Attitudes towards death in nursing staff: The role of resilience

Attitudes towards death in nursing staff: The role of resilience | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Attitudes towards death in nursing staff: The role of resilience Silvia Arribas-García, Eleni Petkari, Joana Jaureguizar, Teresa Sánchez-Gutiérrez, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7808208/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 18 Mar, 2026 Read the published version in BMC Palliative Care → Version 1 posted 10 You are reading this latest preprint version Abstract Background Nurses are not always prepared to deal with strong emotions evoked when caring for suffering patients. Their attitudes-towards-death affect care quality provided to dying patients and their own well-being. This study examined resilience's role on attitudes-towards-death and personal/occupational factors related to each attitude before pandemic impact. Methods This observational, cross-sectional study included 743 nursing professionals from Intensive-Care, Palliative-Care and Oncology units in seven public Spanish hospitals. Participants completed the Death-Attitude-Profile-Revised-Scale, Connor-Davidson-Resilience-Scale and an ad-hoc questionnaire between June 2018 and April 2019. MANOVA tests, correlation analyses, mediation analyses, and Principal Component Analysis were performed. Results Neutral-Acceptance was the predominant attitude (M = 5.68, SD = 0.90), followed by Death-Avoidance (M = 4.54, SD = 1.79). Professional level, age, prior death training, healthcare setting, and resilience significantly affected attitudes (all p < .05). Resilience correlated positively with Neutral-Acceptance and inversely with Fear-of-Death and Death-Avoidance. Mediation analyses revealed complete mediation effects of resilience on relationships between professional factors and key attitudes, with some suppression effects indicated by mediation percentages > 100%. Conclusions Both resilience and prior death training play key roles in attitudes-towards-death; therefore, both should be included as core elements in academic and on-the-job nursing training. death attitudes inservice training nursing psychological resilience Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Introduction Death, as a universal and inevitable phenomenon, represents one of the greatest emotional and professional challenges for nursing staff. It is a multidimensional phenomenon encompassing psychological, social, cultural and economic aspects that impact patients, relatives, and formal caregivers ( 1 , 2 ). In clinical settings such as intensive care, palliative, and oncology units, nurses frequently confront the experience of accompanying individuals through the dying process, demanding not only advanced technical competencies but also emotional skills and reflective attitudes toward death that enable humanized care ( 3 , 4 ). Attitude toward death (ATD) is a complex construct involving cognitive, emotional, behavioural, and spiritual dimensions. Wong et al. (1994) ( 5 ) described a multidimensional model conceptualizing five dimensions. Death acceptance comprises three components: Neutral-Acceptance, referring to death as a natural and inevitable part of life; Approach-Acceptance, implying belief in death as a gateway to a happier afterlife; and Escape-Acceptance, considering death as a preferred alternative to suffering ( 6 ). In contrast, Fear-of-Death refers to anxiety and fear emotions evoked when confronting death, while Death-Avoidance is a defense mechanism leading to avoiding thinking or talking about death. These attitudes significantly affect both hospice nursing care quality and nurses' psychological well-being ( 3 , 7 , 8 ). Recent studies show that although many professionals accept death as natural, they also exhibit significant levels of fear and avoidance, creating conflict between personal and professional roles ( 4 , 9 ). Fear responses strongly predict psychopathology ( 10 ) and, if untreated, can cause despair, helplessness, anger or depression ( 11 ). Similarly, death avoidance represents a dysfunctional ATD, as blocking thoughts about death prevents implementing personal or professional skills to face death and adequately care for dying people. Conversely, considering death as a natural life sequence allows for more relaxed approaches, favouring higher quality end-of-life care and enhancing nurses' psychological wellbeing ( 12 ). However, people's overall ATD appears to be a combination of different attitudes that counterbalance each other, rather than following a single pattern ( 5 ). Although ATD appears closely related to nurses' psychological wellbeing ( 12 , 13 ), literature regarding influencing factors remains inconclusive. Sociodemographic findings are often contradictory. Some studies report female nurses tend toward more fear-driven attitudes compared to males ( 14 , 15 ), while others suggest the opposite ( 4 ). Additionally, some evidence suggests male nurses may exhibit more accepting attitudes, perceiving death as natural or as means to alleviate suffering ( 9 , 16 ). Age differences are similarly inconsistent. Some studies suggest younger nurses demonstrate more Death Acceptance ( 17 ), whereas others associate youth with Death-Avoidance or heightened Fear-of-Death ( 5 , 18 ). These discrepancies may reflect interactions between personal experience, cultural narratives, and clinical exposure during early professional development. Occupational context and experience strongly influence ATD. Novice nurses frequently report more fear-based responses ( 18 , 19 ), whereas increased clinical exposure promotes greater acceptance and emotional readiness ( 20 ). The healthcare setting is particularly noteworthy: nurses with longer experience in palliative or hospice settings tend to report more accepting ATD than those in Intensive Care Units (ICU) or oncology, who may display more fear-based or avoidant attitudes, reflecting the emotional burden and unpredictable nature of these environments ( 4 , 21 ). However, Guo et al. (2024) ( 16 ) found that working in Intensive Care and Palliative Care Units, together with personality traits, is associated with higher death competence in novice nurses, while frequent exposure to patient death may serve as a hindering factor, underscoring considerable variability in findings. Professional training level is crucial. Registered nurses, typically with formal death education, display more acceptance ATD than auxiliary nursing care technicians ( 22 ). Recent studies confirm that targeted training enhances acceptance, reduces fear, and improves end-of-life care quality ( 23 – 25 ). Such programs strengthen emotional competences, enhance resilience and foster self-awareness regarding emotional responses to death, promoting more positive ATD and improved psychological adjustment ( 9 , 26 ). Nurses' ATD serve as mediators between moral distress and core palliative competencies, highlighting that positive attitudes strengthen ethical practice and psychological resilience ( 25 ). Aligned with these findings, Powell et al. (2020) ( 27 ) proposed that resilience plays a key protective role against detrimental effects of dysfunctional ATD, suggesting that resilience enhances nurses' capacity for compassionate care and emotional regulation, particularly when stressful experiences are integrated into coherent personal narratives. Resilience is understood as the individual's ability to cope with stress and adversity while maintaining, or rapidly restoring, psychological well-being and functional capacity ( 28 , 29 ). Contemporary literature emphasizes that resilience should be conceptualized as a dynamic and multifaceted process encompassing pre-adversity functioning, the nature of aversive context, and availability of intrapersonal and interpersonal resources ( 30 , 31 ). Richardson's meta-theory of resilience ( 32 ) defines resilience as a dynamic process of biopsychospiritual reintegration following disruption due to stress or adversity, involving coping and adapting to restore equilibrium with four possible outcomes: resilient reintegration (growth and strengthening), homeostatic reintegration (return to baseline), maladaptive reintegration (unhealthy coping strategies), or dysfunctional reintegration (decline in functioning). The Psychological Immunity-Psychological Elasticity (PI-PE) model ( 33 ) highlights two core mechanisms: stressor-specific tolerance and narrative construction, with four potential adaptive outcomes: sustainability (resistance), recovery (rebound resilience), transformation (psychological reconfiguration), and thriving (flourishing). In clinical care contexts, repeated exposure to death may compromise nurses' capacity for effective psychological reintegration, particularly when accompanied by fear-based or avoidant attitudes. Lower resilience levels increase likelihood of developing dysfunctional ATD. Conversely, nurses with higher resilience demonstrate greater Neutral Acceptance and lower Fear and Avoidance ( 8 , 34 ). Furthermore, resilience may mediate relationships between perceived meaning in life and attitudes toward death, facilitating healthier emotional adaptation to suffering and loss. Resilience enables nurses to construct coherent narratives around professional experiences, supporting adaptive engagement with clinical responsibilities and fostering personal growth ( 29 , 35 ). It has been associated with greater authenticity in interactions with dying patients ( 13 ) and fewer psychological symptoms, greater occupational engagement, enhanced perceived control, increased job satisfaction, and improved overall well-being ( 36 , 37 ). Resilience and acceptance attitudes toward death protect nurses against distress, helping them cope with trauma and vulnerability associated with suffering and death ( 13 , 38 ). Therefore, fostering resilience and reflective engagement with death should be prioritized in nursing education and clinical supervision to safeguard both caregiver wellbeing and care quality. Nurses' attitudes toward death are shaped by complex interplay of individual, professional, and contextual factors, with resilience emerging as a key protective mechanism. However, empirical findings regarding determinants of functional ATD among nurses remain inconclusive. Drawing on existing literature, the present study aims to examine relationships between personal and occupational variables, resilience, and ATD in a large sample of nursing professionals across varying seniority levels and healthcare settings, prior to COVID-19 pandemic impact—a period that profoundly altered experiences related to dying and death. Additionally, the study explores the potential moderating role of resilience between these factors and nurses' ATD. A clearer understanding of this relationship is essential for informing targeted death education strategies aimed at fostering more adaptive attitudes and improving end-of-life care quality. METHODS Participants This