Attitudes Towards End-of-Life Care Among Nursing Students: A Cross-Sectional Descriptive Study in a Southern European Undergraduate Nursing Program

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Overall Comment 

Thank you for the opportunity to review this manuscript. The topic is relevant and important, as nursing students’ attitudes toward end-of-life care are closely associated with future clinical practice and quality of patient care. The study addresses an educational and professional issue with potential implications for nursing curricula and palliative care preparation. 

 The manuscript has merit; however, substantial revisions are required to improve clarity, methodological transparency, consistency in reporting, and interpretation of findings. Several sections require clarification, particularly regarding participant recruitment, measurement procedures, statistical analysis, and presentation of results. Concerns also remain regarding potential confounding factors related to respondents’ prior training and placement experiences in end-of-life care, which may influence interpretation of the findings. 

 Title and Abstract 

1. Please specify whether the study used the Spanish version of FATCOD (FATCOD-S). 
2. Ensure consistency in naming the instrument throughout the manuscript. 

Introduction 

1. Please provide the full term for “EOLC” at its first appearance (P1, L38). 
2. Please add examples to support the statement in P2 (L90–91). 
3. Please indicate when nursing students typically begin receiving education related to palliative care within the curriculum. 
4. Please include evidence demonstrating that nursing students or newly graduated nurses may encounter challenges related to end-of-life care, communication, or preparedness. 

Methods 

1. The description of educational programs may be more suitable in the Introduction section.  
2. Please ensure consistent terminology regarding FATCOD-S and clarify that it refers to the Spanish version if applicable.  
3. Please clarify the participant recruitment and data collection procedures. The manuscript states that “data collection was conducted in person,” while respondents completed online questionnaires. Please specify whether eligible respondents were approached in person and subsequently provided with a QR code or electronic link to complete the survey.  
4. Please clarify how FATCOD-S scores were analyzed. Were scores analyzed as continuous variables (means/medians), categorized into groups (e.g., low, moderate, high attitudes), or both?  
5. Please provide justification for the statistical methods used. 

Results 

1. For consistency, consider using “respondents” rather than alternating between “participants” and “respondents.” 
2. Sociodemographic characteristics should be incorporated under Section 3.1 rather than presented separately. 
3. Clinical placement experience in end-of-life care appears to be an important variable that may influence attitudes and should receive greater consideration in the analysis. 
4. Please clarify why p-values are presented in Table 2 and specify the statistical comparisons being conducted. 
5. The FATCOD-S categories presented in Figure 1 appear inconsistent with those described in the Methods section. Please revise for consistency. 
6. The presentation of findings requires revision to improve clarity and interpretability. 
7. There are concerns regarding the analytical approach. Approximately one-third of respondents had placement experience in end-of-life care and only around 40% received related training. These characteristics may substantially influence attitudes toward end-of-life care and should be considered in the analysis and interpretation. Additional analyses or adjustment for these factors may strengthen the findings. 

Discussion 

1. Major methodological concerns should be addressed before interpretation of findings. Reanalysis of the data may be necessary to improve methodological rigor and ensure conclusions are supported by reliable and reproducible analytical methods. 

Conclusion 

1. Please ensure conclusions are aligned with findings after revision of the analytical approach. 

References 

1. Not reviewed at this stage. 

Professional English editing: Yes 

Standard report for publications: Not presented. Need to be submitted for the next revision 

Author Response

Response to Reviewer 1

 We would like to sincerely thank the Reviewer for the thorough evaluation of our manuscript and for the constructive comments and suggestions provided. We appreciate the time and effort devoted to reviewing our work.

We have carefully considered all comments and revised the manuscript accordingly. To facilitate the review process, all modifications introduced in the revised manuscript have been highlighted in red.

Below, we provide a detailed point-by-point response to each comment. Reviewer comments are reproduced first, followed by our responses and a description of the corresponding changes made in the manuscript.

 TITLE AND ABSTRACT 

Reviewer Comment:

1. Please specify whether the study used the Spanish version of FATCOD (FATCOD-S). 
2. Ensure consistency in naming the instrument throughout the manuscript. 

Response:

Thank you for this observation. We have clarified that the instrument used in this study was the validated Spanish version of the Frommelt Attitude Toward Care of the Dying Scale (FATCOD-S), both in the Abstract and Methods sections. We also revised the terminology throughout the manuscript to ensure consistency and to clearly distinguish the original FATCOD scale from the Spanish adaptation (FATCOD-S) used in the present study.

This revision has been incorporated into the manuscript and highlighted in red. Abstract (line 20-21); Introduction (lines 87-90) and Methods (lines 142 to 143 and 162-163).

INTRODUCTION

Reviewer Comment:

1. Please provide the full term for “EOLC” at its first appearance (P1, L38).

Response:

Thank you for this observation. We have revised the Introduction section to provide the full term “end-of-life care” before introducing the abbreviation “EOLC” at its first appearance in the manuscript.

The corresponding changes have been highlighted in red in the revised manuscript (line 41).

Reviewer Comment:

2. Please add examples to support the statement in P2 (L90–91).

Response:
Thank you for this suggestion. We have expanded this statement by providing examples from previous studies showing that factors such as prior clinical exposure to dying patients and specific palliative care education may influence nursing students’ attitudes towards end-of-life care. Relevant references have been added to support this statement.

The corresponding modification has been highlighted in red in the revised manuscript (line 91 to 97).

Reviewer Comment:

3. Please indicate when nursing students typically begin receiving education related to palliative care within the curriculum.

Response:
Thank you for this observation. We have added information to the Introduction describing when nursing students are exposed to end-of-life care education within the curriculum. Specifically, we clarified that students begin clinical placements during the second year of the programme, whereas specific theoretical training in palliative and end-of-life care is delivered during the third year.

The requested information has been added and highlighted in red in the revised manuscript (Lines 97-103).

Reviewer Comment:

4. Please include evidence demonstrating that nursing students or newly graduated nurses may encounter challenges related to end-of-life care, communication, or preparedness.

Response:
Thank you for this valuable suggestion. We have expanded the Introduction by incorporating evidence from previous studies showing that nursing students and newly graduated nurses may experience challenges related to end-of-life care, including communication with dying patients and their families, emotional distress associated with death, and limited perceived preparedness to manage end-of-life situations.

The relevant changes have been highlighted in red in the revised manuscript (lines 80-86).

 METHODS 

Reviewer Comment:

1. The description of educational programs may be more suitable in the Introduction section. 

Response:

Thank you for this suggestion. We agree that the general description of the undergraduate nursing program is more appropriately presented in the Introduction section. Therefore, we moved this information to the Introduction and retained only a brief description of the educational context in the Methods section. We also expanded the description of the end-of-life care training provided during the program.

The corresponding modifications have been highlighted in red in the revised manuscript (lines 97-103).

