Introduction
The uncertain death rate and the rapid spread of COVID-19 caused a great psychological disorders among people, including depression, suicide and death anxiety [1, 2]. Death anxiety is a common problem among the elderly [3]. Death anxiety can affect the performance of daily tasks and the self-care ability of the elderly [4]. Therefore, appropriate interventions are necessary to reduce it [5]. One of the ways to reduce death anxiety is self-care education. Among the dimensions of self-care education, we can mention psychological and spiritual self-care skills. These skills can reduce anxiety and stress in people [6].
The increase in the use of telecommunication methods to provide health services for people with chronic conditions is one of the most promising developments in health care [7]. Among the methods of telecommunication, telephone calls are frequently used in remote nursing. Some studies have shown that telephone follow-up and distance education by nurses can lead to the improvement of self-care behaviors in patients [8]. The study aims to assess the effect of psychological/spiritual self-care education through telenursing on the death anxiety of healthy older adults in Gonabad, northern Iran, during the COVID-19 pandemic.

Methods
This is a randomized controlled clinical trial. The study population consists of all elderly people ≥60 years old under the coverage of urban community health centers in Gonabad county. The sample size was determined 12 per group using G*Power software based on a similar study [9]at a confidence level of 95% considering a test power of 90%. With a 10% probability of sample drop, it increased to 26 per group (52 in total). The criteria for entering the study were willingness to participate in the study, age 60 years or older, ability to hear and talk, cognitive health, being a Persian speaker, non-participation in any training course to relieve anxiety, having telephone at home, and having death anxiety. Exclusion criteria were psychiatric disorders or mental illnesses based on the medical records, not participating in face-to-face educational sessions, simultaneous participation in other educational programs, hospitalization or emotional trauma in the past 3 months, interruption of telephone communication for 2 weeks, hospitalization during the study, death of relatives and any similar unexpected events during the intervention. The tool used in this research was a two-part questionnaire that included a demographic form and the Templer death anxiety scale.
The participants were divided into two groups of intervention and control. The people in the intervention group were divided into two groups of 9 and one group of 8 (due to the prevention of the spread of COVID-19 and better compliance with health regulations). For each group, a one-hour face-to-face meeting was held in the community health center to provide information on aging, COVID-19 and ways to prevent it, death and fear of it, connection with and trust in God and his role in reducing anxiety, watching religious films, and listening to relaxation music. After providing face-to-face education, telephone follow-up was conducted twice a week in the first month and once a week in the second month. Also, a telephone number was provided to the elderly so that they could ask questions, if any. Each telephone conversation lasted 10-15 minutes. Then, immediately after the follow-up, the post-test assessment was conducted. To comply with ethical issues, after collecting the data, educational materials were provided to the control group. SPSS software was used to analyze the data. The significance level was set at 0.05.

Results
There was no significant difference in the demographic variables between the two groups (P>0.05). According to the independent t-test results, no significant difference was observed in death anxiety between the two groups before the intervention; however, the difference was statistically significant between two groups after the intervention. The difference in death anxiety of the two groups was statistically significant before and after the intervention (Table 1).



Conclusion
The results showed that psychological/spiritual self-care education through telenursing was effective in reducing the death anxiety of the elderly during the COVID-19 pandemic in Iran. It seems that this educational method is a good way to reduce the death anxiety of older adults. 

Ethical Considerations

Compliance with ethical guidelines
The study was approved by the Ethics Committee of Gonabad University of Medical Sciences (Code: IR.GMU.REC.1400.016).

Funding
This article is the result of a master's thesis of Ramin Soleimanpour Manzari, approved by Department of Nursing, Faculty of Nursing, Gonabad University of Medical Sciences.

Authors' contributions
All authors contributed equally to preparing this article.

Conflicts of interest
The authors declared no conflict of interest.

Acknowledgements
The researchers of this study are grateful for the cooperation of the Research and Technology Vice-Chancellor, the Health Vice-Chancellor of Gonabad University of Medical Sciences and the personnel of health centers and the elderly.