Self-Perceived Competencies and Attitudes on Palliative Care in Undergraduate Nursing Students: A Multicenter Descriptive Study

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Dear Authors:

Congratulations on your work. It's an interesting and well written study that meets the criteria of publication by Nursing Reports.

Even though there are some issues to address:

- There isn't any reference to the ethical procedures;

- The conclusion doesn't answer to the aim of the manuscript, it should sumarize the main results and also point out the implications for practice and training and identify any needs on future investigation.

I would suggest a minor revision.

Best regards,

Comments on the Quality of English Language

Minor editing of English language required

Author Response

Comments 1: There isn't any reference to the ethical procedures;

Response 1: Thank you for bringing this to our attention. We have added a section titled "2.5. Ethical Issues" (Lines 205 onward), stating that the study was conducted in accordance with the Helsinki Declaration and approved by the Local Ethics Committee (Ethics Committee Palermo 1 N. 05/2022, 11/05/2022). Participants provided informed consent after receiving detailed information, and their anonymity was maintained throughout the study.

Comments 2: The conclusion doesn't answer to the aim of the manuscript, it should sumarize the main results and also point out the implications for practice and training and identify any needs on future investigation.

Response 2: Thank you for your insightful feedback. We have revised the conclusion (Lines 362 onward) to better address the aims of the manuscript. The updated conclusion summarizes the main findings, emphasizes the implications for practice and training, and identifies areas for future research. Specifically, we highlight the low to intermediate levels of perceived palliative care competence among Italian nursing students, the improvement with academic progression, and the significant impact of practical training. We underscore the importance of integrating comprehensive palliative care education—including practical experiences—earlier in nursing curricula and suggest examining the long-term impacts on nursing practice and patient outcomes.

Reviewer 2 Report

Comments and Suggestions for Authors

Thank you for this important paper that shows the importance of palliative care education in nursing programs in relation to attitudes and competencies in application to practice.  You have a good sample size to bring meaning to your results.  I did have some questions about analysis of some of the demographic data you collect.  For example, you collect data on personal bereavement and religion but it is unclear how you are using these in your analysis. Is this descriptive alone?  There also are some important regional differences among the sample and I am curious about the between university differences.  Overall, an important paper to advance palliative care nursing in nursing education. 

Author Response

Comments 1: You have a good sample size to bring meaning to your results.  I did have some questions about analysis of some of the demographic data you collect.  For example, you collect data on personal bereavement and religion but it is unclear how you are using these in your analysis. Is this descriptive alone? 

Response 1: Thank you for your positive feedback on our sample size and for raising this important point. We collected data on personal bereavement and religion to provide a comprehensive demographic profile of the participants. However, in our analysis, these variables did not show statistically significant associations with the primary outcomes. As a result, we included them solely in the descriptive statistics and did not incorporate them into the inferential statistical models 

Comments 2: There also are some important regional differences among the sample and I am curious about the between university differences. 

Thank you for your insightful observation regarding regional differences and inter-university variations. We have indeed noted significant differences among universities in our results (Line 240 onward). Specifically, the University of Messina contributed more to the highest quartile of perceived competence, while the University of Catania contributed more to the lowest quartile. Additionally, there were significant differences in emotional attitudes among universities (p = 0.0035).

These differences appear to be correlated with variations in curricular content, particularly the presence of compulsory theoretical training in palliative care. Students from universities with such compulsory training (Messina and Palermo) were more likely to be in the upper quartile, whereas those from universities without it (Catania) were more often in the lower quartile (p = 0.013). We have expanded on this in the manuscript to explain how differences in curricula may account for the observed regional disparities. Your comment has allowed us to highlight the impact of educational programs on student competencies more clearly.

Reviewer 3 Report

Comments and Suggestions for Authors

I consider this article to be of significant value in terms of acceptance and publication as it addresses a relevant and current topic for the training of future nurses: the skills and attitudes of nursing students facing palliative care and terminally ill patients. This multicentre study, using valid and reliable measurement tools, provides a comprehensive picture of this problem at different Italian universities. In addition, the large sample size reinforces the validity of the results, which has important practical implications for palliative care teaching and improving the quality of hospice care.

However, I propose that the discussion section be revised to increase its consistency and depth. In particular, a more critical analysis of the results based on existing literature is recommended, with more integration of international evidence on the relationship between palliative care attitudes, practical training and skills development. It is also important to highlight the implications for educational policy and clinical practice, clearly pointing out how the results can help improve nursing curricula, particularly in a European context.

With these comments, this article can present a more solid discussion and provide a more meaningful contribution to the literature on nursing education and palliative care.

Therefore, I propose to accept this article for publication and make suggestions for improvement.