  Reviewer Comment:

1. Please ensure consistent terminology regarding FATCOD-S and clarify that it refers to the Spanish version if applicable.  

Response:

Thank you for this observation. As noted above, we have revised the manuscript to ensure consistent use of the term FATCOD-S throughout the text and clarified that it refers to the validated Spanish version of the Frommelt Attitude Toward Care of the Dying Scale. These modifications were incorporated in the relevant sections of the manuscript, including the Abstract, Introduction, Methods, and Strengths section.

This revision has been incorporated into the manuscript and highlighted in red. Abstract (lines 20-21); Introduction (lines 88-91) and Methods (lines 142 to 146 and 162-163).

Reviewer Comment:

1. Please clarify the participant recruitment and data collection procedures. The manuscript states that “data collection was conducted in person,” while respondents completed online questionnaires. Please specify whether eligible respondents were approached in person and subsequently provided with a QR code or electronic link to complete the survey.  

Response:

Thank you for this observation. We have clarified the participant recruitment and data collection procedures in the Methods section. Eligible students were approached in person during scheduled academic activities and were subsequently provided with a QR code linking to the online questionnaire, which they completed electronically. This procedure allowed data collection to be conducted in person while ensuring anonymous online survey completion.

The corresponding modification has been highlighted in red in the revised manuscript (lines 183-191).

Reviewer Comment:

1. Please clarify how FATCOD-S scores were analyzed. Were scores analyzed as continuous variables (means/medians), categorized into groups (e.g., low, moderate, high attitudes), or both?  

Response:

We agree that this required clarification. We have revised the Methods to state that the FATCOD-S was handled primarily as a continuous total score after reverse coding of negatively worded items. The published cut-off categories were retained only as secondary descriptive groupings to facilitate interpretation and comparison with previous research. We also clarified that item-level responses are ordinal and are presented descriptively as response frequencies and medians with interquartile ranges.

Sections 2.2 (lines 154-159) and 2.4 (lines 200-204) now distinguish between the continuous FATCOD-S total score, the descriptive categories, and the ordinal item-level analyses. These modifications have been highlighted in red in the revised manuscript.

Reviewer Comment:

1. Please provide justification for the statistical methods used. 

Response:

We have expanded the Data Analysis section. The revised text justifies the use of frequencies and percentages for categorical variables; medians and interquartile ranges for quantitative variables due to non-normal distributions; chi-square or Fisher’s exact tests for categorical comparisons; and Mann–Whitney U or Kruskal–Wallis tests for non-normally distributed quantitative comparisons. We also clarified that the item-level analyses were exploratory and descriptive.

Manuscript changes: Section 2.4 has been rewritten to specify each analysis according to variable type, distribution, and analytical purpose. These modifications have been highlighted in red in the revised manuscript (lines 193-226).

RESULTS 

Reviewer Comment:

1. For consistency, consider using “respondents” rather than alternating between “participants” and “respondents.” 

Response:

Thank you for this suggestion. We have revised the terminology throughout the manuscript to ensure consistency and now use the term “respondents” instead of alternating between “participants” and “respondents” where appropriate.

The corresponding modifications have been highlighted in red throughout the revised manuscript.

Reviewer Comment:

2. Sociodemographic characteristics should be incorporated under Section 3.1 rather than presented separately.

Response:

Thank you for this suggestion. We have reorganised the Results section by incorporating the sociodemographic characteristics of the respondents into Section 3.1, together with the academic characteristics and experiences related to EOLC.

The corresponding modifications have been highlighted in red in the revised manuscript (lines 240-244).

Reviewer Comment:

3. Clinical placement experience in end-of-life care appears to be an important variable that may influence attitudes and should receive greater consideration in the analysis. 

Response:

Thank you for this observation. We agree that clinical placement experience in end-of-life care may influence students’ attitudes towards EOLC. To provide greater consideration of this variable, completion of a clinical placement in an EOLC unit was included as a covariate in the exploratory multivariable regression model. Although the association was positive, it did not remain statistically significant after adjustment for other educational and experiential variables (β = 1.87, 95% CI −0.32 to 4.06, p = 0.095). The Results and Discussion sections were revised accordingly to ensure that clinical placement experience is considered when interpreting the findings.

The corresponding modifications have been highlighted in red (section 3.3., lines 356-372 and table 3; section 4.1., lines 494-498, and 508-526).

Reviewer Comment:

4. Please clarify why p-values are presented in Table 2 and specify the statistical comparisons being conducted. 

Response:

We agree that the p-values in the item-level table were difficult to interpret because they did not represent meaningful between-group comparisons. We have therefore removed the p-value column from Table 2 and retained the table as a descriptive item-level summary of response distributions and medians with interquartile ranges.

With regard to the second point concerning the statistical comparisons conducted, we have revised the Data Analysis section to justify the statistical tests used. Because quantitative variables showed non-normal distributions, medians and interquartile ranges were reported, and non-parametric tests were used for bivariate comparisons. Chi-square or Fisher’s exact tests were used for categorical variables. In addition, an exploratory multivariable linear regression model was added to adjust for relevant educational and experiential variables.

Manuscript changes: Table 2 has been reformatted as a descriptive table and the p-value column has been removed. In addition, Section 2.4 (Data Analysis) has been revised to clarify the statistical comparisons performed and the statistical tests used, including the incorporation of an exploratory multivariable linear regression model.

These changes have been highlighted in red in the revised manuscript. In particular, Section 2.4 (Data Analysis) has been comprehensively revised and rewritten to provide a clearer justification of the statistical methods used, clarify the analytical strategy, and describe the exploratory adjusted multivariable analysis.

Reviewer Comment:

5. The FATCOD-S categories presented in Figure 1 appear inconsistent with those described in the Methods section. Please revise for consistency. 

Response:

Thank you for this observation. We have revised Figures 1 and 2 to ensure that the FATCOD-S categories are presented consistently with those described in the Methods section. The category labels used in both figures are now fully aligned with the methodological description, although abbreviated to optimise the use of space and improve figure readability.

Reviewer Comment:

6. The presentation of findings requires revision to improve clarity and interpretability. 

Response:

Thank you for this observation. We have revised the Results section to improve the clarity and interpretability of the findings. Descriptive results were reorganised, sociodemographic characteristics were integrated into Section 3.1, and the presentation of FATCOD-S results was clarified. In addition, an exploratory multivariable analysis was incorporated to distinguish adjusted associations from unadjusted bivariate findings and to facilitate a more robust interpretation of factors associated with attitudes towards EOLC. Following the inclusion of this exploratory multivariable analysis, two figures were removed because they did not provide additional information beyond that presented in the adjusted analysis and were therefore considered redundant. The Discussion was also revised to ensure a more cautious interpretation of the results.

The corresponding modifications have been highlighted in red throughout the Results and Discussion sections.