observational, cross-sectional study used a convenience sample of n = 743 nursing professionals from seven public hospitals of the Basque Health Service (Spain). Participants included Registered Nurses (RN) with Bachelor of Science in Nursing degrees and Auxiliary Nursing Care Technicians (ANCT) working in Intensive Care (n = 374), Oncology (n = 277), and Palliative Care (n = 122) units. Nurses in Primary Care services and nursing students were excluded. The sample was predominantly female (90.5%), with 56.8% under 45 years and 69.7% holding Bachelor of Nursing degrees. Most professionals (74.1%) had over 5 years hospital experience, though only 38.3% had specific death and bereavement training. Overall resilience levels were medium-high ( M = 28.43, SD = 6.02), with 25.3% showing high resilience. Complete sample characteristics are presented in Table 1 . Table 1 Sample characteristics and descriptive statistics by subgroup. Variable n % Fear of Death M(SD) Death Avoidance M(SD) Neutral Acceptance M(SD) Approach Acceptance M(SD) Escape Acceptance M(SD) Gender Male 69 9.5 3.13 (1.36) 3.46 (1.45) 5.76 (0.87) 2.59 (1.29) 3.23 (1.49) Female 654 90.5 2.95 (1.25) 4.58 (1.80) 5.67 (0.90) 2.85 (1.42) 3.29 (1.51) Age ≤ 45 years 411 56.8 2.98 (1.27) 4.61 (1.78) 5.65 (0.91) 2.65 (1.31) 3.02 (1.38) > 45 years 312 43.2 2.98 (1.25) 4.45 (1.81) 5.72 (0.89) 3.08 (1.52) 3.66 (1.59) Professional Level Registered Nurse 504 69.7 2.97 (1.26) 4.46 (1.75) 5.70 (0.90) 2.73 (1.40) 3.20 (1.48) ANCT 219 30.3 3.02 (1.26) 4.71 (1.88) 5.64 (0.91) 3.08 (1.44) 3.53 (1.54) Healthcare Setting Intensive Care 374 51.7 3.01 (1.28) 4.75 (1.79) 5.66 (0.89) 2.84 (1.42) 3.25 (1.46) Oncology 227 31.4 2.96 (1.24) 4.36 (1.74) 5.69 (0.90) 2.87 (1.50) 3.29 (1.54) Palliative Care 122 16.9 2.92 (1.24) 4.19 (1.89) 5.72 (0.92) 2.78 (1.25) 3.46 (1.59) Years of Experience ≤ 5 years 187 25.9 2.95 (1.22) 4.60 (1.84) 5.65 (0.88) 2.82 (1.36) 3.20 (1.45) > 5 years 536 74.1 2.99 (1.27) 4.51 (1.77) 5.69 (0.91) 2.85 (1.44) 3.33 (1.53) Prior Death Training Yes 277 38.3 2.96 (1.25) 4.40 (1.78) 5.73 (0.93) 3.01 (1.50) 3.39 (1.54) No 446 61.7 2.99 (1.26) 4.63 (1.79) 5.65 (0.88) 2.73 (1.35) 3.24 (1.48) Resilience Level Low-Medium 540 74.7 3.05 (1.26) 4.64 (1.78) 5.64 (0.91) 2.78 (1.37) 3.35 (1.48) High 183 25.3 2.79 (1.25) 4.23 (1.82) 5.81 (0.86) 3.00 (1.55) 3.15 (1.58) Overall Sample 743 100 2.98 (1.26) 4.54 (1.79) 5.68 (0.90) 2.83 (1.41) 3.28 (1.51) Note: ANCT = Auxiliary Nursing Care Technician, M = Mean, SD = Standard Deviation. Resilience overall: M = 28.43, SD = 6.02 Procedure Nursing managers and supervisors of ICU, Palliative Care and Oncology units at each participating hospital were initially contacted. Following approval, eligible nursing staff attended one-hour informational sessions within each unit. Participants received paper-and-pencil questionnaires with envelopes for anonymous submission into opaque, sealed boxes. To accommodate high rotation among nursing personnel, informational sessions were repeated fortnightly. Recruitment was conducted from June 2018 to April 2019, adhering to STROBE guidelines for reporting observational research. Instruments Sociodemographic and professional variables. Data about gender, age, professional level, healthcare setting, years of experience and prior training related to death and/or bereavement were collected through an ad-hoc questionnaire. Attitudes toward death. The Death Attitude Profile-Revised scale (DAP-R) ( 5 ) Spanish validated version by Sáez et al. (2020) ( 39 ) was used. This multidimensional questionnaire consists of 32 items rated on a seven-point Likert scale (1 = totally disagree to 7 = totally agree), measuring five ATD: Fear-of-Death (seven items) and Death-Avoidance (five items), considered negative attitudes; Neutral-Acceptance (five items), Approach-Acceptance (10 items) and Escape-Acceptance (five items), considered positive attitudes (Gesser et al., 1988). Participant scores are calculated by combining dimensions with highest mean scores to form the pattern reflecting their attitude towards death. Cronbach's alpha was α = .86. Resilience. The Connor-Davidson Resilience Scale (CD-RISC-10) ( 40 ) Spanish version by Notario-Pacheco et al. (2011) was used. It consists of 10 items scored on a Likert scale (0 = totally disagree to 4 = totally agree). Higher scores indicate higher resilience levels (range 0–40). Cronbach's alpha was α = .85. Data analysis Data analyses were performed using Python (version 3.8) with NumPy, Pandas, SciPy, Statsmodels, and Scikit-learn libraries. Missing values were handled through Random Forest-based iterative imputation. Normality testing was based on skewness and kurtosis values (< 2 and < 7 respectively) ( 41 , 42 ), supported by the Central Limit Theorem for large samples. Descriptive statistics included means, standard deviations, frequencies, and percentages. Pearson and Spearman correlation coefficients assessed associations between variables. For healthcare settings, dummy variables were created for each setting. One-way multivariate analysis of variance (MANOVA) examined differences in ATD by independent variables (sex, age, professional level, healthcare setting, seniority, prior training, and resilience). Resilience was categorized using quartiles: low-medium (up to third quartile) and high (above third quartile). Bonferroni correction was applied for post-hoc tests. Mediation analyses used Baron and Kenny's approach supplemented with bootstrapping (5,000 samples), testing: effect of independent variables on dependent variables (path c), effect of independent variables on mediator (path a), effect of mediator on dependent variables controlling for independent variables (path b) and calculating indirect effect (a*b) and proportion mediated. Hierarchical regression analyses with centered variables examined whether resilience moderated relationships between personal/occupational factors and ATD. Principal Component Analysis (PCA) identified underlying patterns in death attitudes. Independent samples t-tests and one-way ANOVAs with Tukey post-hoc tests compared attitudes across groups. Statistical significance was set at p < .05, with effect sizes reported using partial eta squared (η²) for MANOVA, Cohen's d for t-tests, and R² for regression models. Ethical considerations The study was approved by the Research and Ethics Committee of the Basque Ethics Committee for Research (CEIm-E PI2018066) and conducted according to the 1964 Declaration of Helsinki and subsequent amendments. Informed consent was obtained from all participants. Participant anonymity and confidentiality were ensured. RESULTS Descriptive analysis of attitudes towards death Nursing professionals showed highest scores in Neutral-Acceptance of death (M = 5.68, SD = 0.90), followed by Death-Avoidance (M = 4.54, SD = 1.79) and Escape-Acceptance (M = 3.28, SD = 1.51). Lower scores were reported for Fear-of-Death (M = 2.98, SD = 1.26) and Approach-Acceptance (M = 2.83, SD = 1.41) (Fig. 1 ). Correlations between variables Resilience showed weak negative correlations with Fear-of-Death (r=-.20, p < .01) and Death-Avoidance (r=-.13, p < .01), and a weak positive correlation with Neutral-Acceptance (r = .11, p < .01) (Fig. 2 ), indicating that more resilient nursing professionals tend to accept death as natural and experience less fear and avoidance. Age was positively correlated with Approach-Acceptance (r = .15, p < .01) and Escape-Acceptance (r = .21, p < .01). Professional level showed positive correlations with Death-Avoidance (r = .11, p < .01), Approach-Acceptance (r = .12, p < .01), and Escape-Acceptance (r = .10, p < .01). Prior training about death correlated positively with Approach-Acceptance (r = .10, p < .05) and negatively with Death-Avoidance (r=-.09, p < .05). Working in Intensive Care units was positively associated with Death-Avoidance (r = .13, p < .01), while working in Palliative Care showed negative correlations with both Fear-of-Death (r=-.07, p < .05) and Death-Avoidance (r=-.11, p < .01). Strong positive correlations were found between Fear-of-Death and Death-Avoidance (r = .58, p < .01), and moderate positive correlations between Approach-Acceptance and Escape-Acceptance (r = .42, p < .01). Fear-of-Death showed moderate negative correlation with Neutral-Acceptance (r=-.36, p < .01), and Death-Avoidance was also negatively correlated with Neutral-Acceptance (r=-.34, p < .01) (Fig. 3 ). Effects of personal and occupational factors on attitudes toward death MANOVA analyses revealed several significant effects (Table 2 ). Gender showed a significant but small effect (F = 2.16, p = 0.048, η²=0.014), while age demonstrated a moderate effect (F = 11.08, p < .001, η²=0.065). Professional level (F = 5.43, p = 0.001, η²=0.034), prior training (F = 4.00, p = 0.006, η²=0.026), healthcare setting (F = 1.93, p = 0.001, η²=0.025), and resilience (F = 10.37, p < .001, η²=0.061) all showed significant effects on death attitudes. Table 2 Multivariate effects of personal and occupational variables on death attitudes (MANOVA results). Factor Pillai's Trace F df p η² Sig. Gender 0.014 2.16 53,700 0.048 0.014 * Age 0.07 11.08 53,700 < .001 0.065 *** Professional level 0.035 5.43 53,700 0.001 0.034 ** Prior training 0.026 4 53,700 0.006 0.026 ** Healthcare setting 0.025 1.93 103,695 0.001 0.025 ** Resilience 0.065 10.37 53,700 < .001 0.061 *** Note: * p < .05, ** p < .01, *** p < .001 Specific group differences revealed several significant patterns (Table 3 ): Table 3 Mediation analyses: direct, indirect, and total effects of resilience on death attitudes. Predictor Outcome Total Effect (c) p Direct Effect (c') p Indirect Effect (a*b) % Mediated Mediation Type Professional Level Fear of Death -0.042 0.68 0.061 0.543 -0.103 245.9 Complete Professional Level Neutral Acceptance -0.026 0.718 -0.079 0.277 0.052 -201.2 Complete Prior Training Fear of Death 0.057 0.547 -0.002 0.981 0.06 104 Complete Prior Training Death Avoidance 0.37 0.006 0.322 0.017 0.048 13 Partial Prior Training Neutral Acceptance -0.128 0.06 -0.099 0.142 -0.029 22.4 Complete Note: Only significant mediation effects are shown. Mediation percentages > 100% indicate suppression effects. Age: Older nurses (> 45 years) showed significantly higher Approach-Acceptance (M = 3.08 ± 1.52 vs. M = 2.65 ± 1.31, F = 16.076, p < .001, η²=0.022) and Escape-Acceptance (M = 3.66 ± 1.59 vs. M = 3.02 ± 1.38, F = 33.633, p < .001, η²=0.045) than younger nurses. Professional level: ANCT showed significantly higher Death-Avoidance (M = 4.71 ± 1.88 vs. M = 4.46 ± 1.75, F = 8.618, p = 0.003, η²=0.012), Approach-Acceptance (M = 3.08 ± 1.44 vs. M = 2.73 ± 1.40, F = 19.279, p = 0.002, η²=0.013), and Escape-Acceptance (M = 3.53 ± 1.54 vs. M = 3.20 ± 1.48, F = 16.03, p = 0.008, η²=0.010) than Registered Nurses. Healthcare setting: Professionals working in ICU showed significantly higher Death-Avoidance than those in Palliative Care (M = 4.75 ± 1.79 vs. M = 4.19 ± 1.89, F = 7.58, p = 0.001, η²=0.021). Prior death training: Professionals