Nursing student attitudes toward dying patient care: A European multicenter cross-sectional study

Nursing student attitudes toward dying patient care: A European multicenter cross-sectional study


  • Paola Ferri
  • Rosaria Di Lorenzo Psychiatric Intensive Treatment Facility, Mental Health and Drug Abuse Department of AUSL-Modena
  • Serena Stifani Nursing Degree Course of Modena, University of Modena and Reggio Emilia
  • Elena Morotti Nursing Degree Course of Modena, University of Modena and Reggio Emilia
  • Matilde Vagnini Assistenza domiciliare di Sassuolo, AUSL-Modena
  • María Francisca Jiménez Herrera Grado de Enfermería, Tarragona, Universidad Rovira i Virgili
  • Antonio Bonacaro Department of Adult and Mental Health Nursing, Anglia Ruskin University
  • Giovanna Artioli Palliative Care Unit. Azienda USL-IRCCS di Reggio Emilia
  • Ivan Rubbi Nursing Degree Course of Faenza, University of Bologna
  • Alvisa Palese Department of Medical Science, Udine University


Nursing students, Nursing education, FATCOD-B, Attitudes towards caring for dying patients, palliative care


Background and aim of the work

Nursing education plays a key role in preparing future nurses to deal with dying patients, which represents one of the most emotionally involving aspect of nursing. The aims of the study were to explore nursing students’ attitudes towards care of dying patients in three different European contexts and to analyze the variables that can influence them.


We conducted an international multicenter cross-sectional study. We administered the Frommelt Attitude Toward Care of the Dying Scale form B (FATCOD-B) and a demographic form to 569 students, enrolled in the Nursing Programmes in three different countries (Italy, Spain and the United Kingdom), who accepted to participate in the study. The data were analyzed using SPSS software version 26.0.


Median total FATCOD-B scores indicated intermediate levels of students’ attitudes towards care for dying patients, with a statistically significant difference among the three student groups. The median total FATCOD-B scores did not statistically significantly change in students with different age, gender, year of study, religious believes, nursing education on palliative care, previous experiences of dying patient care and personal grieving.


In our study, nursing students feel partially prepared in caring for dying patients and their attitudes do not change as the course of study progresses. No selected variables had an impact on students’ attitudes towards palliative care. Since nurses play a vital role in ensuring the quality of care, education on end-of-life care should be offered as a core part of undergraduate nursing programs.


Committee on Approaching Death: Addressing Key End-of-life Issues; Institute of Medicine. Dying in America: Improving Quality and Honoring Individual Preferences Near the End-of-life. Washington (DC): National Academies Press (US); 2015.

World Health Organization. National cancer control programmes: policies and managerial guidelines. 2nd ed. 2002.

Dunn KS, Otten C, Stephens E. Nursing experience and the care of dying patients. Oncol Nurs Forum 2005; 32: 97-104.

Abu-El-Noor NI, Abu-El-Noor MK. Attitude of Palestinian Nursing Students Toward Caring for Dying Patients: A Call for Change in Health Education Policy. J Holist Nurs 2016; 34: 193-9.

Wang L, Li C, Zhang Q, Li Y. Clinical nurses' attitudes towards death and caring for dying patients in China. Int J Palliat Nurs 2018; 24: 33-9.

Jiang Q, Lu Y, Ying Y, Zhao H. Attitudes and knowledge of undergraduate nursing students about palliative care: An analysis of influencing factors. Nurse Educ Today 2019; 80: 15-21.

Arslan D, Akca NK, Simsek N, Zorba P. Student nurses' attitudes toward dying patients in central Anatolia. Int J Nurs Knowl 2014; 25: 183-8.

Lindqvist O, Tishelman C, Hagelin CL, Clark JB, Daud ML, Dickman A, Benedetti FD, Galushko M, Lunder U, Lundquist G, Miccinesi G, Sauter SB, Fürst CJ, Rasmussen BH. Complexity in non-pharmacological caregiving activities at the end-of-life: an international qualitative study. PLoS Med 2012; 9: e1001173.

Browall M, Melin-Johansson C, Strang S, Danielson E, Henoch I. Health care staff's opinions about existential issues among patients with cancer. Palliat Support Care 2010; 8: 59e68.

Mastroianni C, Piredda M, Taboga C, Mirabella F, Marfoli E, Casale G, Matarese M, Frommelt KH, De Marinis MG. Frommelt Attitudes Toward Care of the Dying Scale Form B: Psychometric Testing of the Italian Version for Students. OMEGA—Journal of Death and Dying 2015; 70: 227-50.