Reviewer Comment:

7. There are concerns regarding the analytical approach. Approximately one-third of respondents had placement experience in end-of-life care and only around 40% received related training. These characteristics may substantially influence attitudes toward end-of-life care and should be considered in the analysis and interpretation. Additional analyses or adjustment for these factors may strengthen the findings. 

Response:

We agree. We revised the analytical plan and interpretation to address the potential influence of previous EOLC training, clinical placement in units where EOLC is provided, previous personal experience with a loved one receiving EOLC, academic year, age and gender. An exploratory adjusted linear regression model was added using the reverse-coded FATCOD-S total score as the dependent variable. In the complete-case model (n = 572), fourth-year status (β = 4.83, 95% CI 1.63 to 8.03, p = 0.003) and previous EOLC training (β = 2.29, 95% CI 0.03 to 4.55, p = 0.047) were associated with higher FATCOD-S total scores. Previous experience with a loved one receiving EOLC and completion of a clinical placement in an EOLC unit showed positive but non-significant associations. The Discussion has also been revised to avoid interpreting bivariate associations as independent effects.

The corresponding modifications have been highlighted in red in Section 2.4 (lines 212–226), Section 3.3 (lines 356–372 and Table 3), and Section 4 (lines 494-498 and 508-522).

DISCUSSION

Reviewer Comment:

1. Major methodological concerns should be addressed before interpretation of findings. Reanalysis of the data may be necessary to improve methodological rigor and ensure conclusions are supported by reliable and reproducible analytical methods.

Response:

We have revised the manuscript so that methodological issues are addressed before interpretation. The revised Discussion now explicitly states that the findings are associations, not causal effects, and that academic year may overlap with curricular exposure, clinical placement, previous training, and previous personal experience.

The corresponding modifications have been highlighted in red throughout the revised manuscript. Because these changes were implemented across multiple paragraphs of the Discussion and Limitations sections, individual line numbers are not provided. The revised text now contains more cautious wording and explicitly acknowledges the potential confounding role of previous EOLC training, clinical exposure, and related factors when interpreting the observed associations.

CONCLUSION

Reviewer Comment:

1. Please ensure conclusions are aligned with findings after revision of the analytical approach. 

Response:

Thank you for this observation. We have revised the Conclusion section to ensure that it is fully aligned with the revised analytical approach and the adjusted findings. The conclusions now avoid causal language, emphasise the exploratory nature of the observed associations, acknowledge the potential influence of training and clinical exposure, and explicitly state that the findings should be interpreted as associations rather than evidence of causal effects.

The corresponding modifications have been highlighted in red in the Conclusions section of the revised manuscript (lines 594-611).

Reviewer Comment:

Standard report for publications: Not presented. Need to be submitted for the next revision 

Response:

Thank you for this observation. The standard reporting guideline checklist has now been completed and is included as a supplementary document with the revised submission.

We appreciate the reviewer’s detailed and constructive comments. Addressing these suggestions has enabled us to improve the methodological transparency, interpretation of the findings, and overall presentation of the study. We hope that the revised manuscript satisfactorily addresses all concerns raised.

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

Great data and findings! Good job on the manuscript. A lot of my comments are grammatical, but if this publication accepts British English then leave it! I was just making these suggestions in the event it needs to be different.

Line 22 – spelling of recognized 

Line 24 – consider rewording to “reported feeling unprepared to care for...” 

Line 39 – spelling of hospitalization  

Line 53 – space between care and ( 

Line 54 – remove space between parenthesis and period  

Line 56 – spelling of depersonalization 

Line 58 - remove space between parenthesis and period 

Line 68 – remove captials from ED 

Line 69 – spelling of maximizing 

Line 71 – remove capitals from Primary Care  

Line 96 – spelling of optimize  

Line 108 – spelling of program throughout the entire article 

Line 111 – is there any way to go more in detail at some point in the article on what theoretical training is given in the 3rd year for these students? What is the structure of it? 

Line 173 – spelling of utilized  

Line 312 – spelling of favorable  

Line 315 – spelling of analyzing  

Line 323 – could you speak more about what type of training your institution offers (see above comment on line 111) 

Line 356 – spelling organized  

Line 438 – spelling generalized 

Lines 457-458 seem out of place? 

Line 471 – spelling favorable  

Comments on the Quality of English Language

Grammar issues noted above. 

Author Response

Response to Reviewer 2

We sincerely thank the reviewer for the positive evaluation of our manuscript and for the constructive comments provided. We are grateful for the careful review and the helpful suggestions, particularly regarding language and style. We have carefully considered all comments and revised the manuscript accordingly.

Reviewer Comment:

Lines 22, 39, 56, 69, 96, 108, 173, 312, 315, 356, 438, and 471 – spelling revisions.

Response:
Thank you for these observations. We have reviewed the manuscript and standardised the language to ensure consistency with American English spelling throughout the text.

The corresponding changes have been highlighted in red in the revised manuscript.

Reviewer Comment:

Line 111 – is there any way to go more in detail at some point in the article on what theoretical training is given in the 3rd year for these students? What is the structure of it?

Response:
Thank you for this valuable suggestion. We have expanded the Introduction section to provide a brief description of the theoretical end-of-life care training delivered during the third year of the nursing program, including its main educational content areas.

The corresponding modification has been highlighted in red in the revised manuscript (lines 97-103)

 Reviewer Comment:

Line 323 – could you speak more about what type of training your institution offers (see above comment on line 111)

Response:

Thank you for this observation. As suggested in the previous comment (Line 111), we have expanded the description of the theoretical EOLC training provided within the nursing program, including its main content areas and teaching methods.

The corresponding modification has been highlighted in red in the revised manuscript (lines 97-103)

Reviewer Comment:

Lines 457-458 seem out of place? 

Response:

Thank you for this observation. We have revised this statement in the Limitations section to improve its clarity and coherence with the overall scope of the study. The wording has been modified to refer to the transferability of the findings to other educational and cultural contexts rather than to generalizability across regions or countries.

The corresponding modification has been highlighted in red in the revised manuscript (Section 4.2., lines 541-590).

We sincerely thank the reviewer for the valuable feedback and encouraging comments. We have carefully considered all suggestions and revised the manuscript accordingly. We hope that the changes made have strengthened the manuscript and adequately addressed all points raised.

Author Response File: Author Response.pdf

Reviewer 3 Report

Comments and Suggestions for Authors

Thank you so much for allowing me to review this manuscript. It addresses an important and relevant topic in nursing education, namely nursing students’ attitudes toward end-of-life care and their perceived preparedness to provide such care. The manuscript is generally well structured and clearly written. However, I found several methodological, statistical, and interpretative issues which should be addressed before the manuscript can be considered for publication.

1. The manuscript reports that the sample size was calculated based on a population of 1,312 nursing students, a confidence level of 95%, and a margin of error of 3%. However, additional information is required regarding the assumptions used in the calculation, including the expected prevalence or proportion, application of finite population correction, and anticipated response rate. Also, the study employed convenience sampling, which may introduce selection bias and limit representativeness. Although this limitation is acknowledged, its potential impact on the findings warrants further discussion.