with prior training showed significantly lower Death-Avoidance (M = 4.40 ± 1.78 vs. M = 4.63 ± 1.79, F = 5.568, p = 0.019, η²=0.008) and higher Approach-Acceptance (M = 3.01 ± 1.50 vs. M = 2.73 ± 1.35, F = 6.551, p = 0.011, η²=0.009) than those without training. Resilience: High resilience professionals showed significantly lower Fear-of-Death (M = 2.79 ± 1.25 vs. M = 3.05 ± 1.26, F = 25.396, p < .001, η²=0.034) and Death-Avoidance (M = 4.23 ± 1.82 vs. M = 4.64 ± 1.78, F = 6.21, p = 0.013, η²=0.009), and higher Neutral-Acceptance (M = 5.81 ± 0.86 vs. M = 5.64 ± 0.91, F = 9.879, p = 0.002, η²=0.014) than low-medium resilience professionals (Fig. 4 ). Mediating role of resilience Mediation analyses revealed that resilience functioned as significant mediator between several personal/occupational factors and attitudes toward death (Table 4 ): Table 4 Group comparisons of death attitudes by personal and occupational variables (ANOVA results). Variable Death Attitude Group 1 Group 2 Group 1 M ± SD Group 2 M ± SD F df p η² Age Approach Acceptance ≤ 45 years > 45 years 2.65 ± 1.31 3.08 ± 1.52 16.076 1,721 < .001 0.022 Escape Acceptance 3.02 ± 1.38 3.66 ± 1.59 33.633 1,721 < .001 0.045 Professional Level Death Avoidance RN ANCT 4.46 ± 1.75 4.71 ± 1.88 8.618 1,721 0.003 0.012 Approach Acceptance 2.73 ± 1.40 3.08 ± 1.44 19.279 1,721 0.002 0.013 Escape Acceptance 3.20 ± 1.48 3.53 ± 1.54 16.03 1,721 0.008 0.01 Healthcare Setting Death Avoidance ICU Palliative 4.75 ± 1.79 4.19 ± 1.89 7.58 2,720 0.001 0.021 Prior Training Death Avoidance Yes No 4.40 ± 1.78 4.63 ± 1.79 5.568 1,721 0.019 0.008 Approach Acceptance 3.01 ± 1.50 2.73 ± 1.35 6.551 1,721 0.011 0.009 Resilience Fear of Death High Low-Medium 2.79 ± 1.25 3.05 ± 1.26 25.396 1,721 < .001 0.034 Death Avoidance 4.23 ± 1.82 4.64 ± 1.78 6.21 1,721 0.013 0.009 Neutral Acceptance 5.81 ± 0.86 5.64 ± 0.91 9.879 1,721 0.002 0.014 Note: RN = Registered Nurse, ANCT = Auxiliary Nursing Care Technician, ICU = Intensive Care Units Fear-of-Death: Resilience completely mediated the relationship between professional level and Fear-of-Death (proportion mediated: 245.9%), with ANCT showing higher Fear-of-Death through lower resilience. This large percentage indicates a suppression effect, where the indirect effect through resilience is stronger than the original direct effect. Similarly, resilience completely mediated the relationship between prior training and Fear-of-Death (proportion mediated: 104.0%), with trained professionals experiencing less fear through enhanced resilience. Death-Avoidance: Resilience partially mediated the relationship between prior training and Death-Avoidance (proportion mediated: 13.0%). Neutral-Acceptance: Resilience completely mediated the relationship between professional level and Neutral-Acceptance (proportion mediated: -201.2%), with ANCT showing lower Neutral-Acceptance through reduced resilience. The negative percentage indicates that the mediating effect works in the opposite direction to the direct effect. Resilience also completely mediated the relationship between prior training and Neutral-Acceptance (proportion mediated: 22.4%). No significant mediating effects of resilience were found for Approach-Acceptance or Escape-Acceptance. Moderating role of resilience Moderation analyses examined whether relationships between personal/occupational factors and attitudes toward death varied depending on resilience levels. Only one significant moderation effect was identified: resilience moderated the relationship between professional level (ANCT) and Escape-Acceptance, although the effect size was minimal. Simple slope analysis showed the relationship between being an ANCT and Escape-Acceptance was slightly stronger for nurses with high resilience (B = 1.94) compared to those with low resilience (B = 1.93). Principal component analysis of death attitudes Principal Component Analysis identified two main components explaining 67.27% of variance in death attitudes (Fig. 5 ). The first component (38.91% of variance) was heavily loaded with Fear-of Death (.857) and Death-Avoidance (.797), with negative loading for Neutral-Acceptance (-.619), representing negative/avoidant orientation toward death. The second component (28.35% of variance) was primarily loaded with Escape-Acceptance (.830) and Approach-Acceptance (.734), representing a transcendence-oriented perspective viewing death as either escape from suffering or gateway to afterlife. DISCUSSION Neutral-Acceptance was the predominant ATD among nursing professionals, implying that most professionals in high emotional healthcare settings consider death a natural part of life, accepting it without welcoming nor rejecting it, emphasizing motivation to live meaningfully ( 43 ). However, considering ATD as a complex pattern ( 5 ), findings suggest that alongside Neutral-Acceptance, avoiding death was also commonly practiced. This combination suggests that although nurses face death daily, they opt for cognitive approaches while leaving aside emotional processing by avoiding feelings about death. Such approach may act as a self-preservation mechanism protecting them from the deep impact of accompanying suffering individuals at end-of-life. Nonetheless, Cybulska et al. (2022) ( 4 ) found nurses showed high Neutral-Acceptance and Fear-of-Death levels with low avoidance. A feasible explanation comes from Approach-Acceptance's key role, as proposed through Meaning Management Theory (MMT) ( 43 ) and Terror-Management Theory (TMT) ( 44 ). MMT focuses on building meaningful life goals despite death's reality, while TMT establishes that humans use avoidance and denial to protect themselves from mortality awareness terror. Approach-Acceptance would offer, according to TMT, better afterlife alternatives to reinforce symbolic immortality. However, such focus contributes to emphasizing death rather than life. Kraitenberger et al. (2021) ( 45 )concluded that believing in happier afterlife could be unsuccessful at avoiding anxious death thoughts, increasing rather than reducing fear responses. Both in this study and Xu et al. (2019) ( 9 ), participants reported lowest Approach-Acceptance levels, while Cybulska's study (2022) ( 4 ) showed similar levels to Fear-of-Death and Neutral-Acceptance, creating different overall ATD. When nurses avoid thinking about death, fear-driven responses may arise; however, they remain lower than when viewing death as transition to desirable afterlife. Results, similar to Kraitenberger et al. (2021) ( 45 ), suggest that as Fear-of-Death grows, attempts to avoid death thoughts and construct meaningful-afterlife versions increase. Higher Neutral-Acceptance indicates lower Fear-of-Death, enabling higher quality patient-focused care and more efficient emotional management ( 46 ). Neither sex nor working at oncology-related settings influenced how nurses face death. However, nurses at ICU showed comparatively higher avoidance attitudes than those at Palliative Care Units. Palliative Care correlated inversely with Fear-of-Death and Death-Avoidance, implying that establishing working cultures promoting compassionate approaches to patient suffering would improve nurses' coping cognitive and affective skills ( 4 , 14 ), regardless of death-exposure time. Years of professional experience did not influence different ATD usage. However, older nurses showed higher Approach and Escape-Acceptance levels, suggesting that life experience itself, not work experience, promotes reflection processes around non-quality life or life-after-death sense. Results align with Gama et al. (2013) ( 14 ) and Cybulska et al. (2022) ( 4 ), who reported higher Escape-Acceptance in older nurses, showing nurses opt for higher life quality rather than longevity, perhaps related to personal death experiences both in and outside workplace ( 47 ). Both professional level and prior death training relate to ATD changes. Professionals without nursing bachelor's degrees show higher Death-Avoidance than Registered Nurses, same as professionals without prior death training. This aligns with Xu et al. (2019) ( 9 ) where nursing trainees receiving specific death training showed higher Neutral-Acceptance levels. Results reinforce that death training should be included as core curriculum part on ongoing basis throughout careers. This is supported by Cheong et al. (2020) ( 48 ), who found Fear-of-Death and Death-Avoidance significantly decreased after 6-week death coping workshops. Prior training implies directly discussing end-of-life, involving reflection on its meaning, promoting greater emotional contact and encouraging deeper empathic insight. Confronting these mental processes makes not thinking about death nearly impossible, but not necessarily more pleasant. Although results show lower Approach-Acceptance in Registered Nurses, this approach increases with specific death-training. This could imply that nurses without work experience think of death rationally as events occurring with illness; however, comprehensive on-job training may push them toward constructing meaningful life approaches helping shape less negative ATD, aligning with previous research ( 9 , 17 , 23 , 49 ). Resilience plays a key role in developing positive ATD through adaptation processes under stress or trauma, where negative events transform into opportunities for cultivating strengths and self-growth ( 32 ). Highly resilient nursing staff showed lower Fear-of-Death and Death-Avoidance levels, and higher Neutral-Acceptance. While sociodemographic variables such as sex or age, and professional variables like professional level, prior training, healthcare setting or seniority showed no interaction effects or significant relationships with Neutral-Acceptance, resilience correlated positively with Neutral-Acceptance, supporting its nature as protective mechanism in palliative healthcare professionals ( 50 ). Findings support the Psychological-Immunity/Psychological-Elasticity model (PI-PE) ( 33 ), proposing that tolerance and narrative construction are crucial elements enhancing adaptive coping outcomes with stressors such as death and dying patients. As tolerance is acquired resistance response, it can be developed through trained exposure to specific stressors; therefore, tolerance can be specific to some stressors but not others. The ability to incorporate stressful experiences into self-narrative, or create new narratives making sense of negative experiences, is reminiscent of Meaning Management Theory. Linked to Neutral-Acceptance, resilient nurses would build positive life views despite sickness or death proximity, making each moment worthy of living ( 29 , 43 ). Strengths and limitations This study contributes to existing literature given the paucity of publications on ATD and resilience's role in nursing staff. The large sample size, including professionals from different healthcare settings in different hospitals, with diversity in professional levels and death training degrees, ensures findings' generalizability. Rigorous