Mok E, Chiu PC. Nurse-patient relationships in palliative care. J Adv Nurs 2004; 48: 475e483.

Johnston B., Smith L.N. Nurses' and patients' perceptions of expert palliative nursing care. J Adv Nurs 2006; 54: 700e709.

Ferrell B., Malloy P., Mazanec P., Virani R. CARES: AACN's new competencies and recommendations for educating undergraduate nursing students to improve palliative care. J Prof Nurs 2016; 32: 327e333.

Gillett K, O'Neill B., Bloomfield JG. Factors influencing the development of end-of-life communication skills: a focus group study of nursing and medical students. Nurse Educ Today 2016; 36: 395e400.

Lewis C, Reid J, McLernon Z, Ingham R, Traynor M. The impact of a simulated intervention on attitudes of undergraduate nursing and medical students towards end-of-life care provision. BMC Palliat Care 2016; 15: 67.

Tait V, Higgs M, Magann L, Dixon J, Davis JM, Fernandez R. Attitudes of non-palliative care nurses towards palliative care. Int J Palliat Care 2015: 1-6.

Peters L, Cant R, Payne S, O'Connor M, McDermott F, Hood K, Morphet J, Shimoinaba K. How death anxiety impacts nurses' caring for patients at the end-of-life: a review of literature. Open Nurs J 2013; 7: 14-21.

Brockopp DY, King DB, Hamilton JE. The dying patient: A comparative study of nurse caregiver characteristics. Death Studies 1991; 15: 245-58.

Payne SA, Dean SJ, Kalus C. A comparative study of death anxiety in hospice and emergency nurses. Journal of Advanced Nursing 1998; 28: 700-6.

Servaty HL, Krejci MJ, HayslipBJr. Relationships among death anxiety, communication apprehension with the dying, and empathy in those seeking occupations as nurses and physicians. Death Studies 1996; 20: 149-61.

Thompson EHJr. Palliative and curative care nurses’ attitudes toward dying and death in the hospital setting. OMEGA 1995; 16: 233-42.

Waltman NL, Zimmerman L. Variations among nurses in behavioral intentions toward the dying. The Hospice Journal 1992; 7: 37-49.

Mallory J.L. The impact of a palliative care educational component on attitudes toward care of the dying in undergraduate nursing students. J Prof Nurs 2003; 19: 305-12.

Cooper J, Barnett M. Aspects of caring for dying patients which cause anxiety to first year student nurses. Int J PalliatNurs 2005; 11: 423-30.

Ek K, Westin L, Prahl C, Österlind J, Bergh I, Henoch I, Hammarlund K. Death and caring for dying patients: exploring first-year nursing students' descriptive experiences. Int J Palliat Nurs 2014; 20: 509-15.

Strang S, Bergh I, Ek K, Hammarlund K, Prahl C, Westin L, Österlind J, Henoch I. Swedish nursing students' reasoning about emotionally demanding issues in caring for dying patients. Int J Palliat Nurs 2014; 20: 194-200.

Allchin L. Caring for the dying: nursing student perspectives. J Hospice PalliatNurs 2006; 8: 112-9.

Smith-Stoner M, Hall-Lord ML, Hedelin B, Petzäll K. Nursing students' concerns about end-of-life in California, Norway and Sweden. Int J Palliat Nurs 2011; 17: 271-7.

Chow SK, Wong LT, Chan YK, Chung TY. The impact and importance of clinical learning experience in supporting nursing students in end-of-life care: cluster analysis. Nurse Educ Pract 2014; 14: 532-7.

Österlind J, Prahl C, Westin L, Strang S, Bergh I, Henoch I, Hammarlund K, Ek K. Nursing students' perceptions of caring for dying people, after one year in nursing school. Nurse Educ Today 2016; 41: 12-6.

Ballesteros M, Centeno C, Arantzamendi M. A qualitative exploratory study of nursing students' assessment of the contribution of palliative care learning. Nurse Educ Today 2014; 34: 1-6.

Mutto EM, Errazquin A, Rabhansl MM, Villar MJ. Nursing education: the experience, attitudes, and impact of caring for dying patients by undergraduate Argentinian nursing students. J Palliat Med 2010; 13: 1445-50.