2. The FATCOD-S is fundamentally a continuous measure of attitudes toward care of dying patients. The categorization of scores into "very negative," "negative," "positive," and "very positive" attitudes should be more clearly justified. While the authors cite a previous study adopting these categories, such classifications are not universally established and may reduce statistical sensitivity and obscure meaningful variation within the data.

3. A substantial number of statistical tests were conducted across FATCOD-S items, sub-dimensions, demographic variables, and educational characteristics. No adjustment for multiple comparisons is reported. The authors should discuss whether correction procedures were considered and justify their analytical approach.

4. Only two participants identified as non-binary. Statistical comparisons involving this subgroup are unlikely to be meaningful and should be interpreted with extreme caution. The authors should avoid drawing conclusions based on this subgroup and explicitly acknowledge the limitation imposed by the very small sample size.

5. The discussion suggests that progression through the nursing curriculum and increased clinical exposure may explain differences observed across academic years. However, the cross-sectional design does not permit conclusions regarding developmental changes or causal relationships. Differences between academic years may reflect cohort effects rather than progression through training. Interpretations throughout the discussion should therefore be revised to avoid causal implications.

6. One of the central conclusions of the manuscript concerns the coexistence of positive attitudes and low perceived preparedness. However, preparedness appears to have been assessed using a single self-reported question rather than a validated measure of preparedness or competence. The authors should acknowledge this limitation more explicitly and avoid over-interpreting preparedness as an indicator of actual clinical competence.

7. The methods section indicates that quantitative variables were summarized using medians and interquartile ranges because data were non-normally distributed. However, age is reported as mean ± standard deviation. The reporting strategy should be made consistent or justified.

8. Section 4.1 is dedicated to strengths, while Section 4.2 is entitled “Limitations and strengths.” This structure is somewhat confusing. The manuscript would benefit from clearer separation of strengths and limitations or consolidation into a single section.

9. The introduction contains some repetition regarding the educational importance of attitudes toward EOLC and could be streamlined.

10. The terminology used throughout the manuscript alternates between “end-of-life care” and “palliative care.” The relationship between these concepts should be clarified.

11. Several tables, particularly Table 2, are difficult to interpret and would benefit from improved formatting and presentation.

Thank you again for allowing me to review this manuscript. It truly addresses an important aspect of undergraduate nursing education and contributes useful data regarding students’ attitudes toward end-of-life care. I believe the findings are potentially valuable for curriculum development and future research. However, several methodological and analytical issues require clarification and revision before the manuscript can be considered for publication. I therefore recommend major revision.

Author Response

Response to Reviewer 3

We sincerely thank the reviewer for the thorough evaluation of our manuscript and for the constructive comments provided. We appreciate the recognition of the relevance of the topic and the overall structure of the manuscript. We have carefully considered all methodological, statistical, and interpretative concerns raised and have revised the manuscript accordingly. The revisions undertaken are detailed in our responses below.

Reviewer Comment:

1. The manuscript reports that the sample size was calculated based on a population of 1,312 nursing students, a confidence level of 95%, and a margin of error of 3%. However, additional information is required regarding the assumptions used in the calculation, including the expected prevalence or proportion, application of finite population correction, and anticipated response rate. Also, the study employed convenience sampling, which may introduce selection bias and limit representativeness. Although this limitation is acknowledged, its potential impact on the findings warrants further discussion.

Response:

Thank you for this observation. We have expanded the sample-size calculation. The revised Methods specify that the calculation assumed an expected proportion of 50% to maximise variability, a 95% confidence level, a 3% precision, and finite population correction for the reference population of 1,312 students. The calculation yielded a minimum required sample of 589 students; the target was increased to approximately 600 to allow for invalid or incomplete questionnaires. We also report that 594 questionnaires were received and 593 were valid, representing 45.2% of the reference population.

Furthermore, we expanded the limitations to address voluntary participation, possible self-selection bias, and the absence of data on non-participants.

The corresponding modifications have been highlighted in red in the revised manuscript (Section 2.1., lines 123-134; section 2.3. lines 189-191; and section 4.2., lines 546-551).

Reviewer Comment:

2. The FATCOD-S is fundamentally a continuous measure of attitudes toward care of dying patients. The categorization of scores into "very negative," "negative," "positive," and "very positive" attitudes should be more clearly justified. While the authors cite a previous study adopting these categories, such classifications are not universally established and may reduce statistical sensitivity and obscure meaningful variation within the data.

Response:

We agree. The Methods now state that the continuous reverse-coded FATCOD-S total score is the primary analytical measure. The categories are retained only as descriptive groupings based on previous literature and are not interpreted as universal psychometric thresholds. After recalculation with reverse coding, the total score was 125.0 (IQR 119.0–131.0), and the categorical distribution was updated. Because only two participants were classified as negative or very negative after reverse coding, the category-based cross-tabulation was removed, and the continuous score was used for the adjusted analysis.

Manuscript changes: Sections 2.2, 2.4, 3.2, and 4.2 now clarify the role and limitations of the cut-off categories, and the corresponding modifications have been highlighted in red in the revised manuscript (lines 152-160, 198-204, 259-262, 543-545).

Reviewer Comment:

3. A substantial number of statistical tests were conducted across FATCOD-S items, sub-dimensions, demographic variables, and educational characteristics. No adjustment for multiple comparisons is reported. The authors should discuss whether correction procedures were considered and justify their analytical approach.

Response:

We agree that the large number of comparisons increases the possibility of type I error. In response, we have clarified in the Data Analysis section that no formal multiplicity correction was applied because the item-level and domain-level analyses were exploratory rather than confirmatory, and that the main inferential interpretation was based on the FATCOD-S total score and the adjusted multivariable model. We also revised the Results section to emphasise that domain-level findings should be interpreted as exploratory and that p-values should be considered alongside the magnitude and educational relevance of the observed differences. Finally, this issue is now acknowledged in the Limitations section.

The corresponding modifications have been highlighted in red in the revised manuscript (Section 2.4., lines 222-226; section 3.2., 315-319; and section 4.2., 571-577).

 Reviewer Comment: 

4. Only two participants identified as non-binary. Statistical comparisons involving this subgroup are unlikely to be meaningful and should be interpreted with extreme caution. The authors should avoid drawing conclusions based on this subgroup and explicitly acknowledge the limitation imposed by the very small sample size.

Response:

We thank the reviewer for this important observation. We agree that the number of participants who identified as non-binary was extremely small (n = 2), making statistical comparisons involving this subgroup unreliable and limiting the interpretability of any observed differences. Accordingly, we have revised the manuscript to explicitly state that gender-based comparisons involving non-binary participants should be interpreted with extreme caution and that no substantive conclusions regarding attitudes towards EOLC among non-binary students can be drawn from the present data.