statistical analyses performed allow robust conclusions about how resilience plays major roles in nurses' coping with patient death. Importantly, the study was conducted before COVID-19 pandemic outbreak, allowing ATD exploration prior to negative impacts caused by huge death numbers and subsequent frustration and helplessness experienced during pandemic times. However, limitations exist. First, cross-sectional design prevents causal inferences. Second, other factors such as religious beliefs, trait-anxiety or death exposure could affect nurses' attitudes toward death and were not included. Third, convenience sampling may have affected findings. Fourth, information obtained through self-reported questionnaires could include social desirability bias. After living through COVID-19 pandemic, replicating this study is essential to explore direct pandemic impacts on nurses, not only on ATD, but also on resilience building processes and compare findings with current state of nurses' everyday routines. Adding randomized sampling and including nurses from services where death is less prevalent may allow further findings replication. Furthermore, longitudinal designs will enable analysis of potential influences that specific death training may have over ATD, as well as natural ATD evolution over time due to professional and personal experiences. Incorporating instruments measuring dimensions such as nurses' personal and professional wellbeing, empathy, social support perception, and religious beliefs will allow obtaining more complete profiles of nurses' weaknesses and strengths. Based on these, tailored training and support strategies can be designed to guarantee not only professionals' emotional well-being, but also care quality provided to patients. Conclusion The findings provide greater insight about interactions between sociodemographic and professional variables and attitudes towards death in nursing staff working at high-emotional-impact units. Results reinforce death attitudes' complexity, showcasing use of neutral death approaches combined with avoidance and fear-driven responses. Furthermore, findings support resilience's key role, as resilient professionals are more prone to show higher Neutral-Acceptance and experience fewer negative attitudes. Finally, specific on-job death training should be included as core theme in healthcare professionals' training, as it assists nursing staff with confronting death and dying people in more adaptive ways, improving care quality and self-well-being. Abbreviations ANCT Auxiliary Nursing Care Technician ATD Attitude toward death ICU Intensive Care Units MMT Meaning Management Theory PI-PE Psychological Immunity – Psychological Elasticity RN Registered Nurse TMT Terror Management Theory Declarations Ethics approval and consent to participate The study was approved by the Research and Ethics Committee of the Basque Ethics Committee for Research (CEIm-E PI2018066) and conducted according to the 1964 Declaration of Helsinki and subsequent amendments. Informed consent was obtained from all participants. Participant anonymity and confidentiality were ensured. Consent for publication Not applicable Data availability statement The data that support the findings of this study are available from the corresponding author, S.A-G., upon reasonable request. Competing interests The authors declare that they have no competing interests. Funding The present research has not received specific support from public sector agencies, commercial sector, or non-profit entities. Authors´contributions S.A-G., E.P., J.J., T.S-G., I.M. and S.D. made substantial contributions to the work. S.A-G.: conceptualization (lead); investigation – data collection; writing – original draft (lead); interpretation of data; writing- review and editing. E.P.: project administration; writing – original draft (lead). J.J.: conceptualization (lead); writing – original draft (supporting). T.S-G.: project administration; writing – original draft (lead). I.M.: writing – original draft (supporting); writing- review and editing. 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1","display":"","copyAsset":false,"role":"figure","size":52778,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003e\u003cstrong\u003eDistribution of death attitudes among nursing professionals:\u003c/strong\u003e\u003c/em\u003e\u003cstrong\u003e \u003c/strong\u003eMean scores for the five death attitudes measured by the Death Attitude Profile-Revised scale (DAP-R). Error bars represent standard errors. Higher scores indicate stronger endorsement of the attitude (scale range: 1-7).\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7808208/v1/08e1d55c3aa315b5b54af188.png"},{"id":94760111,"identity":"c6cd8c9d-734a-4423-89b6-c6e23d600a67","added_by":"auto","created_at":"2025-10-30 11:54:14","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":56999,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003e\u003cstrong\u003eRelationship between resilience and death attitudes: Correlations between resilience scores and the five death attitudes.\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eNote: *p \u0026lt; .05, **p \u0026lt; .01.\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-7808208/v1/3d57f53e7f2fd01c54db5095.png"},{"id":94760118,"identity":"b548909c-6b98-400f-b31a-81365c358c3c","added_by":"auto","created_at":"2025-10-30 11:54:15","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":126519,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003e\u003cstrong\u003eCorrelation matrix of death attitudes:\u003c/strong\u003e\u003c/em\u003e Visual representation of the relationships between the five dimensions of death attitudes. Stronger blue colors indicate stronger positive correlations, while stronger red colors indicate stronger negative correlations.\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-7808208/v1/e957ec805d3cda7e23c3f4c6.png"},{"id":94823668,"identity":"7211bfbb-b285-42e3-8891-5e50584be282","added_by":"auto","created_at":"2025-10-31 06:47:49","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":55366,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003e\u003cstrong\u003eDeath attitudes by resilience level:\u003c/strong\u003e\u003c/em\u003eComparison between nursing professionals with Low-Medium Resilience (n=458) and High Resilience (n=284). Significant differences were found in Fear-of-Death, Death-Avoidance, and Neutral-Acceptance. * indicates statistically significant differences (p \u0026lt; .05).\u003c/p\u003e","description":"","filename":"floatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-7808208/v1/cd1a0de851043028438efb6f.png"},{"id":94823852,"identity":"9e8606aa-f8d7-4ad1-843b-c753db0ece6c","added_by":"auto","created_at":"2025-10-31 06:48:07","extension":"jpeg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":244047,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003e\u003cstrong\u003ePrincipal Component Analysis biplot\u003c/strong\u003e\u003c/em\u003e\u003cem\u003e:\u003c/em\u003e PCA biplot shows the relationship between death attitudes. Component 1 (38.91% of variance) primarily represents negative attitudes toward death, while Component 2 (28.35% of variance) represents acceptance.\u003c/p\u003e","description":"","filename":"floatimage5.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7808208/v1/695d14d709085f1e9800060b.jpeg"},{"id":105223794,"identity":"f5d68465-88b5-4098-9760-09027e6f32a1","added_by":"auto","created_at":"2026-03-23 16:11:03","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1776766,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7808208/v1/d4412277-ba8d-44eb-a23e-26c987219c91.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Attitudes towards death in nursing staff: The role of resilience","fulltext":[{"header":"Introduction","content":"\u003cp\u003eDeath, as a universal and inevitable phenomenon, represents one of the greatest emotional and professional challenges for nursing staff. It is a multidimensional phenomenon encompassing psychological, social, cultural and economic aspects that impact patients, relatives, and formal caregivers (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). In clinical settings such as intensive care, palliative, and oncology units, nurses frequently confront the experience of accompanying individuals through the dying process, demanding not only advanced technical competencies but also emotional skills and reflective attitudes toward death that enable humanized care (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eAttitude toward death (ATD) is a complex construct involving cognitive, emotional, behavioural, and spiritual dimensions. Wong et al. (1994) (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e) described a multidimensional model conceptualizing five dimensions. Death acceptance comprises three components: Neutral-Acceptance, referring to death as a natural and inevitable part of life; Approach-Acceptance, implying belief in death as a gateway to a happier afterlife; and Escape-Acceptance, considering death as a preferred alternative to suffering (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). In contrast, Fear-of-Death refers to anxiety and fear emotions evoked when confronting death, while Death-Avoidance is a defense mechanism leading to avoiding thinking or talking about death.\u003c/p\u003e\u003cp\u003eThese attitudes significantly affect both hospice nursing care quality and nurses' psychological well-being (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Recent studies show that although many professionals accept death as natural, they also exhibit significant levels of fear and avoidance, creating conflict between personal and professional roles (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Fear responses strongly predict psychopathology (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e) and, if untreated, can cause despair, helplessness, anger or depression (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Similarly, death avoidance represents a dysfunctional ATD, as blocking thoughts about death prevents implementing personal or professional skills to face death and adequately care for dying people.\u003c/p\u003e\u003cp\u003eConversely, considering death as a natural life sequence allows for more relaxed approaches, favouring higher quality end-of-life care and enhancing nurses' psychological wellbeing (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). However, people's overall ATD appears to be a combination of different attitudes that counterbalance each other, rather than following a single pattern (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eAlthough ATD appears closely related to nurses' psychological wellbeing (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e), literature regarding influencing factors remains inconclusive. Sociodemographic findings are often contradictory. Some studies report female nurses tend toward more fear-driven attitudes compared to males (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e), while others suggest the opposite (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Additionally, some evidence suggests male nurses may exhibit more accepting attitudes, perceiving death as natural or as means to alleviate suffering (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eAge differences are similarly inconsistent. Some studies suggest younger nurses demonstrate more Death Acceptance (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e), whereas others associate youth with Death-Avoidance or heightened Fear-of-Death (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). These discrepancies may reflect interactions between personal experience, cultural narratives, and clinical exposure during early professional development.