Author Response

Comments 1: 

However, I propose that the discussion section be revised to increase its consistency and depth. In particular, a more critical analysis of the results based on existing literature is recommended, with more integration of international evidence on the relationship between palliative care attitudes, practical training and skills development. It is also important to highlight the implications for educational policy and clinical practice, clearly pointing out how the results can help improve nursing curricula, particularly in a European context.

With these comments, this article can present a more solid discussion and provide a more meaningful contribution to the literature on nursing education and palliative care.

Response 1: 

Thank you for your constructive feedback. We have revised the discussion section to enhance its consistency and depth. Specifically, we have provided a more critical analysis of our results in the context of existing literature, integrating international evidence on the relationship between palliative care attitudes, practical training, and skills development. This includes discussions on the challenges of adding palliative care content to crowded nursing curricula and recommendations for integrated, multidisciplinary teaching approaches (Lines 312–328).

We have also highlighted the implications for educational policy and clinical practice, particularly within the European context. Our findings underscore the need for curriculum development to build workforce capacity in palliative care. By designing culturally and socioeconomically relevant curricula that integrate theoretical and experiential learning, nursing schools can better prepare students for end-of-life care as we explained in line 345. We emphasize the role of health policy, clinical, and academic leaders in prioritizing this integration to meet increasing patient needs.

Reviewer 4 Report

Comments and Suggestions for Authors

This is an interesting paper but a few clarifications may be necessary:

1. line 105 this is confusing and it is unclear what attitudes/.. neutral" means - there is  a need to explain more fully

2. Methods

There is no comment about how the participants were recruited - and the % who took part

3. Results 

The numbers o f students would be helpful as well as % - line 201/202

4. Figure 2 is in the paper but is not referenced at all and there is no explanation of these results.

5. line 312 Limitations

The response rate may affect this - if only a % of all participants did complete the study this could bias the results

A short sentence about the "self perception" vs their true understanding / knowledge would be helpful.  Although self perception is important is there a risk that participants over emphasise their knowledge and understanding?

Comments on the Quality of English Language

Overall very good but a final check may be helpful

Author Response

Comments 1: 

This is an interesting paper but a few clarifications may be necessary:

1. line 105 this is confusing and it is unclear what attitudes/.. neutral" means - there is  a need to explain more fully

Response 1: Thank you for your valuable feedback. We agree that the description on line 105 was unclear. To address this, we have revised the paragraph starting from line 99 to provide a more detailed explanation of the study mentioned. The updated text elaborates on the multicentre European study involving Spain, England, and Italy, which assessed nursing students' attitudes towards caring for dying patients using the FATCOD-B scale. We have clarified that students across all three countries exhibited moderate attitudes, with scores falling in the middle range of the scale.

Comments 2: Methods: There is no comment about how the participants were recruited - and the % who took part

Response 2: Thank you for pointing out the need for more information on participant recruitment. We have added a detailed explanation on line 132 in the Methods section. Specifically, we described how participants were recruited from nursing schools across the region and noted that 89% of the total nursing students participated in the study and their distribution relative to the single universities, which does not create significant bias. 


Comments 3: Results - The numbers o f students would be helpful as well as % - line 201/202

Response 3: We appreciate your suggestion to include the actual numbers of students alongside percentages for better clarity. We have updated the text on line 212 to include both the number of students and the corresponding percentages

Comments 4. Figure 2 is in the paper but is not referenced at all and there is no explanation of these results.

Response 4: Thank you for bringing to our attention that Figure 2 was not referenced in the text. We have corrected this oversight by adding a reference and explanation starting from line 256. We now discuss the findings illustrated in Figure 2, ensuring it is fully integrated into the manuscript and its results are clearly explained.

Comments 5. line 312 Limitations The response rate may affect this - if only a % of all participants did complete the study this could bias the results. A short sentence about the "self perception" vs their true understanding / knowledge would be helpful.  Although self perception is important is there a risk that participants over emphasise their knowledge and understanding?

Response 5: 

Thank you for highlighting the potential impact of response rate and self-perception bias on our study's limitations. We have addressed these concerns by adding a statement on line 349, noting that our study included 89% of the total nursing students in the region, which mitigates concerns about response rate bias.

Additionally, we have expanded on the limitations regarding self-perceived competence starting from line 353. We acknowledge that while our multi-item questionnaire suggests coherent self-perception among participants, self-reported measures may not always accurately reflect actual knowledge or skills. There is indeed a risk that participants might overestimate their understanding. We suggest that future research should incorporate objective assessments of palliative care knowledge and skills alongside self-reported data. Extending the analysis beyond regional boundaries could also provide a broader perspective on nursing students' competencies and attitudes towards palliative care.