In addition, we clarified the methodological approach in the Statistical Analysis section. Non-binary participants were retained in the descriptive analyses to accurately represent the study sample; however, they were excluded from the adjusted multivariable model because the very small subgroup size would have produced unstable parameter estimates. Furthermore, the limitations section has been strengthened to explicitly acknowledge that the very low representation of non-binary respondents precludes meaningful statistical inference for this subgroup, limits the interpretation of gender-based comparisons, and restricts the generalisability of findings across gender groups.

The corresponding modifications have been highlighted in red in the revised manuscript (lines section 2.4., lines 218-221; section 3.2., 295-300 and section 4.2., lines 558-562).

Reviewer Comment:

5. The discussion suggests that progression through the nursing curriculum and increased clinical exposure may explain differences observed across academic years. However, the cross-sectional design does not permit conclusions regarding developmental changes or causal relationships. Differences between academic years may reflect cohort effects rather than progression through training. Interpretations throughout the discussion should therefore be revised to avoid causal implications.

Response:

We thank the reviewer for this important observation. We agree that the cross-sectional design does not permit conclusions regarding developmental changes or causal relationships between academic progression and attitudes towards EOLC. Accordingly, we revised the Discussion to avoid causal interpretations of the differences observed across academic years. We now explicitly state that these findings should be interpreted as associations rather than causal effects and acknowledge that differences between academic years may reflect cohort effects rather than progression through training.

The corresponding modifications have been highlighted in red in the revised manuscript (lines 508-522).

Reviewer Comment:

6. One of the central conclusions of the manuscript concerns the coexistence of positive attitudes and low perceived preparedness. However, preparedness appears to have been assessed using a single self-reported question rather than a validated measure of preparedness or competence. The authors should acknowledge this limitation more explicitly and avoid over-interpreting preparedness as an indicator of actual clinical competence.

Response:

We thank the reviewer for this important observation. We agree that preparedness was assessed using a single self-reported item rather than a validated measure of preparedness or clinical competence. Accordingly, we have revised the manuscript to clarify that the findings relate to students’ perceived readiness and should not be interpreted as an indicator of actual clinical competence. We now explicitly state that the observed coexistence of positive attitudes towards EOLC and low preparedness reflects self-reported perceptions rather than an objective assessment of competence.

In addition, we have strengthened the limitations section by explicitly acknowledging that preparedness was measured using a single self-reported question and that this variable should therefore be interpreted with caution as a subjective indicator of readiness rather than actual ability to provide EOLC in clinical practice.

These changes have been highlighted in red in the Discussion (lines 401–405) and Limitations section (lines 582–587).

Reviewer Comment:

7. The methods section indicates that quantitative variables were summarized using medians and interquartile ranges because data were non-normally distributed. However, age is reported as mean ± standard deviation. The reporting strategy should be made consistent or justified.

Response:

We agree and have made the presentation consistent. Age is now reported as median and interquartile range in the Results and Table 1, in line with the statistical strategy described in the Methods. The median age was 21.0 years (IQR 20.0–22.0).

Manuscript changes: Results (line 242) and Table 1 have been marked to replace mean ± standard deviation with median and interquartile range. The corresponding modifications have been highlighted in red in the revised manuscript

Reviewer Comment: 

8. Section 4.1 is dedicated to strengths, while Section 4.2 is entitled “Limitations and strengths.” This structure is somewhat confusing. The manuscript would benefit from clearer separation of strengths and limitations or consolidation into a single section.

Response:

We thank the reviewer for this observation. We agree that the previous structure could be confusing because strengths were addressed in more than one section. To improve clarity and avoid redundancy, the manuscript has been revised so that strengths and limitations are presented in separate sections. Section 4.1 is now devoted exclusively to the study strengths, whereas Section 4.2 has been renamed “Limitations” and now contains only the study limitations.

These changes have been highlighted in red in the revised manuscript (sections 4.1. and 4.2., lines 533-590).

 Reviewer Comment: 

9. The introduction contains some repetition regarding the educational importance of attitudes toward EOLC and could be streamlined.

Response:

Thank you for this observation. We have revised the Introduction to reduce repetition and improve conciseness. Several statements regarding the educational importance of attitudes towards EOLC were condensed, and the section was streamlined to improve the overall flow of the manuscript.

The relevant changes in the Introduction section have been highlighted in red throughout the Introduction section of the revised manuscript.

Reviewer Comment:

10. The terminology used throughout the manuscript alternates between “end-of-life care” and “palliative care.” The relationship between these concepts should be clarified.

Response:

We thank the reviewer for this observation. We agree that the alternating use of the terms “palliative care” and “end-of-life care” may create ambiguity. To improve consistency and clarity, we have revised the manuscript to use the term “end-of-life care (EOLC)” throughout, as this more accurately reflects the focus of the study, the questionnaire employed, and the variables analysed. References to “palliative care” have been retained only when referring specifically to the literature, educational programs, or concepts that were originally described using that terminology.

These changes have been highlighted in red throughout the revised manuscript.

 Reviewer Comment:

11. Several tables, particularly Table 2, are difficult to interpret and would benefit from improved formatting and presentation.

Response:

We have simplified the presentation of Table 2 by removing the p-value columns and clarifying that the table is descriptive. We also added text to focus the Results on the most educationally relevant findings rather than relying on a dense item-by-item interpretation. If the journal permits, the full item-level table may also be moved to supplementary material and replaced in the main text with a more concise table of the main patterns.

Manuscript changes: Table 2 and the surrounding Results text have been revised (lines 259-266).

Once again, we sincerely thank the reviewer for the detailed and constructive evaluation of our manuscript. We appreciate the recognition of the relevance of the topic and the potential contribution of the findings to nursing education and future research. In response to the concerns raised, we have undertaken substantial revisions to clarify the methodology, strengthen the statistical analyses, and ensure a more cautious interpretation of the findings. We hope that the revised manuscript satisfactorily addresses all comments and concerns and that the changes made have strengthened the overall quality and rigor of the study.

Author Response File: Author Response.pdf

Reviewer 4 Report

Comments and Suggestions for Authors

This study focuses on a current and educationally significant topic: nursing students' attitudes toward end-of-life care. The study's strengths include a sufficiently large sample size, the use of the validated FATCOD-S scale, and the implications of the findings for undergraduate nursing education. However, the article has some important areas that need improvement in terms of methodology, analytical skills, and structure.

The title generally reflects the content of the study; however, the cross-sectional nature of the research is not sufficiently evident in the title. Using the phrase "cross-sectional descriptive study" instead of "descriptive study" would more accurately describe the research design. Furthermore, specifying in the title whether the study was conducted in a single-center setting or within a specific educational context would more realistically reflect the scope of the findings.