\u003c/p\u003e\u003cp\u003eOccupational context and experience strongly influence ATD. Novice nurses frequently report more fear-based responses (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e), whereas increased clinical exposure promotes greater acceptance and emotional readiness (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). The healthcare setting is particularly noteworthy: nurses with longer experience in palliative or hospice settings tend to report more accepting ATD than those in Intensive Care Units (ICU) or oncology, who may display more fear-based or avoidant attitudes, reflecting the emotional burden and unpredictable nature of these environments (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). However, Guo et al. (2024) (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e) found that working in Intensive Care and Palliative Care Units, together with personality traits, is associated with higher death competence in novice nurses, while frequent exposure to patient death may serve as a hindering factor, underscoring considerable variability in findings.\u003c/p\u003e\u003cp\u003eProfessional training level is crucial. Registered nurses, typically with formal death education, display more acceptance ATD than auxiliary nursing care technicians (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Recent studies confirm that targeted training enhances acceptance, reduces fear, and improves end-of-life care quality (\u003cspan additionalcitationids=\"CR24\" citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). Such programs strengthen emotional competences, enhance resilience and foster self-awareness regarding emotional responses to death, promoting more positive ATD and improved psychological adjustment (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). Nurses' ATD serve as mediators between moral distress and core palliative competencies, highlighting that positive attitudes strengthen ethical practice and psychological resilience (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eAligned with these findings, Powell et al. (2020) (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e) proposed that resilience plays a key protective role against detrimental effects of dysfunctional ATD, suggesting that resilience enhances nurses' capacity for compassionate care and emotional regulation, particularly when stressful experiences are integrated into coherent personal narratives. Resilience is understood as the individual's ability to cope with stress and adversity while maintaining, or rapidly restoring, psychological well-being and functional capacity (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). Contemporary literature emphasizes that resilience should be conceptualized as a dynamic and multifaceted process encompassing pre-adversity functioning, the nature of aversive context, and availability of intrapersonal and interpersonal resources (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eRichardson's meta-theory of resilience (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e) defines resilience as a dynamic process of biopsychospiritual reintegration following disruption due to stress or adversity, involving coping and adapting to restore equilibrium with four possible outcomes: resilient reintegration (growth and strengthening), homeostatic reintegration (return to baseline), maladaptive reintegration (unhealthy coping strategies), or dysfunctional reintegration (decline in functioning).\u003c/p\u003e\u003cp\u003eThe Psychological Immunity-Psychological Elasticity (PI-PE) model (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e) highlights two core mechanisms: stressor-specific tolerance and narrative construction, with four potential adaptive outcomes: sustainability (resistance), recovery (rebound resilience), transformation (psychological reconfiguration), and thriving (flourishing).\u003c/p\u003e\u003cp\u003eIn clinical care contexts, repeated exposure to death may compromise nurses' capacity for effective psychological reintegration, particularly when accompanied by fear-based or avoidant attitudes. Lower resilience levels increase likelihood of developing dysfunctional ATD. Conversely, nurses with higher resilience demonstrate greater Neutral Acceptance and lower Fear and Avoidance (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). Furthermore, resilience may mediate relationships between perceived meaning in life and attitudes toward death, facilitating healthier emotional adaptation to suffering and loss.\u003c/p\u003e\u003cp\u003eResilience enables nurses to construct coherent narratives around professional experiences, supporting adaptive engagement with clinical responsibilities and fostering personal growth (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e). It has been associated with greater authenticity in interactions with dying patients (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e) and fewer psychological symptoms, greater occupational engagement, enhanced perceived control, increased job satisfaction, and improved overall well-being (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eResilience and acceptance attitudes toward death protect nurses against distress, helping them cope with trauma and vulnerability associated with suffering and death (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e). Therefore, fostering resilience and reflective engagement with death should be prioritized in nursing education and clinical supervision to safeguard both caregiver wellbeing and care quality.\u003c/p\u003e\u003cp\u003eNurses' attitudes toward death are shaped by complex interplay of individual, professional, and contextual factors, with resilience emerging as a key protective mechanism. However, empirical findings regarding determinants of functional ATD among nurses remain inconclusive. Drawing on existing literature, the present study aims to examine relationships between personal and occupational variables, resilience, and ATD in a large sample of nursing professionals across varying seniority levels and healthcare settings, prior to COVID-19 pandemic impact\u0026mdash;a period that profoundly altered experiences related to dying and death. Additionally, the study explores the potential moderating role of resilience between these factors and nurses' ATD. A clearer understanding of this relationship is essential for informing targeted death education strategies aimed at fostering more adaptive attitudes and improving end-of-life care quality.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eParticipants\u003c/h2\u003e\u003cp\u003eThis observational, cross-sectional study used a convenience sample of n\u0026thinsp;=\u0026thinsp;743 nursing professionals from seven public hospitals of the Basque Health Service (Spain). Participants included Registered Nurses (RN) with Bachelor of Science in Nursing degrees and Auxiliary Nursing Care Technicians (ANCT) working in Intensive Care (n\u0026thinsp;=\u0026thinsp;374), Oncology (n\u0026thinsp;=\u0026thinsp;277), and Palliative Care (n\u0026thinsp;=\u0026thinsp;122) units. Nurses in Primary Care services and nursing students were excluded.\u003c/p\u003e\u003cp\u003eThe sample was predominantly female (90.5%), with 56.8% under 45 years and 69.7% holding Bachelor of Nursing degrees. Most professionals (74.1%) had over 5 years hospital experience, though only 38.3% had specific death and bereavement training. Overall resilience levels were medium-high (\u003cem\u003eM\u003c/em\u003e\u0026thinsp;=\u0026thinsp;28.43, \u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;6.02), with 25.3% showing high resilience. Complete sample characteristics are presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eSample characteristics and descriptive statistics by subgroup.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"8\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003en\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e%\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eFear of Death M(SD)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eDeath Avoidance M(SD)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eNeutral Acceptance M(SD)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eApproach Acceptance M(SD)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003eEscape Acceptance M(SD)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGender\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e69\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e3.13 (1.36)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e3.46 (1.45)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e5.76 (0.87)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e2.59 (1.29)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e3.23 (1.49)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e654\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" 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colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026le;\u0026thinsp;45 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e411\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e56.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e2.98 (1.27)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e4.61 (1.78)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e5.65 (0.91)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e2.65 (1.31)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e3.02 (1.38)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;45 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e312\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e43.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e2.98 (1.25)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e4.45 (1.81)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e5.72 (0.89)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e3.08 (1.52)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e3.66 (1.59)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eProfessional Level\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRegistered Nurse\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e504\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e69.