherent and robust, without overlapping, and have sufficient supporting data to address my research question.

Phase 5: Refining, Defining and Naming Themes. To refine and define the themes, one of the methods is to write a summary for each theme and how they contribute to understanding the data. The short summary also can be described as a story of the data. I drafted an outline and finalised the data extracts for the story before officially start reporting the analysis, so it was able to give me an idea of why I categorised it in this way, what I should include in the report, how it will contribute to addressing my research question, why the research should care about it and consider to give a complete presentation of the dataset. The drafting process also surrounds the central organising concept. It would be the one part of the theme definition because it highlights the analytical interpretation of the data and describes the key concept encapsulated in the theme. However, it is also a stage where I can still revise my themes. In the process of drafting, it further aided me in organising ideas and themes, so I managed to find a gap in describing the theme. This process facilitates rigour and identify any further need for refinement. Next, a good name is required for each theme. It is a necessary process, because a good name will signal the theme's focus and its analytical scope or content. However, there is no rush to do it at once. I noted the scope for each theme and ideas for the theme names, but I only managed to finalise the theme name that both my supervisors and I were satisfied with, almost toward the end of the thesis writing process.

Phase 6: Writing Up the Report. Finally, we reached the phase of putting the analysis into actual words. The previous phase had aided me to this stage. I had my theme and a short summary. At this stage, it involves a polished analysis and a report. A polished analysis, where I include what is in the data, why that is interesting and significant to get attention, and which part of it answers my research question; a polished report, where I further explain what is in the polished analysis to existing theory and research. In some sense, this phase was to describe the journey of exploration and discovery and should be the final part of the journey. However, the Braun and Clarke leave the opportunity for the researchers always to move backwards and refine and reconceptualise some aspects of the journey, including the themes. As they had said, reflexive TA should not be a rigid structure and process but a guide for data analysis.

Note from Braun and Clarke

(temporary title, to avoid mix-up with the six-phase section)

Throughout the analysis, the researcher's reflexivity is crucial ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"XxIOQBGu","properties":{"formattedCitation":"(Braun & Clarke, 2024)","plainCitation":"(Braun & Clarke, 2024)","noteIndex":0},"citationItems":[{"id":89,"uris":["http://zotero.org/users/local/Nb00G2jp/items/TK8W6P6C"],"uri":["http://zotero.org/users/local/Nb00G2jp/items/TK8W6P6C"],"itemData":{"id":89,"type":"article-journal","title":"Supporting best practice in reflexive thematic analysis reporting in Palliative Medicine: A review of published research and introduction to the Reflexive Thematic Analysis Reporting Guidelines (RTARG)","container-title":"Palliative Medicine","page":"02692163241234800","source":"SAGE Journals","abstract":"Background: Reflexive thematic analysis is widely used in qualitative research published in Palliative Medicine, and in the broader field of health research. However, this approach is often not used well. Common problems in published reflexive thematic analysis in general include assuming thematic analysis is a singular approach, rather than a family of methods, confusing themes and topics, and treating and reporting reflexive thematic analysis as if it is atheoretical.nPurpose: We reviewed 20 papers published in Palliative Medicine between 2014 and 2022 that cited Braun and Clarke, identified using the search term thematic analysis and the default relevance setting on the journal webpage. The aim of the review was to identify common problems and instances of good practice. Problems centred around a lack of methodological coherence, and a lack of reflexive openness, clarity and detail in reporting. We considered contributors to these common problems, including the use of reporting checklists that are not coherent with the values of reflexive thematic analysis. To support qualitative researchers in producing coherent and reflexively open reports of reflexive thematic analysis we have developed the Reflexive Thematic Analysis Reporting Guidelines (the RTARG; in Supplemental Materials) informed by this review, other reviews we have done and our values and experience as qualitative researchers. The RTARG is also intended for use by peer reviewers to encourage methodologically coherent reviewing.nKey learning points: Methodological incoherence and a lack of transparency are common problems in reflexive thematic analysis research published in Palliative Medicine. Coherence can be facilitated by researchers and reviewers striving to be knowing thoughtful, deliberative, reflexive and theoretically aware practitioners and appraisers of reflexive thematic analysis and developing an understanding of the diversity within the thematic analysis family of methods.","DOI":"10.1177/02692163241234800","ISSN":"0269-2163","shortTitle":"Supporting best practice in reflexive thematic analysis reporting in Palliative Medicine","journalAbbreviation":"Palliat Med","language":"en","author":[{"family":"Braun","given":"Virginia"},{"family":"Clarke","given":"Victoria"}],"issued":{"date-parts":[["2024",3,12]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Braun & Clarke, 2024). This approach recognises and values the subjectivity of researchers, which inherently shapes the knowledge produced. Descriptive measures such as 'accurate' and 'reliable' coding may not work as the analysis is reflected from the researchers background. It would be difficult to judge if the analysis is right or wrong, but the researcher has to ensure that sufficient explanation is provided for their decision at the last phase of the process. Braun and Clarke (2021) recommend keeping a reflective journal throughout the study. The journal serves as a tool for the researcher to gain insight into personal experiences, thoughts, and feelings, as well as inform decision-making and interpretation during data analysis to enhance the research process's quality.