The abstract includes the study's aim, methods, and main findings; however, some findings are repeated, and the conclusion section ends with relatively general statements. The main contribution of the study is that, despite students' positive attitudes, they do not feel sufficiently prepared for end-of-life care; therefore, this finding should be more centrally emphasized in the abstract. Furthermore, the abstract does not briefly address the limitations of the study or points to consider when interpreting the findings.

The introduction highlights the importance of end-of-life care in nursing education and clinical practice. However, the section occasionally turns into a broad literature review, and the specific research gap of the study is not defined sharply enough. Although the emphasis is on the Southern European or Spanish undergraduate nursing context, it should be more clearly justified what specific gap exists in the existing literature within this context. The reasons for the necessity of the research, how it differs from previous studies, and what knowledge gap it aims to fill should be more clearly stated.

The methods section generally describes the research design, sample, data collection process, and the scale used. However, the use of convenience sampling limits the external validity of the study. Since the sample was selected from different campuses of a single university, it is difficult to generalize the results to nursing students in Spain or other countries. This should not only be mentioned in the limitations section but also more visibly considered when interpreting the findings.

Although the sample size calculation is given, the sampling process is not sufficiently detailed. The study does not clearly specify how participants were invited, the response rate, the characteristics of students who did not participate in the study, and potential bias in voluntary participation. This deficiency may increase the likelihood that students who participated in the study may have a more engaged or positive attitude towards the subject, especially in an emotionally and ethically sensitive topic such as end-of-life care.

While the use of the FATCOD-S scale is appropriate, the rationale for the threshold values ​​used in categorizing scale scores should be more strongly explained. Furthermore, it is stated that some items are grouped under conceptual sub-dimensions; however, it appears that this grouping has not been tested using a psychometric method such as confirmatory factor analysis. Therefore, interpretations regarding the sub-dimensions should be limited, and it should be more clearly stated that this classification is used solely for descriptive purposes.

The statistical analysis section presents descriptive and comparative analyses; however, the analysis plan is limited. The study only includes two-variable comparisons, preventing the control of potential confounding variables that could affect attitudes. Including variables such as academic year, clinical practice experience, previous end-of-life care experience, education status, and gender in the model to perform a multivariate analysis could have increased the analytical power of the study. As it stands, it is unclear whether some relationships are independent effects or reflections of other variables.

The findings section is detailed; however, the tables and figures are quite dense, making it difficult for the reader to focus on the key findings. In particular, the lengthy table relating to FATCOD-S items reduces the interpretability of the findings if not selectively summarized in the text. A more synthetic presentation of the findings is needed, and statistically significant differences that may be clinically or educationally limited should be interpreted more carefully. Furthermore, comparative interpretations should be avoided in some groups, particularly due to the very low number of non-binary participants.

While the relationship between academic year and attitudes is interesting, the cross-sectional design limits the interpretation of this relationship as a development dependent on the educational process. The observation of more positive attitudes in third-year students may point to a curriculum effect; however, it may also be related to cohort differences, selection effects, or differences in clinical experience. Therefore, causal or developmental inferences should be made more cautiously when interpreting the findings.

The discussion section relates the findings to the literature; however, some interpretations contain stronger inferences than the study design allows. In particular, statements that clinical exposure improves attitudes, that educational programs increase readiness, or that the decline in fourth-year attitudes is related to clinical reality should be kept at the hypothesis level. Rewriting these interpretations with more cautious expressions such as "may suggest" or "may be associated with" will increase scientific consistency.

The discussion provides a significant contribution to the study's main finding: the divergence between positive attitudes and low readiness. However, the possible reasons for this divergence could be addressed more systematically. For example, factors such as curriculum content, simulation opportunities, clinical guidance, emotional support mechanisms, near-death experience, and communication skills could be discussed more comprehensively under separate headings. While these points are included in the current discussion, they are sometimes repetitive and not sufficiently linked to a theoretical framework.

The limitations section includes many important points; however, it needs structural improvement. The use of the headings “Study Strengths” followed by “Limitations and strengths” in the article creates repetition. Strengths and limitations should be organized under separate and consistent headings. Furthermore, social desirability bias, the limitations of self-report data, the effects of online data collection, the very small non-binary group, and the lack of psychometric validation for some sub-dimension analyses should be more clearly emphasized.

The conclusion section reflects the results of the study; however, it could be written more concisely and directly. The conclusions should state that the generalizability of recommendations regarding educational programs is limited due to the cross-sectional and single-center nature of the study. The findings support the need for greater emphasis on end-of-life care education in nursing undergraduate programs. However, this proposal should be presented in a more measured way, consistent with the descriptive nature of the available data.

Author Response

Response to Reviewer 4

We sincerely thank the reviewer for the thorough and constructive evaluation of our manuscript. We greatly appreciate the recognition of the relevance of the topic, the strengths of the study design, and the potential implications of the findings for undergraduate nursing education. We have carefully considered all comments and suggestions regarding the methodology, statistical analyses, interpretation of the findings, and manuscript structure. In response, substantial revisions have been made throughout the manuscript, as detailed in our point-by-point responses below.

Reviewer Comment:

The title generally reflects the content of the study; however, the cross-sectional nature of the research is not sufficiently evident in the title. Using the phrase "cross-sectional descriptive study" instead of "descriptive study" would more accurately describe the research design. Furthermore, specifying in the title whether the study was conducted in a single-center setting or within a specific educational context would more realistically reflect the scope of the findings.

Response:

We thank the reviewer for this valuable suggestion. We agree that the title should more clearly reflect both the study design and the educational context in which the research was conducted. Accordingly, the title has been revised to identify the study as a cross-sectional descriptive study and to specify that it was conducted within a Southern European undergraduate nursing program.

The revised title is: “Attitudes Towards End-Of-Life Care Among Nursing Students: A Cross-Sectional Descriptive Study in a Southern European Undergraduate Nursing Program”.

This change has been highlighted in red in the title of the revised manuscript.

 Reviewer Comment:

The abstract includes the study's aim, methods, and main findings; however, some findings are repeated, and the conclusion section ends with relatively general statements. The main contribution of the study is that, despite students' positive attitudes, they do not feel sufficiently prepared for end-of-life care; therefore, this finding should be more centrally emphasized in the abstract. Furthermore, the abstract does not briefly address the limitations of the study or points to consider when interpreting the findings.

Response:

We thank the reviewer for this valuable observation. We agree that the coexistence of positive attitudes towards EOLC and low perceived preparedness represents one of the central findings of the study. Accordingly, the abstract has been revised to place greater emphasis on this result by highlighting that a substantial proportion of students reported feeling unprepared to provide EOLC despite generally positive attitudes towards this type of care.

In addition, the abstract has been streamlined to reduce repetition and improve clarity. The conclusion has been revised to more clearly reflect the main contribution of the study, and a brief statement has been added to remind readers that the findings should be interpreted in light of the study’s cross-sectional design and single-university setting.