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e2.97 (1.26)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e4.46 (1.75)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e5.70 (0.90)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e2.73 (1.40)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e3.20 (1.48)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eANCT\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e219\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e30.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e3.02 (1.26)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e4.71 (1.88)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e5.64 (0.91)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e3.08 (1.44)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e3.53 (1.54)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eHealthcare Setting\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIntensive Care\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e374\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e51.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e3.01 (1.28)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e4.75 (1.79)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e5.66 (0.89)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e2.84 (1.42)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e3.25 (1.46)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOncology\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e227\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e31.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e2.96 (1.24)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e4.36 (1.74)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e5.69 (0.90)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e2.87 (1.50)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e3.29 (1.54)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePalliative Care\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e122\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e16.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e2.92 (1.24)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e4.19 (1.89)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e5.72 (0.92)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e2.78 (1.25)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e3.46 (1.59)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eYears of Experience\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026le;\u0026thinsp;5 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e187\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e25.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e2.95 (1.22)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e4.60 (1.84)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e5.65 (0.88)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e2.82 (1.36)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e3.20 (1.45)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;5 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e536\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e74.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e2.99 (1.27)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e4.51 (1.77)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e5.69 (0.91)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e2.85 (1.44)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e3.33 (1.53)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePrior Death Training\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e277\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e38.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e2.96 (1.25)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e4.40 (1.78)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e5.73 (0.93)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e3.01 (1.50)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e3.39 (1.54)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e446\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e61.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e2.99 (1.26)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e4.63 (1.79)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e5.65 (0.88)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e2.73 (1.35)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e3.24 (1.48)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eResilience Level\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLow-Medium\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e540\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e74.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e3.05 (1.26)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e4.64 (1.78)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e5.64 (0.91)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e2.78 (1.37)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e3.35 (1.48)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHigh\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e183\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e25.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e2.79 (1.25)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e4.23 (1.82)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e5.81 (0.86)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e3.00 (1.55)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e3.15 (1.58)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eOverall Sample\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e743\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e100\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e2.98 (1.26)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e4.54 (1.79)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e5.68 (0.90)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e2.83 (1.41)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e3.28 (1.51)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"8\"\u003eNote: ANCT\u0026thinsp;=\u0026thinsp;Auxiliary Nursing Care Technician, M\u0026thinsp;=\u0026thinsp;Mean, SD\u0026thinsp;=\u0026thinsp;Standard Deviation. Resilience overall: M\u0026thinsp;=\u0026thinsp;28.43, SD\u0026thinsp;=\u0026thinsp;6.02\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eProcedure\u003c/h3\u003e\n\u003cp\u003eNursing managers and supervisors of ICU, Palliative Care and Oncology units at each participating hospital were initially contacted. Following approval, eligible nursing staff attended one-hour informational sessions within each unit. Participants received paper-and-pencil questionnaires with envelopes for anonymous submission into opaque, sealed boxes. To accommodate high rotation among nursing personnel, informational sessions were repeated fortnightly. Recruitment was conducted from June 2018 to April 2019, adhering to STROBE guidelines for reporting observational research.\u003c/p\u003e\n\u003ch3\u003eInstruments\u003c/h3\u003e\n\u003cp\u003eSociodemographic and professional variables. Data about gender, age, professional level, healthcare setting, years of experience and prior training related to death and/or bereavement were collected through an ad-hoc questionnaire.\u003c/p\u003e\u003cp\u003eAttitudes toward death. The Death Attitude Profile-Revised scale (DAP-R) (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e) Spanish validated version by S\u0026aacute;ez et al. (2020) (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e) was used. This multidimensional questionnaire consists of 32 items rated on a seven-point Likert scale (1\u0026thinsp;=\u0026thinsp;totally disagree to 7\u0026thinsp;=\u0026thinsp;totally agree), measuring five ATD: Fear-of-Death (seven items) and Death-Avoidance (five items), considered negative attitudes; Neutral-Acceptance (five items), Approach-Acceptance (10 items) and Escape-Acceptance (five items), considered positive attitudes (Gesser et al., 1988). Participant scores are calculated by combining dimensions with highest mean scores to form the pattern reflecting their attitude towards death. Cronbach's alpha was α\u0026thinsp;=\u0026thinsp;.86.\u003c/p\u003e\u003cp\u003eResilience. The Connor-Davidson Resilience Scale (CD-RISC-10) (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e) Spanish version by Notario-Pacheco et al. (2011) was used. It consists of 10 items scored on a Likert scale (0\u0026thinsp;=\u0026thinsp;totally disagree to 4\u0026thinsp;=\u0026thinsp;totally agree). Higher scores indicate higher resilience levels (range 0\u0026ndash;40). Cronbach's alpha was α\u0026thinsp;=\u0026thinsp;.85.\u003c/p\u003e\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003eData analysis\u003c/h2\u003e\u003cp\u003eData analyses were performed using Python (version 3.8) with NumPy, Pandas, SciPy, Statsmodels, and Scikit-learn libraries. Missing values were handled through Random Forest-based iterative imputation. Normality testing was based on skewness and kurtosis values (\u0026lt;\u0026thinsp;2 and \u0026lt;\u0026thinsp;7 respectively) (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e), supported by the Central Limit Theorem for large samples.\u003c/p\u003e\u003cp\u003eDescriptive statistics included means, standard deviations, frequencies, and percentages. Pearson and Spearman correlation coefficients assessed associations between variables. For healthcare settings, dummy variables were created for each setting.\u003c/p\u003e\u003cp\u003eOne-way multivariate analysis of variance (MANOVA) examined differences in ATD by independent variables (sex, age, professional level, healthcare setting, seniority, prior training, and resilience). Resilience was categorized using quartiles: low-medium (up to third quartile) and high (above third quartile). Bonferroni correction was applied for post-hoc tests.\u003c/p\u003e\u003cp\u003eMediation analyses used Baron and Kenny's approach supplemented with bootstrapping (5,000 samples), testing: effect of independent variables on dependent variables (path c), effect of independent variables on mediator (path a), effect of mediator on dependent variables controlling for independent variables (path b) and calculating indirect effect (a*b) and proportion mediated.\u003c/p\u003e\u003cp\u003eHierarchical regression analyses with centered variables examined whether resilience moderated relationships between personal/occupational factors and ATD. Principal Component Analysis (PCA) identified underlying patterns in death attitudes. Independent samples t-tests and one-way ANOVAs with Tukey post-hoc tests compared attitudes across groups.\u003c/p\u003e\u003cp\u003eStatistical significance was set at p\u0026thinsp;\u0026lt;\u0026thinsp;.05, with effect sizes reported using partial eta squared (η\u0026sup2;) for MANOVA, Cohen's d for t-tests, and R\u0026sup2; for regression models.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eEthical considerations\u003c/h3\u003e\n\u003cp\u003e The study was approved by the Research and Ethics Committee of the Basque Ethics Committee for Research (CEIm-E PI2018066) and conducted according to the 1964 Declaration of Helsinki and subsequent amendments. Informed consent was obtained from all participants. Participant anonymity and confidentiality were ensured.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\u003ch2\u003eDescriptive analysis of attitudes towards death\u003c/h2\u003e\u003cp\u003eNursing professionals showed highest scores in Neutral-Acceptance of death (M\u0026thinsp;=\u0026thinsp;5.68, SD\u0026thinsp;=\u0026thinsp;0.90), followed by Death-Avoidance (M\u0026thinsp;=\u0026thinsp;4.54, SD\u0026thinsp;=\u0026thinsp;1.79) and Escape-Acceptance (M\u0026thinsp;=\u0026thinsp;3.28, SD\u0026thinsp;=\u0026thinsp;1.51). Lower scores were reported for Fear-of-Death (M\u0026thinsp;=\u0026thinsp;2.98, SD\u0026thinsp;=\u0026thinsp;1.26) and Approach-Acceptance (M\u0026thinsp;=\u0026thinsp;2.83, SD\u0026thinsp;=\u0026thinsp;1.41) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eCorrelations between variables\u003c/h3\u003e\n\u003cp\u003eResilience showed weak negative correlations with Fear-of-Death (r=-.20, p\u0026thinsp;\u0026lt;\u0026thinsp;.01) and Death-Avoidance (r=-.13, p\u0026thinsp;\u0026lt;\u0026thinsp;.01), and a weak positive correlation with Neutral-Acceptance (r\u0026thinsp;=\u0026thinsp;.11, p\u0026thinsp;\u0026lt;\u0026thinsp;.01) (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e), indicating that more resilient nursing professionals tend to accept death as natural and experience less fear and avoidance.\u003c/p\u003e\u003cp\u003eAge was positively correlated with Approach-Acceptance (r\u0026thinsp;=\u0026thinsp;.15, p\u0026thinsp;\u0026lt;\u0026thinsp;.01) and Escape-Acceptance (r\u0026thinsp;=\u0026thinsp;.21, p\u0026thinsp;\u0026lt;\u0026thinsp;.01). Professional level showed positive correlations with Death-Avoidance (r\u0026thinsp;=\u0026thinsp;.11, p\u0026thinsp;\u0026lt;\u0026thinsp;.01), Approach-Acceptance (r\u0026thinsp;=\u0026thinsp;.12, p\u0026thinsp;\u0026lt;\u0026thinsp;.01), and Escape-Acceptance (r\u0026thinsp;=\u0026thinsp;.10, p\u0026thinsp;\u0026lt;\u0026thinsp;.01).\u003c/p\u003e\u003cp\u003ePrior training about death correlated positively with Approach-Acceptance (r\u0026thinsp;=\u0026thinsp;.10, p\u0026thinsp;\u0026lt;\u0026thinsp;.05) and negatively with Death-Avoidance (r=-.09, p\u0026thinsp;\u0026lt;\u0026thinsp;.05). Working in Intensive Care units was positively associated with Death-Avoidance (r\u0026thinsp;=\u0026thinsp;.13, p\u0026thinsp;\u0026lt;\u0026thinsp;.01), while working in Palliative Care showed negative correlations with both Fear-of-Death (r=-.07, p\u0026thinsp;\u0026lt;\u0026thinsp;.05) and Death-Avoidance (r=-.11, p\u0026thinsp;\u0026lt;\u0026thinsp;.01).\u003c/p\u003e\u003cp\u003eStrong positive correlations were found between Fear-of-Death and Death-Avoidance (r\u0026thinsp;=\u0026thinsp;.58, p\u0026thinsp;\u0026lt;\u0026thinsp;.01), and moderate positive correlations between Approach-Acceptance and Escape-Acceptance (r\u0026thinsp;=\u0026thinsp;.42, p\u0026thinsp;\u0026lt;\u0026thinsp;.01). Fear-of-Death showed moderate negative correlation with Neutral-Acceptance (r=-.36, p\u0026thinsp;\u0026lt;\u0026thinsp;.01), and Death-Avoidance was also negatively correlated with Neutral-Acceptance (r=-.34, p\u0026thinsp;\u0026lt;\u0026thinsp;.01) (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eEffects of personal and occupational factors on attitudes toward death\u003c/h2\u003e\u003cp\u003eMANOVA analyses revealed several significant effects (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Gender showed a significant but small effect (F\u0026thinsp;=\u0026thinsp;2.16, p\u0026thinsp;=\u0026thinsp;0.048, η\u0026sup2;=0.014), while age demonstrated a moderate effect (F\u0026thinsp;=\u0026thinsp;11.08, p\u0026thinsp;\u0026lt;\u0026thinsp;.001, η\u0026sup2;=0.065). Professional level (F\u0026thinsp;=\u0026thinsp;5.43, p\u0026thinsp;=\u0026thinsp;0.001, η\u0026sup2;=0.034), prior training (F\u0026thinsp;=\u0026thinsp;4.00, p\u0026thinsp;=\u0026thinsp;0.006, η\u0026sup2;=0.026), healthcare setting (F\u0026thinsp;=\u0026thinsp;1.93, p\u0026thinsp;=\u0026thinsp;0.001, η\u0026sup2;=0.025), and resilience (F\u0026thinsp;=\u0026thinsp;10.37, p\u0026thinsp;\u0026lt;\u0026thinsp;.001, η\u0026sup2;=0.061) all showed significant effects on death attitudes.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eMultivariate effects of personal and occupational variables on death attitudes (MANOVA results).\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFactor\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePillai's Trace\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eF\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003edf\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003ep\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eη\u0026sup2;\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eSig.\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGender\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.014\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e53,700\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.048\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.014\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.07\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e11.08\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e53,700\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.065\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e***\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eProfessional level\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.035\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5.43\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e53,700\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.034\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e**\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePrior training\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.026\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e53,700\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.006\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.026\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e**\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHealthcare setting\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.025\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.93\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e103,695\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.025\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e**\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eResilience\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.065\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10.37\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e53,700\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.061\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e***\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"7\"\u003eNote: * p\u0026thinsp;\u0026lt;\u0026thinsp;.05, ** p\u0026thinsp;\u0026lt;\u0026thinsp;.01, *** p\u0026thinsp;\u0026lt;\u0026thinsp;.001\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eSpecific group differences revealed several significant patterns (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e):\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eMediation analyses: direct, indirect, and total effects of resilience on death attitudes.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"9\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePredictor\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOutcome\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eTotal Effect (c)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ep\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eDirect Effect (c')\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003ep\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eIndirect Effect (a*b)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003e% Mediated\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c9\"\u003e\u003cp\u003eMediation Type\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eProfessional Level\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFear of Death\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e-0.042\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.68\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.061\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.543\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e-0.103\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e245.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003eComplete\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eProfessional Level\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNeutral Acceptance\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e-0.026\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.718\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e-0.079\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.277\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.052\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e-201.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003eComplete\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePrior Training\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFear of Death\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.057\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.547\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e-0.002\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.981\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.06\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e104\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003eComplete\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePrior Training\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDeath Avoidance\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.37\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.006\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.322\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.017\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.048\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003ePartial\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePrior Training\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNeutral Acceptance\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e-0.128\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.06\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e-0.099\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.142\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e-0.029\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e22.