Poultney S, Berridge P, Malkin B. Supporting pre-registration nursing students in their exploration of death and dying. Nurse Educ Pract 2014; 14: 345-9.

Jafari M, Rafiei H, Nassehi A, Soleimani F, Arab M, Noormohammadi MR. Caring for dying patients: attitude of nursing students and effects of education. Indian J Palliat Care 2015; 21: 192-7.

Mutto EM, Cantoni MN, Rabhansl MM, Villar MJ. A perspective of end-of-life care education in undergraduate medical and nursing students in Buenos Aires, Argentina. J Palliat Med 2012; 15: 93-8.

Berndtsson IEK, Karlsson MG, Rejnö ÅCU. Nursing students' attitudes toward care of dying patients: A pre- and post-palliative course study. Heliyon 2019; 5: e02578.

Henoch I, Melin-Johansson C, Bergh I, Strang S, Ek K, Hammarlund K, LundhHagelin C, Westin L, Österlind J, Browall M. Undergraduate nursing students' attitudes and preparedness toward caring for dying persons - A longitudinal study. Nurse Educ Pract 2017; 26: 12-20.

Jeffers S. Integration of a Hospice Clinical Experience: Nursing Students' Perceptions. J Hosp Palliat Nurs 2018; 20: 266-71.

Adesina O, DeBellis A, Zannettino L. Third-year Australian nursing students' attitudes, experiences, knowledge, and education concerning end-of-life care. Int J Palliat Nurs 2014; 20: 395-401.

Cerit B. Influence of Training on First-Year Nursing Department Students' Attitudes on Death and Caring for Dying Patients: A Single-Group Pretest-Posttest Experimental Study. Omega (Westport). 2019; 78: 335-47.

Mahan P, Taggart H, Knofczynski G, Warnock S. Transforming Nursing Students’ Attitudes Toward End-of-Life Care. J Hosp Palliat Nur 2019; 21: 496-501.

Bassah N, Seymour J, Cox K. A modified systematic review of research evidence about education for pre-registration nurses in palliative care. BMC Palliat Care 2014; 13: 56-66.

Gillan PC, Van der Riet PJ, Jeong S. End-of-life care education, past and present: a review of the literature. Nurse Educ Today 2014; 34: 331-42.

Paul SS, Renu G, Thampi PT. Creating a Positive Attitude toward Dying Patients among Nursing Students: Is the Current Curriculum Adequate? Indian J Palliat Care 2019; 25: 142-6.

Ayed A, Sayej S, Harazneh L, Fashafsheh I, Eqtait F. The nurses’ knowledge and attitudes towards the palliative care. J Educ Pract 2015; 6: 91-9.

Wilson O, Avalos G, Dowling M. Knowledge of palliative care and attitudes towards nursing the dying patient. Br J Nurs 2016; 25: 600-5.

Anstey S, Powell T, Coles B, Hale R, Gould D. Education and training to enhance end-of-life care for nursing home staff: A systematic literature review. BMJ Support Palliat Care 2016; 6: 353-61.

Kirkpatrick AJ, Cantrell MA, Smeltzer SC. Relationships among nursing student palliative care knowledge, experience, self-awareness, and performance: An end-of-life simulation study. Nurse Educ Today 2019; 73: 23-30.

Spicer S, Heller R, Troth S. Hospice clinical experiences for nursing students: living to the fullest. J Christ Nurs 2015; 32: 46-9.

Venkatasalu MR, Kelleher M, Shao CH. Reported clinical outcomes of high-fidelity simulation versus classroom-based end-of-life care education. Int J Palliat Nurs 2015; 21: 179-86.

Parry M. Student nurses' experience of their first death in clinical practice. Int J Palliat Nurs. 2011; 17: 448-53.

Park KS, Yeom HA. Factors influencing Korean nurses' attitudes towards hospice care. Int Nurs Rev 2014; 61: 563-72.

Dimoula M, Kotronoulas G, Katsaragakis S, Christou M, Sgourou S, Patiraki E. Undergraduate nursing students' knowledge about palliative care and attitudes towards end-of-life care: A three-cohort, cross-sectional survey. Nurse Educ Today 2019; 74: 7-14.

Hagelin CL, Melin-Johansson C, Henoch I, Bergh I, Ek K, Hammarlund K, Prahl C, Strang S, Westin L, Österlind J, Browall M. Factors influencing attitude toward care of dying patients in first-year nursing students. Int J Palliat Nurs 2016; 22: 28-36.