These changes have been highlighted in red in the revised manuscript (lines 26-29, 31-33 and 36-37)

Reviewer Comment:

The introduction highlights the importance of end-of-life care in nursing education and clinical practice. However, the section occasionally turns into a broad literature review, and the specific research gap of the study is not defined sharply enough. Although the emphasis is on the Southern European or Spanish undergraduate nursing context, it should be more clearly justified what specific gap exists in the existing literature within this context. The reasons for the necessity of the research, how it differs from previous studies, and what knowledge gap it aims to fill should be more clearly stated.

 Response:

Thank you for this valuable observation. We have revised the final part of the Introduction to better define the research gap addressed by the present study. Specifically, we further justified the need for research in Southern European undergraduate nursing programmes by highlighting potential differences in curricular organisation, clinical exposure, and end-of-life care education, which may influence students’ attitudes towards EOLC. We also clarified why evidence from other educational and cultural contexts may not be directly transferable to this setting.

The relevant changes in the Introduction section have been highlighted in red in the revised manuscript (Lines 104-111).

Reviewer Comment:

The methods section generally describes the research design, sample, data collection process, and the scale used. However, the use of convenience sampling limits the external validity of the study. Since the sample was selected from different campuses of a single university, it is difficult to generalize the results to nursing students in Spain or other countries. This should not only be mentioned in the limitations section but also more visibly considered when interpreting the findings.

Response:

Thank you for this important comment. We agree that the use of a voluntary convenience sample drawn from different campuses of a single university limits the external validity and generalisability of the findings.

In response, we have revised the manuscript in several ways. First, we have further strengthened the interpretation of the results throughout the Discussion section by introducing additional caution when discussing the findings and by explicitly acknowledging that the observed patterns should be interpreted within the specific educational context represented by the study sample. We have also added a concluding statement to the Discussion emphasising that the findings should not be assumed to be representative of all nursing students in Spain or other countries.

All changes are highlighted in red in the revised manuscript. In particular, statements that could be interpreted as broadly generalisable were qualified by explicitly referring to the study sample and context through expressions such as “included in this study” (line 39), “in our sample” (line 397), and “within the context of this study” (line 490). In addition, statements that strengthen and contextualise the interpretation of the findings were incorporated throughout the Discussion section (lines 424–426, 431–432, and 523–526).

Second, we have reinforced the Limitations section by providing a more detailed discussion of the implications of the single-university setting, the voluntary convenience sampling strategy, and the resulting restrictions on the transferability and generalisability of the findings.

The corresponding changes in the Limitations section have been highlighted in red in lines 543-545.

Third, we have also incorporated this consideration into the Conclusions section, where the implications of the findings are explicitly framed in light of the study design, sampling strategy, and methodological limitations.

The corresponding changes in the Conclusions section have been highlighted in red in lines 607-611.

These revisions were made to ensure that the findings are interpreted within the appropriate methodological boundaries and that their generalisability is not overstated.

 Reviewer Comment:

Although the sample size calculation is given, the sampling process is not sufficiently detailed. The study does not clearly specify how participants were invited, the response rate, the characteristics of students who did not participate in the study, and potential bias in voluntary participation. This deficiency may increase the likelihood that students who participated in the study may have a more engaged or positive attitude towards the subject, especially in an emotionally and ethically sensitive topic such as end-of-life care.

Response:

We have expanded the Data Collection section to describe in-person recruitment, QR-code access to the online questionnaire, voluntary participation, anonymity, absence of incentives, and screening of duplicate or incomplete questionnaires. We also state that non-participant characteristics were not collected because no identifying information was obtained. The Limitations section now discusses the possible overrepresentation of students with greater interest in EOLC or more favourable attitudes.

Manuscript changes: Sections 2.3 (lines 183-191), 4.2 (lines 546-551) and 5 (lines 607-611) have been revised and highlighted in red.

Reviewer Comment:

While the use of the FATCOD-S scale is appropriate, the rationale for the threshold values ​​used in categorizing scale scores should be more strongly explained. Furthermore, it is stated that some items are grouped under conceptual sub-dimensions; however, it appears that this grouping has not been tested using a psychometric method such as confirmatory factor analysis. Therefore, interpretations regarding the sub-dimensions should be limited, and it should be more clearly stated that this classification is used solely for descriptive purposes.

Response:

Thank you for this observation. We have clarified that the cut-offs were taken from previous research and were used only for descriptive interpretation. We explicitly state that they are not universally established thresholds and that categorisation may reduce statistical sensitivity. The continuous FATCOD-S total score remains the preferred analytical outcome.

The corresponding modifications have been highlighted in red in the revised manuscript (Section 2.2, lines 151-159; section 2.4, 198-204; section 3.2, lines 259-266; and 4.2; lines 566-569).

With regard to the second issue, we agree that the conceptual domains considered in this study should not be interpreted as psychometrically validated subscales. No confirmatory factor analysis or additional psychometric testing was performed to evaluate this classification in the present sample. We have therefore clarified in the Methods section that these domains were used solely to facilitate the presentation and interpretation of the results and were not treated as independent psychometric dimensions.

Corresponding revisions were also incorporated into the Methods, Results, Discussion and Limitations sections to avoid overinterpretation of domain-level findings.

The corresponding modifications have been highlighted in red in the revised manuscript (Section 2.2, lines 168-170; section 3.2., 344-346; section 4, 466-469, section 4.2., 570-577).

Reviewer Comment:

The statistical analysis section presents descriptive and comparative analyses; however, the analysis plan is limited. The study only includes two-variable comparisons, preventing the control of potential confounding variables that could affect attitudes. Including variables such as academic year, clinical practice experience, previous end-of-life care experience, education status, and gender in the model to perform a multivariate analysis could have increased the analytical power of the study. As it stands, it is unclear whether some relationships are independent effects or reflections of other variables.

Response:

We agree that the original bivariate analyses did not allow potential confounding factors to be adequately controlled. The revised manuscript now includes an exploratory adjusted linear regression model with the reverse-coded FATCOD-S total score as the dependent variable. Age, academic year, gender, previous experience with a loved one receiving EOLC, previous EOLC training, and clinical placement in an EOLC unit were included as covariates. Because only two participants self-identified as non-binary, they were retained in descriptive analyses but excluded from this adjusted model to avoid unstable estimates. After adjustment, fourth-year status (β = 4.83, 95% CI 1.63 to 8.03, p = 0.003) and previous EOLC training (β = 2.29, 95% CI 0.03 to 4.55, p = 0.047) were associated with higher FATCOD-S total scores. The Discussion has been revised to avoid presenting bivariate associations as independent effects.

Sections 2.4 (lines 212-221); section 3.3. (lines 357-372 and table 3) and section 4 (lines 514-526) have been marked for the adjusted analysis and cautious interpretation.

