1. Introduction
Hospice care, first proposed by Dr. Cicely Saunders in 1967, is a relatively new interdisciplinary field in modern medicine (
Kucharska, 2012
). As a response to societal needs and a reflection of human civilization’s advancement, hospice care aims to provide comprehensive physical, psychological, and social support to terminally ill patients and their families. It upholds the principles of respecting life, alleviating suffering, and enhancing the quality of life. Unlike curative treatment, hospice care focuses on palliative care, prioritizing comfort, dignity, and holistic support in the final stages of life. The Development Plan for Nursing in China (2016-2020) explicitly advocated for the promotion, strengthening, and expansion of hospice care services. In 2016, the Chinese central government issued the “Healthy China 2030” Planning Outline, which emphasized the goal of achieving lifelong health services and protection—from prenatal care to end-of-life support—as a core component of national health development. Within hospice care services, healthcare professionals play a vital role. They must possess not only solid theoretical knowledge and technical skills in palliative care but also a positive and compassionate attitude toward end-of-life issues. This attitude significantly influences both their professional performance and the quality of hospice care delivered. As the future nursing workforce, nursing students’ readiness to provide high quality end-of-life care and more importantly, their attitudes toward hospice care will directly impact the continued development and overall quality of hospice services in China. This paper reviews the current status and influencing factors of nursing students’ attitudes toward care of the dying patients and proposes strategies to improve their preparedness and attitudes in this critical area of practice.
3. Assessment Tool for Nursing Students’ Attitude toward Care of the Dying
3.1. The Frommelt Attitude Toward Care of the Dying Scale (FATCOD)
The Frommelt attitude toward care of the dying scale was developed by Dr. Frommelt (
Frommelt, 1988
), a nursing scholar in the United States, in 1989. The scale has two versions: Form A, which is specifically designed for nurses, and Form B, which applies to nursing students. Form B consists of 30 items rated on a 5-point Likert scale, with total scores ranging from 30 to 150. Higher scores indicate a more positive attitude toward care of the dying. The scale has demonstrated strong reliability, with an inter-rater agreement of 1.0 and a test-retest Pearson correlation coefficient of 0.93 (
Hamdan et al., 2023
). FATCOD has been translated and widely applied in various countries as a standard tool for evaluating attitude toward care of the dying (
Matsui & Braun, 2010
;
Ho et al., 2010
;
Mastroianni et al., 2009
;
Sadowska et al., 2021
;
Wang et al., 2016)
. However, over time, the scale’s psychometric properties have come under scrutiny. Researchers have proposed several revisions and abbreviated versions to enhance its validity and efficiency. One such refined version includes only 9 items, which demonstrated measurement invariance across gender, levels of religiosity, and experiences with dying individuals (
Molinengo et al., 2022
).
Hingley et al. (2023)
used FATCOD-B to evaluate the impact of palliative care communication simulation on undergraduate nursing students. The research results showed that the FATCOD-B score increased significantly before and after the simulation questionnaire.
3.2. Death Attitude Profile-Revised (DAP-R)
The Death Attitude Profile-Revised (DAP-R) was originally developed by Wong and colleagues in 1987 and revised in 1994 (
Wong et al., 2015
). This instrument was designed to assess individuals’ attitudes toward death across multiple dimensions, thereby overcoming the limitations of one-dimensional death attitude measurements. The DAP-R includes five distinct dimensions: fear of death, death avoidance, neutral acceptance, approach acceptance, and escape acceptance. It consists of 32 items rated on a 5-point Likert scale, with higher scores indicating a stronger tendency toward the specific death attitude dimension being measured. The DAP-R has demonstrated high reliability and validity and has been widely used to evaluate death attitudes across diverse populations. It has also been translated and adopted by researchers in various countries, making it a valuable tool for cross-cultural studies in thanatology and end-of-life care education (
Brudek et al., 2020
;
Cruzado et al., 2024
;
Jansen et al., 2019
).
Peng et al. (2025)
used this scale in the study. The research results showed that the attitude of ICU nurses towards death played a partial mediating role between moral distress and core competencies.
Oz et al. (2022)
used the scale to assess the stigmatizing attitudes of nursing students toward individuals who had made suicide attempts as well as these students’ attitudes toward death. The research results show that students have a relatively positive attitude towards death. As the positive attitude towards death increases, the stigmatization of suicide will also decrease.
3.3. Physicians’ End-of-Life Care Attitude Scale (PEAS)
The physicians’ end-of-life care attitude scale (PEAS) was developed by Levetown and colleagues in 1999 (
Levetown et al., 2000
). It is designed to evaluate the effectiveness of palliative care education and to assess physicians’ willingness to provide care for terminally ill patients. Specifically, the scale measures the level of emotional discomfort experienced by physicians during interactions with dying patients and their families. The original version of PEAS consisted of 64 items rated on a 6-point Likert scale, with higher scores indicating a greater concern and attentiveness toward end-of-life care. A later revised version condensed the scale to 31 items, organized into two key dimensions: 1) personal attitudes toward hospice care, and 2) professional attitudes toward specialized end-of-life care. This shortened version has also been adapted for use among clinical nurses and nursing interns to assess both their emotional discomfort when caring for terminally ill patients and their cognitive attitudes toward hospice care.
Peng et al. (2024)
used this scale to investigate nursing students’ attitudes towards end-of-life care, they found that nursing students were less optimistic towards end-of-life care but were more positive towards end-of-life care clients’ needs.
4. Research Status on Nursing Students’ Attitudes toward Care of the Dying Patients
Most studies have adopted quantitative research methods. The results showed that nursing students had positive attitudes towards caring for death 69%.
Ferri et al. (2021)
surveyed 569 nursing students from Italy, Spain, and the UK, and their findings revealed that attitudes toward end-of-life care were at an intermediate level. Nursing students in Pakistan, Jordan, and Turkey had lower scores on hospice care attitudes, indicating poorer attitudes (
Al Qadire, 2022
).
Mastroianni et al. (2021)
also found that nursing students frequently feel unprepared when caring for patients and families in hospice settings. They perceive their curriculum as lacking in adequately covering hospice care and in fostering the necessary attitudes for supporting terminally ill patients.
Tang & Chen (2020)
found that 578 nursing students’ attitudes toward hospice care was 98.63 ± 7.35, which was relatively low. The total score was lower than those found in developed countries (
Nelson et al., 2021
). Overall, nursing students’ attitudes toward end-of-life care vary across different countries. These differences are closely related to variations in educational systems, religious beliefs, and cultural backgrounds among different countries. For example, while some developed countries have universities that offer end-of-life care education to nursing students, in Palestine it was not until 2015 that end-of-life care education was included in the curriculum of the Islamic University Medical School (
Alwawi et al. 2022
).
5. Influencing Factors of Nursing Students’ Attitude toward Care of the Dying Patients
5.1. Gender
Alwawi et al. (2022)
found that gender influences nursing students’ attitudes toward end-of-life care. Female students scored higher in providing supportive care for terminal patients and their families, while male students excelled in emotional care aspects. However, this finding contrasts with studies (
Lo Iacono et al., 2024
), which reported no significant gender differences in attitudes toward hospice care, with male students scoring slightly higher but without statistical significance. In some cultures, female students tend to be more compassionate and empathetic, becoming more expressive and emotionally attuned. These traits may encourage nursing students to develop more positive attitudes. With the advancement of the nursing profession, the demand for male nurses is steadily increasing. When providing education on death and end-of-life care to nursing students, it is important to consider gender differences and adopt a personalized, student-centered teaching approach. Tailoring education to meet the unique needs and perspectives of each student can enhance learning outcomes and better prepare all future nurses for compassionate end-of-life care (
Yu et al., 2022
).
5.2. Internship Experience
Clinical practice experience can deepen nursing students’ understanding and view of hospice care in the hospital environment, and thus promote their more positive view of accepting hospice care in the hospital environment (
Gül et al., 2022
). Nursing students’ internship experiences play a crucial role in fostering a strong professional identity (
Xie et al., 2021
). Therefore, integrating hospice care nursing into their internships could enhance their competence in delivering end-of-life care services (
Jiang et al., 2024
).
5.3. Educational Level
Ye et al. (2021)
found that attitudes toward hospice care are influenced by the level of education, with a positive correlation between education level and attitude. In other words, the higher the education level of nursing students, the more positive their attitudes toward hospice care. This may be related to factors such as age, overall quality, and length of study. For example, nursing students with higher education levels tend to have longer study durations, more clinical observation hours, and more opportunities to interact with critically ill patients, think about death, and learn about hospice care.