Abu Sharour L, Suleiman K, Yehya D, AL-Kaladeh M, Malak M, Subih KM, BaniSalameh A. Nurses' students' attitudes toward death and caring for dying cancer patients during their placement. EMBJ 2017; 12: 189-93.

Leombruni P, Miniotti M, Zizzi F, Sica C, Bovero A, Castelli L, Torta R. Attitudes of medical students toward the care of the dying in relation to personality traits: harm avoidance and self-directedness make a difference. Am J Hosp Palliat Care 2015; 32: 824-32.

Iranmanesh S, Axelsson K, Häggström T, Sävenstedt S. Caring for dying people: Attitudes among Iranian and Swedish nursing students. Indian J Palliat Care 2010; 16: 147-53.

European Association for Palliative Care. A Guide for Development of Palliative Nurse Education in Europe. Palliative Nurse Education: Report of the EAPC Task Force. 2004. Link:

Ministero dell’Istruzione, dell’Università e della Ricerca. Circolare n. 512 del 10/01/2020. Insegnamento e apprendimento delle cure palliative e della terapia del dolore. Link:

Zheng R, Lee SF, Bloomer MJ. How new graduate nurses experience patient death: A systematic review and qualitative meta-synthesis. Int J Nurs Stud 2016; 53: 320-30.

FrommeltKH. Attitudes toward care of the terminally ill: an educational intervention. Am J Hosp Palliat Care 2003; 20: 13-22.

Edo-GualM, Tomás-SábadoJ, Gómez-Benito J, Monforte-RoyoC, Aradilla-Herrero A. Spanish Adaptation of the Frommelt Attitude Toward Care of the Dying Scale (FATCOD-S) in Nursing Undergraduates. Omega (Westport) 2018;78:120-42.

Laporte P, Juvet T, Desbiens J-F, et al. Factors affecting attitudes towards caring for terminally ill patients among nursing students in Switzerland: a cross-sectional study. BMJ Open 2020;10:e037553.

Wang Y. Lecture-simulation-combined Education Improve Nursing Undergraduates' Knowledge and Attitude for Palliative Care. International Journal of Learning, Teaching and Educational Research 2020; 19: 81-97.

Tok HH, Cerit B. The effect of creative drama education on first-year undergraduate nursing student attitudes toward caring for dying patients. Nurse Educ Today 2021;97:104696.

Leombruni P, Miniotti M, Bovero A, Zizzi F, Castelli L, Torta R. Attitudes toward caring for dying patients: An overview among Italian nursing students and preliminary psychometrics of the FATCOD-B scale. Journal of Nursing Education and Practice 2014; 4: 188-96.

Dobrowolska B, Mazur E, Pilewska-Kozak A, Dońka K, Kosicka B, Palese A. Predicted difficulties, educational needs, and interest in working in end-of-life care among nursing and medical students. Nurse Educ Today 2019;83: 104194.

ZulfatulA’la M, Setioputro B, Kurniawan DE. Nursing Students’ Attitudes towards Caring for Dying Patients. Nurse Media Journal of Nursing 2018; 8:25-34.

Martins Pereira S, Hernández-Marrero P, Pasman HR, Capelas ML, Larkin P, Francke AL. Nursing education on palliative care across Europe: Results and recommendations from the EAPC Taskforce on preparation for practice in palliative care nursing across the EU based on an online survey and country reports. Palliat Med 2021;35:130-41.

Mastroianni C, Ramon Codina M, D’Angelo D, Petitti T, Latina R, Casale G, Turrziani A, Piredda M, de Marinis MG. Palliative Care Education in Undergraduate Nursing Curriculum in Italy. Journal of Hospice & Palliative Nursing 2019; 21: 96-103.

Ferri P, Muzzalupo J, Di Lorenzo R. Patients' perception of dignity in an Italian general hospital: a cross-sectional analysis. BMC Health Serv Res 2015; 15: 41.

Dobrina R, Tenze M, Palese A. An overview of hospice and palliative care nursing models and theories. Int J Palliat Nurs 2014;20:75-81.






Original articles: Health Professions 1/2021

How to Cite

Ferri P, Di Lorenzo R, Stifani S, Morotti E, Vagnini M, Jiménez Herrera MF, et al. Nursing student attitudes toward dying patient care: A European multicenter cross-sectional study. Acta Biomed [Internet]. 2021 Mar. 31 [cited 2024 Jul. 15];92(S2):e2021018. Available from: