Death and Dying Attitude Through the Eyes of Nursing Students during Clinical Training: A Cross-Sectional Study in the United Arab Emirates

For nursing students

Study summary

Caring for a dying patient is one of the hardest parts of clinical training, and this study asked a straightforward question: how do nursing students actually feel about death, and are they ready to care for patients at the end of life? Researchers surveyed 122 senior and junior nursing students at a university in the United Arab Emirates in March 2025, using two well-known, validated tools: the Death Attitude Profile-Revised (DAP-R), a 32-item scale measuring five dimensions of how people relate to death (fear of death, death avoidance, neutral acceptance, approach acceptance, and escape acceptance), and the Frommelt Attitudes Toward Care of the Dying (FATCOD) scale, a 30-item tool measuring comfort and attitude specifically toward providing end-of-life care.

Overall, students landed in neutral territory on death attitudes generally, but their FATCOD scores told a more concerning story: only about 26% of students scored in the higher range for positive attitudes toward caring for dying patients, meaning most students are not yet comfortable with this part of nursing work. Meanwhile, on the DAP-R, most students scored high on approach acceptance (which reflects belief in an afterlife) and neutral acceptance (seeing death as a natural part of life) but also carried substantial fear of death, death avoidance, and escape acceptance (seeing death as relief from a painful life) — with roughly two-thirds of students scoring elevated on each of these harder dimensions.

The statistics behind these attitudes matter for understanding what shapes readiness. Death avoidance had the strongest negative relationship with comfort in dying-patient care (a correlation of about -0.51), followed by fear of death (about -0.38) and escape acceptance (about -0.32) — meaning students who tended to avoid thinking about death or feared it more intensely reported feeling less prepared and less comfortable providing end-of-life care. When researchers combined these factors in a regression model, death avoidance, escape acceptance, and neutral acceptance together explained about 43% of the variation in students' comfort with dying-patient care — a meaningful chunk, though more than half of the variation is explained by other factors not measured here. Age, education level, GPA, and clinical performance scores were also statistically linked to attitude scores, suggesting that maturity and academic/clinical experience play some role, though the study does not establish that one causes the other. One specific gender difference emerged: female students scored significantly higher on death avoidance than male students.

Why does this matter for nursing students and new grads? Because the study's authors argue that fear, avoidance, and using death as an 'escape narrative' are not just abstract psychological traits — they are linked to how confident and present a nurse can be at a patient's bedside during their final days. If a student is uncomfortable even thinking about death, that discomfort can show up as avoidance behaviors, rushed communication, or missed opportunities to support a dying patient and their family. The researchers frame the comparatively low FATCOD scores as a signal that palliative and end-of-life care content needs stronger, more structured integration into nursing curricula — not just a lecture or two, but repeated clinical exposure, opportunities to debrief and reflect after difficult experiences, and explicit coping-skills training.

A few honest caveats belong in your reading of this study. It surveyed a single university in the UAE using a convenience sample (not a random, nationally representative one), so findings may not generalize to nursing students elsewhere, including Canada. It is a cross-sectional snapshot — one point in time — so it cannot show whether attitudes change as students progress through their program or after taking a dedicated palliative care course. Self-reported surveys are also vulnerable to students answering in ways they think are expected ('social desirability') rather than how they truly feel. Still, the tools used (DAP-R and FATCOD) are validated instruments used internationally, and the study's message is a useful prompt for any student: reflect honestly on your own comfort with death, seek out structured clinical exposure and debriefing when death care arises in placement, and don't assume neutral acceptance of death in the abstract automatically means comfort providing hands-on end-of-life care in practice.

For educators

Teaching and appraisal notes

This cross-sectional survey study (Elzeiny, Loutfy, Van Belkum, Magdi, Elbatanouny, Al Hariri, Alazazmeh & Alrefai, 2025, published in Palliative Medicine Reports) examined death attitudes and end-of-life care preparedness among 122 senior and junior nursing students at a single university in the United Arab Emirates, surveyed in March 2025 via convenience sampling (78.2% response rate from 156 eligible students). The study paired two validated instruments: the 32-item, 7-point-Likert Death Attitude Profile-Revised (DAP-R), which yields five subscale scores (fear of death, death avoidance, neutral acceptance, approach acceptance, escape acceptance), and the 30-item, 5-point-Likert Frommelt Attitudes Toward Care of the Dying (FATCOD) scale, which measures comfort/attitude specifically toward providing care to dying patients. Data were analyzed in SPSS v25 using Pearson correlation, independent-samples t-tests, and multiple linear regression (alpha = 0.05).

Key quantitative findings worth foregrounding in class discussion: mean FATCOD score was 96.81 (SD 11.90), with only 26.2% of students scoring in the higher comfort range — indicating that, despite showing conceptual acceptance of death (high approach and neutral acceptance subscale scores), most students do not yet feel prepared to actually deliver end-of-life care. Fear of death (r = -0.384, p < .001), death avoidance (r = -0.506, p < .001), and escape acceptance (r = -0.322, p < .001) were all significantly, negatively correlated with FATCOD scores; neutral acceptance and approach acceptance showed no significant relationship. A regression model combining death avoidance, escape acceptance, and neutral acceptance explained 42.9% of variance in FATCOD scores (R² = 0.429), with death avoidance the strongest negative predictor. Female students scored significantly higher on death avoidance than male students (p = .043); no other significant gender differences were reported. Age, education level (junior vs. senior), GPA, and clinical performance scores were also statistically associated with DAP-R and FATCOD scores, consistent with the idea that maturation and clinical exposure shape death attitudes, though the cross-sectional design cannot establish causal direction.

For teaching purposes, this is a strong case study for illustrating the difference between abstract acceptance of mortality and operational readiness to provide hands-on end-of-life nursing care — a distinction students often conflate. It is also useful for demonstrating how psychometric subscale scores (rather than a single global 'death attitude' score) reveal a more nuanced, sometimes contradictory picture (e.g., students can score high on neutral/approach acceptance while simultaneously scoring high on avoidance and escape acceptance). Discussion can productively extend to the cultural and religious framing the authors offer — noting Islamic traditions' emphasis on death acceptance as context for the UAE sample — and to the practical curricular recommendations the authors make: structured, repeated clinical exposure to dying patients (not one-off encounters), reflective debriefing after such encounters, and explicit psychological coping-skills instruction integrated across the nursing program rather than isolated in a single palliative care unit.

Methodological limitations to flag for critical appraisal: single-institution convenience sample limits generalizability across regions and programs; cross-sectional design precludes any claim about how attitudes change over time or in response to a specific curricular intervention; self-report measures carry social-desirability risk; the study did not collect specific religious-affiliation data despite discussing religious/cultural influences, and did not deeply probe prior personal exposure to death or prior palliative care coursework as covariates — all of which limit causal interpretation of the reported associations. Instructors assigning this article should encourage students to distinguish the study's genuinely reported statistics from the authors' interpretive recommendations, and to consider how findings might or might not transfer to a Canadian clinical education context.