5.4. Hospice Education Experience
Research indicates that nursing students who have received prior education in hospice care generally exhibit more positive attitudes toward it than those without such training (
Alwawi et al., 2022
). Hospice care and death education programs could enhance the students’ positive attitude toward hospice care and recommended incorporating relevant content into the curriculum (
Chover-Sierra & Martínez-Sabater, 2020
). However, some studies found that the overall positive impact after a hospice care course was minimal, suggesting the need to further deepen hospice care education. This includes making appropriate adjustments to the course content, duration, and teaching methods (
Osakwe et al., 2023
).
5.5. Hospice Care Experience
Mastroianni et al. (2021)
found that hospice care experience can influence nursing students’ attitudes toward hospice care. Students reported that both the duration of hospice care education and prior hospice care experiences were independently associated with more positive attitudes. However, some studies suggest that prior hospice care experiences do not necessarily impact students’ perspectives on end-of-life care. This discrepancy may be attributed to negative experiences or challenging encounters while caring for terminal patients, which could shape their attitudes toward providing such care (
Lo Iacono et al., 2024
).
5.6. Religious Beliefs
Ye et al. (2021)
found that nursing students with religious beliefs scored slightly higher on the hospice care attitude scale compared to those without religious beliefs. Some studies have found no correlation between religious beliefs and attitudes toward hospice care, which may be due to the small proportion of religious individuals in the study population. Another reason is that all the participants in the study shared the same religious beliefs (
Lo Iacono et al., 2024
).
García-Navarro et al. (2021)
produced evidence that religious culture prevails in attitudes towards death. Most religious cultures include contents about death; therefore, it is important to respect students’ religious beliefs in nursing education (
Ye et al., 2021
). This approach not only enhances students’ understanding of death and dying but also prepares them to provide compassionate care to patients from various religious and cultural backgrounds.
5.7. Personal Attitude to Death
Attitude toward death refers to individuals’ thoughts or perspectives on death, as well as their mental state when preparing to react appropriately to the experience of death. This attitude typically involves a mental state when discussing death (
Xiao et al., 2020
). Researchers found that nursing students’ attitudes towards end-of-life care were positively correlated with fear of death and acceptance of death, and negatively correlated with avoidance of death (
Yu et al., 2022
). Students who are marked by characteristics of fear of death, avoidance of death, and avoidance of acceptance require additional education and assistance to develop a positive attitude and perspective on death (
Petrongolo & Toothaker, 2021
). Students who hold a more inclusive or neutral attitude toward death are more likely to show empathy and confidence in hospice care.
5.8. Have a Family Member with a Serious Illness
Tang & Chen (2020)
found that nursing students who have a family member with a serious illness scored higher on attitudes toward hospice care compared to those who did not. This could be due to the empathy that students with a sick family member might develop for terminal patients, as they may psychologically wish for their loved ones to receive better care during the end stages of illness.
5.9. Current Family Loss Experience
Nursing students who have recently experienced the death of a family member scored higher in their hospice care attitudes compared to others. This may be because these students psychologically hope that their loved ones receive better care during the final stages of illness (
Alwawi et al., 2022
). Nursing students with such experiences can develop empathy for their loss, enabling them to view hospice care from the patient’s perspective. Experiencing similar situations helps to alleviate negative emotions and fosters the development of knowledge and skills (
Abelsson & Willman, 2020
).
5.10. Willingness to Care for the Terminally Ill
Researchers found that more than half of the nursing students are unwilling to care for terminally ill patients, and their hospice care attitude scores are lower than those who are willing to care for terminal patients (
Wang et al., 2016
). The other research also indicates that the willingness to care for terminal patients is related to the hospice care attitude scores of nursing students (
Xiong et al., 2023
). A nursing student’s subjective willingness to care for terminally ill patients enables them to take an active role in providing care.
5.11. Openness to Discussing Death at Home
Gao (2023)
found that whether or not death is openly discussed at home is a factor influencing nursing students’ attitudes toward palliative care. Compared to nursing students from families where death is not discussed, those who can openly talk about death at home tend to have more positive attitudes toward palliative care. This indicates that a supportive family environment helps foster a healthy and positive view of death, and nursing students with such a perspective are better able to accept and understand terminally ill patients.