Positionality

Before sharing the data analysis and findings of the study, I discuss my background and positionality and their relevance to this research. In February 2023, I came to New Zealand to pursue my postgraduate study in Health Psychology at Te Herenga Waka Victoria University of Wellington. By the time I analysed the interview data, I had been here for more than a year. During this one year of living in New Zealand, I stayed in the university hall, which allowed me to immerse myself in local culture, food, and people. I acknowledge my limited knowledge of New Zealands culture, specifically te Ao Mori (Remark: this study did not involve any Maori participants). However, I am from Malaysia, a multicultural country. Similar to New Zealand, in Malaysia, we have different races, which include Malay (indigenous group), Chinese, Indian and other minority groups. Living in a multicultural country and interacting with people who have different cultures for most of my life enabled me to practice cultural sensitivity, like respecting each other's culture, adapting to different environments, and accepting each other's cultural differences. In addition, admittedly, as an international student, I position myself as a foreign researcher who is an outsider to the New Zealander community. I am unsure if not having enough understanding of New Zealander culture would affect data analysis, which is particularly relevant to issues I faced in data analysis. Despite being a foreign researcher, I strive to practice cultural awareness and competence in data analysis. Ethical ConsiderationsThe ethical aspects of this study have been approved by an independent group called the Health and Disability Ethics Committee (HDEC). It checks that studies meet ethical standards. The Northern A Health and Disability Ethics Committee has approved this study through the entire review pathway [ref 2023 EXP 18493]. The ethical considerations shed light on Te Tiriti o Waitangi because my study took place within the context of Aotearoa, and the research ethics were discussed.

Te Tiriti o WaitangiEnsuring culturally and contextually sensitive research is crucial in New Zealand due to its multicultural nature. In this research, we uphold the principles of the Treaty of Waitangi. Specifically, emphasising partnership (respecting cultural diversity), protection (ensuring individual rights), participation (granting control over the research process and involving different races and ethnicities), tino rangatiratanga (self-determination) and equity (MOH, 2024). During the interview process, the interviewers established relationships with participants by considering their cultural backgrounds and needs. This included asking about ethnicity and accommodating cultural preferences, such as offering options like karakia before interviews, to ensure a respectful and inclusive environment. Participants were also allowed to have a cultural advisor present during the interview if needed.

This research's participants come from diverse backgrounds, encompassing different age groups, genders, races, and ethnicities. They are all health professionals in New Zealand. However, Mori participants were not included in this study cohort due to the sensitive nature of the topic of AD. Their experiences are being explored in the sister project 'Waerea' where the Mori researchers can ensure the cultural safety of participants.

EthicsThe principle of respect and care for the person ensures that research participants have informed consent and the right to exercise autonomy. The researchers ensured that participants were fully informed about the nature of the research and were taking part in this research voluntarily. Our participant information sheet and consent form included the study's purpose, procedures, confidentiality limits, potential discomfort, and participants' withdrawal rights. For instance, participants were informed that they had the right to withdraw at any point of the research process before data analysis started and that no penalty was associated with withdrawal. This would lead to another ethical consideration of doing no harm.

The current study explores the emotional experiences of NPHPs of their involvement with patients under their care who are receiving AD. Revisiting memories of their patients going through the AD process during the interview may lead to feelings of distress. Hence, minimising harm was an important ethical consideration for this research. As such, the researchers did have additional support resources ready for the participants if needed. A follow-up check-in email or call was made to all participants the day after the interview. As stated in the informed consent form, the participants had the right to pause or stop participating in the interview at any time and for any reason. Fortunately, there were no signs of emotional distress when NPHPs discussed previous experiences of involving in AD.

Furthermore, all collected information is strictly confidential. Considering the chosen method, achieving complete anonymity was impossible since the interviewers knew the participants' identities. However, to ensure confidentiality, the research team member who conducted the interview replaced identifiable details, such as real names, organisations, locations, and any other sensitive personal information, with pseudonyms chosen by the participants. This de-identification occurred before coding and importing textual data files into NVivo.

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