Reviewer Comment:

The findings section is detailed; however, the tables and figures are quite dense, making it difficult for the reader to focus on the key findings. In particular, the lengthy table relating to FATCOD-S items reduces the interpretability of the findings if not selectively summarized in the text. A more synthetic presentation of the findings is needed, and statistically significant differences that may be clinically or educationally limited should be interpreted more carefully. Furthermore, comparative interpretations should be avoided in some groups, particularly due to the very low number of non-binary participants.

Response:

Thank you for this valuable comment. We agree that the presentation of the findings should facilitate identification of the key results and avoid overinterpretation of statistically significant differences with limited clinical or educational relevance.

In response, we have revised the Results section to provide a more synthetic presentation of the findings. Specifically, we added a concise summary of the main patterns identified in the item-level FATCOD-S results to improve the interpretability of the extensive item-level table and help readers focus on the most relevant findings. Furthermore, we have simplified the presentation of Table 2 by removing the p-value columns and clarifying that the table is descriptive. In addition, two figures that provided limited additional information were removed to reduce the overall density of the Results section.

We also introduced more cautious wording when discussing statistically significant differences derived from exploratory domain-level analyses, emphasizing that their educational relevance should be interpreted carefully and in light of the magnitude of the observed differences. Furthermore, comparative interpretations involving the non-binary group were avoided as far as possible, and additional cautionary statements were included because of the very small number of participants in this category.

All changes have been highlighted in red in the revised manuscript (section 3.2., lines 259-266 and table 2; 298-302, 315-319, 328-333, 344-346; section 3.3., 357-361)

Reviewer Comment:

While the relationship between academic year and attitudes is interesting, the cross-sectional design limits the interpretation of this relationship as a development dependent on the educational process. The observation of more positive attitudes in third-year students may point to a curriculum effect; however, it may also be related to cohort differences, selection effects, or differences in clinical experience. Therefore, causal or developmental inferences should be made more cautiously when interpreting the findings.

Response:

Thank you for this important comment. We agree that the cross-sectional design does not allow developmental or causal inferences regarding the relationship between academic year and attitudes towards EOLC.

In response, we revised the Discussion to avoid interpreting differences across academic years as evidence of progression attributable to the educational process. The text now explicitly states that these findings should be interpreted as associations rather than causal effects and acknowledges that the observed differences may reflect cohort effects, differences in clinical exposure, previous training, or other unmeasured factors rather than educational progression itself.

These revisions were introduced to ensure a more cautious interpretation of the findings and to avoid overstating the implications of the observed associations.

All changes have been highlighted in red in the revised manuscript (lines 504-507, 508-510, 519-522).

Reviewer Comment:

The discussion section relates the findings to the literature; however, some interpretations contain stronger inferences than the study design allows. In particular, statements that clinical exposure improves attitudes, that educational programs increase readiness, or that the decline in fourth-year attitudes is related to clinical reality should be kept at the hypothesis level. Rewriting these interpretations with more cautious expressions such as "may suggest" or "may be associated with" will increase scientific consistency.

Response:

Thank you for this comment. We agree that some interpretations could be expressed more cautiously given the cross-sectional design of the study. Accordingly, we revised the Discussion section and replaced several statements with more tentative wording (e.g., “may suggest”, “may be associated with”, and “may reflect”) to avoid causal or developmental interpretations and ensure consistency with the study design.

All changes have been highlighted in red in the revised manuscript (lines, 427, 429-432, 444-447, 466-469).

Reviewer Comment:

The discussion provides a significant contribution to the study's main finding: the divergence between positive attitudes and low readiness. However, the possible reasons for this divergence could be addressed more systematically. For example, factors such as curriculum content, simulation opportunities, clinical guidance, emotional support mechanisms, near-death experience, and communication skills could be discussed more comprehensively under separate headings. While these points are included in the current discussion, they are sometimes repetitive and not sufficiently linked to a theoretical framework.

Response:

Thank you for this suggestion. In response, we substantially revised and reorganized the entire Discussion section to provide a more structured explanation of the discrepancy between positive attitudes and low perceived preparedness. We reduced repetitive content and expanded the discussion of educational, emotional, ethical, organizational, and clinical factors that may contribute to this finding.

As these revisions involved a broad restructuring and rewriting of the Discussion section, rather than isolated modifications, it is not possible to provide specific line numbers for all changes. To facilitate review, all revised text has been highlighted in red in the revised manuscript.

Reviewer Comment:

The limitations section includes many important points; however, it needs structural improvement. The use of the headings “Study Strengths” followed by “Limitations and strengths” in the article creates repetition. Strengths and limitations should be organized under separate and consistent headings. Furthermore, social desirability bias, the limitations of self-report data, the effects of online data collection, the very small non-binary group, and the lack of psychometric validation for some sub-dimension analyses should be more clearly emphasized.

Response:

Thank you for this comment. We agree that the presentation of strengths and limitations should be clear and internally consistent. In response, the Discussion section was restructured to improve coherence, and strengths and limitations are now presented under separate headings (Sections 4.1 and 4.2), avoiding the previous overlap between these sections.

In addition, the Limitations section has been expanded and now explicitly addresses limitations associated with self-report data and self-report measures, including potential social desirability bias (lines 546-551), the limitations of self-report data (578-580), the very small number of non-binary respondents (lines 558-562), and the lack of psychometric validation of the exploratory domain-level analyses (lines 570-574).

All changes have been highlighted in red in the revised manuscript in section 4.2.

Reviewer Comment:

The conclusion section reflects the results of the study; however, it could be written more concisely and directly. The conclusions should state that the generalizability of recommendations regarding educational programs is limited due to the cross-sectional and single-center nature of the study. The findings support the need for greater emphasis on end-of-life care education in nursing undergraduate programs. However, this proposal should be presented in a more measured way, consistent with the descriptive nature of the available data.

 Response:

Thank you for this comment. We agree that the conclusions should remain proportionate to the descriptive and cross-sectional nature of the study. In response, we revised the Conclusions section to make it more concise and direct, while ensuring that the educational implications are presented in a more measured manner.

We also explicitly acknowledge that the implications of the findings are limited by the study’s cross-sectional design, single-university setting, voluntary convenience sampling strategy, and exploratory analytical approach. Accordingly, the conclusions now emphasise that the observed findings should be interpreted as associations within a specific educational context rather than as evidence of causal relationships or broadly generalisable conclusions.

All changes have been highlighted in red in the Conclusions section of the revised manuscript.

We are grateful for the reviewer’s detailed and insightful comments. The concerns raised prompted substantial revisions to the methodology, statistical analyses, discussion, and interpretation of the findings, which we believe have significantly strengthened the manuscript. We hope that the revised version satisfactorily addresses all comments and concerns and is now suitable for publication.

Author Response File: Author Response.pdf

Round 2

Reviewer 4 Report

Comments and Suggestions for Authors

The authors have reflected all suggestions in sufficient revisions.