6. Strategies for Improving the End-of-Life Care Attitude of Nursing Students
6.1. Enhancing Nursing Faculty Attitudes Toward Hospice Care
Nursing faculty play a pivotal role in the professional socialization of students. Beyond imparting clinical knowledge and skills, they profoundly influence students’ attitudes and values related to humanistic care. Therefore, improving nursing educators’ own attitudes toward end-of-life care is a foundational step in cultivating nursing professionals with strong palliative care competencies. To address this, Nursing colleges and universities should incorporate hospice care education into the teacher development plan and provide opportunities for nursing teachers to participate in continuing education on hospice care, such as attending hospice care seminars and participating in practical activities in hospice care hospitals. The changes in the hospice care attitudes of nursing teachers can be evaluated through methods such as questionnaires, qualitative interviews, and hospice care teaching competitions, and personalized intervention measures can be given in a timely manner.
6.2. Strengthening Life Education and Hospice Care Training for Nursing Students
For nursing students, their values regarding life and their perception of its meaning significantly influence their attitudes toward end-of-life care. Several studies have shown that nursing students’ attitudes toward end-of-life care become more positive after participating in specialized education courses (
Li et al., 2021
). Both elective and mandatory end-of-life care courses can influence students’ perspectives (
Wang et al., 2023
). Many researchers have found that teaching methods such as video sharing, case analysis, group discussions, role-playing, drawing human figures, and situational simulations effectively help students grasp the essence of end-of-life care (
Bu et al., 2022
;
Rao et al., 2023
). These approaches allow students to experience and understand the physical and psychological challenges faced by terminal patients and their families. Nursing students also believe that death education should be a vital part of end-of-life care training (
Wang et al., 2023
).
6.3. Encouraging Students to Participate in Hospice Volunteer Activities
Volunteers are a popular unpaid support role in end-of-life care (
Downey et al., 2024
). Volunteer activities can have a positive impact on the religious beliefs and spirituality of volunteers (
Claxton-Oldfield et al., 2020
). Some studies found that participating in hospice volunteer activities allows nursing students to gain firsthand experience with terminally ill patients and death, helping them recognize the value and significance of death education. This experience enables them to more actively confront the fear and uncertainty associated with death during their internships. It also helps them assist terminal patients and their families in developing a healthy view of life and death, encouraging a rational approach to facing death (
Bao et al., 2020
;
DeDiego et al., 2023
). Hospice care volunteer programs offer nursing students the opportunity to engage with terminally ill patients and their families, providing experiential learning opportunities.
7. Conclusion
Nursing students’ attitudes toward end-of-life care represent a complex integration of cognitive understanding and emotional orientation. These attitudes reflect not only their comprehension of the meaning of life but also their psychological adaptability in facing death and grief. The development of a positive attitude toward hospice care depends not only on theoretical knowledge, but more importantly, on the gradual formation of personal values, emotional sensitivity, and professional identity. Both domestic and international scholars have conducted extensive research on nursing students’ attitudes toward end-of-life care. Various assessment tools and attitude scales have been developed to facilitate the evaluation of these attitudes. However, the research methods are relatively limited; combining qualitative and quantitative approaches is necessary to gain a deeper and more comprehensive understanding of individuals’ attitudes toward end-of-life care. Findings consistently suggest that nursing students’ attitudes toward hospice care still require significant improvement, underscoring the need for more effective educational strategies and practical exposure. Nursing educators must thoroughly identify and analyze the key factors that influence nursing students’ attitudes toward end-of-life care in order to develop targeted educational strategies. End-of-life care education should be integrated throughout the entire nursing curriculum, emphasizing both theoretical instruction and practical experience. This approach aims to foster students’ professional competence as well as their capacity for humanistic care. By encouraging reflection on life experiences and emotional expression, educators can help students deepen their understanding of death and enhance their psychological adaptability, ultimately cultivating a positive and mature attitude toward hospice care. However, systematic exploration of end-of-life care education in China remains limited. Therefore, future efforts should focus on strengthening research into effective educational pathways and methods for nursing students. It is essential to establish a scientific, structured, and continuous teaching framework that goes beyond knowledge transmission to include the cultivation of attitudes and the awakening of emotional awareness—thereby nurturing nursing professionals who possess both technical competence and a strong sense of compassion.