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003eComplete\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"9\"\u003eNote: Only significant mediation effects are shown. Mediation percentages\u0026thinsp;\u0026gt;\u0026thinsp;100% indicate suppression effects.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eAge: Older nurses (\u0026gt;\u0026thinsp;45 years) showed significantly higher Approach-Acceptance (M\u0026thinsp;=\u0026thinsp;3.08\u0026thinsp;\u0026plusmn;\u0026thinsp;1.52 vs. M\u0026thinsp;=\u0026thinsp;2.65\u0026thinsp;\u0026plusmn;\u0026thinsp;1.31, F\u0026thinsp;=\u0026thinsp;16.076, p\u0026thinsp;\u0026lt;\u0026thinsp;.001, η\u0026sup2;=0.022) and Escape-Acceptance (M\u0026thinsp;=\u0026thinsp;3.66\u0026thinsp;\u0026plusmn;\u0026thinsp;1.59 vs. M\u0026thinsp;=\u0026thinsp;3.02\u0026thinsp;\u0026plusmn;\u0026thinsp;1.38, F\u0026thinsp;=\u0026thinsp;33.633, p\u0026thinsp;\u0026lt;\u0026thinsp;.001, η\u0026sup2;=0.045) than younger nurses.\u003c/p\u003e\u003cp\u003eProfessional level: ANCT showed significantly higher Death-Avoidance (M\u0026thinsp;=\u0026thinsp;4.71\u0026thinsp;\u0026plusmn;\u0026thinsp;1.88 vs. M\u0026thinsp;=\u0026thinsp;4.46\u0026thinsp;\u0026plusmn;\u0026thinsp;1.75, F\u0026thinsp;=\u0026thinsp;8.618, p\u0026thinsp;=\u0026thinsp;0.003, η\u0026sup2;=0.012), Approach-Acceptance (M\u0026thinsp;=\u0026thinsp;3.08\u0026thinsp;\u0026plusmn;\u0026thinsp;1.44 vs. M\u0026thinsp;=\u0026thinsp;2.73\u0026thinsp;\u0026plusmn;\u0026thinsp;1.40, F\u0026thinsp;=\u0026thinsp;19.279, p\u0026thinsp;=\u0026thinsp;0.002, η\u0026sup2;=0.013), and Escape-Acceptance (M\u0026thinsp;=\u0026thinsp;3.53\u0026thinsp;\u0026plusmn;\u0026thinsp;1.54 vs. M\u0026thinsp;=\u0026thinsp;3.20\u0026thinsp;\u0026plusmn;\u0026thinsp;1.48, F\u0026thinsp;=\u0026thinsp;16.03, p\u0026thinsp;=\u0026thinsp;0.008, η\u0026sup2;=0.010) than Registered Nurses.\u003c/p\u003e\u003cp\u003eHealthcare setting: Professionals working in ICU showed significantly higher Death-Avoidance than those in Palliative Care (M\u0026thinsp;=\u0026thinsp;4.75\u0026thinsp;\u0026plusmn;\u0026thinsp;1.79 vs. M\u0026thinsp;=\u0026thinsp;4.19\u0026thinsp;\u0026plusmn;\u0026thinsp;1.89, F\u0026thinsp;=\u0026thinsp;7.58, p\u0026thinsp;=\u0026thinsp;0.001, η\u0026sup2;=0.021).\u003c/p\u003e\u003cp\u003ePrior death training: Professionals with prior training showed significantly lower Death-Avoidance (M\u0026thinsp;=\u0026thinsp;4.40\u0026thinsp;\u0026plusmn;\u0026thinsp;1.78 vs. M\u0026thinsp;=\u0026thinsp;4.63\u0026thinsp;\u0026plusmn;\u0026thinsp;1.79, F\u0026thinsp;=\u0026thinsp;5.568, p\u0026thinsp;=\u0026thinsp;0.019, η\u0026sup2;=0.008) and higher Approach-Acceptance (M\u0026thinsp;=\u0026thinsp;3.01\u0026thinsp;\u0026plusmn;\u0026thinsp;1.50 vs. M\u0026thinsp;=\u0026thinsp;2.73\u0026thinsp;\u0026plusmn;\u0026thinsp;1.35, F\u0026thinsp;=\u0026thinsp;6.551, p\u0026thinsp;=\u0026thinsp;0.011, η\u0026sup2;=0.009) than those without training.\u003c/p\u003e\u003cp\u003eResilience: High resilience professionals showed significantly lower Fear-of-Death (M\u0026thinsp;=\u0026thinsp;2.79\u0026thinsp;\u0026plusmn;\u0026thinsp;1.25 vs. M\u0026thinsp;=\u0026thinsp;3.05\u0026thinsp;\u0026plusmn;\u0026thinsp;1.26, F\u0026thinsp;=\u0026thinsp;25.396, p\u0026thinsp;\u0026lt;\u0026thinsp;.001, η\u0026sup2;=0.034) and Death-Avoidance (M\u0026thinsp;=\u0026thinsp;4.23\u0026thinsp;\u0026plusmn;\u0026thinsp;1.82 vs. M\u0026thinsp;=\u0026thinsp;4.64\u0026thinsp;\u0026plusmn;\u0026thinsp;1.78, F\u0026thinsp;=\u0026thinsp;6.21, p\u0026thinsp;=\u0026thinsp;0.013, η\u0026sup2;=0.009), and higher Neutral-Acceptance (M\u0026thinsp;=\u0026thinsp;5.81\u0026thinsp;\u0026plusmn;\u0026thinsp;0.86 vs. M\u0026thinsp;=\u0026thinsp;5.64\u0026thinsp;\u0026plusmn;\u0026thinsp;0.91, F\u0026thinsp;=\u0026thinsp;9.879, p\u0026thinsp;=\u0026thinsp;0.002, η\u0026sup2;=0.014) than low-medium resilience professionals (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eMediating role of resilience\u003c/h2\u003e\u003cp\u003eMediation analyses revealed that resilience functioned as significant mediator between several personal/occupational factors and attitudes toward death (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e):\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eGroup comparisons of death attitudes by personal and occupational variables (ANOVA results).\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"10\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDeath Attitude\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eGroup 1\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eGroup 2\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eGroup 1 M\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eGroup 2 M\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eF\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003edf\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c9\"\u003e\u003cp\u003ep\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c10\"\u003e\u003cp\u003eη\u0026sup2;\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eAge\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eApproach Acceptance\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u0026le;\u0026thinsp;45 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;45 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e\u003cp\u003e2.65\u0026thinsp;\u0026plusmn;\u0026thinsp;1.31\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e\u003cp\u003e3.08\u0026thinsp;\u0026plusmn;\u0026thinsp;1.52\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e16.076\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e1,721\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e0.022\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEscape Acceptance\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e\u003cp\u003e3.02\u0026thinsp;\u0026plusmn;\u0026thinsp;1.38\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e\u003cp\u003e3.66\u0026thinsp;\u0026plusmn;\u0026thinsp;1.59\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e33.633\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e1,721\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e0.045\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eProfessional Level\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDeath Avoidance\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eRN\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eANCT\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e\u003cp\u003e4.46\u0026thinsp;\u0026plusmn;\u0026thinsp;1.75\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e\u003cp\u003e4.71\u0026thinsp;\u0026plusmn;\u0026thinsp;1.88\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e8.618\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e1,721\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.003\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e0.012\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eApproach Acceptance\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e\u003cp\u003e2.73\u0026thinsp;\u0026plusmn;\u0026thinsp;1.40\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e\u003cp\u003e3.08\u0026thinsp;\u0026plusmn;\u0026thinsp;1.44\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e19.279\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e1,721\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.002\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e0.013\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEscape Acceptance\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e\u003cp\u003e3.20\u0026thinsp;\u0026plusmn;\u0026thinsp;1.48\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e\u003cp\u003e3.53\u0026thinsp;\u0026plusmn;\u0026thinsp;1.54\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e16.03\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e1,721\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.008\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e0.01\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHealthcare Setting\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDeath Avoidance\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eICU\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePalliative\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e\u003cp\u003e4.75\u0026thinsp;\u0026plusmn;\u0026thinsp;1.79\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e\u003cp\u003e4.19\u0026thinsp;\u0026plusmn;\u0026thinsp;1.89\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e7.58\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e2,720\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e0.021\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003ePrior Training\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDeath Avoidance\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e\u003cp\u003e4.40\u0026thinsp;\u0026plusmn;\u0026thinsp;1.78\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e\u003cp\u003e4.63\u0026thinsp;\u0026plusmn;\u0026thinsp;1.79\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e5.568\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e1,721\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.019\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e0.008\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eApproach Acceptance\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e\u003cp\u003e3.01\u0026thinsp;\u0026plusmn;\u0026thinsp;1.50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e\u003cp\u003e2.73\u0026thinsp;\u0026plusmn;\u0026thinsp;1.35\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e6.551\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e1,721\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.011\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e0.009\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eResilience\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFear of Death\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eHigh\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eLow-Medium\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e\u003cp\u003e2.79\u0026thinsp;\u0026plusmn;\u0026thinsp;1.25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e\u003cp\u003e3.05\u0026thinsp;\u0026plusmn;\u0026thinsp;1.26\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e25.396\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e1,721\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e0.034\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDeath Avoidance\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e\u003cp\u003e4.23\u0026thinsp;\u0026plusmn;\u0026thinsp;1.82\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e\u003cp\u003e4.64\u0026thinsp;\u0026plusmn;\u0026thinsp;1.78\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e6.21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e1,721\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.013\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e0.009\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNeutral Acceptance\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e\u003cp\u003e5.81\u0026thinsp;\u0026plusmn;\u0026thinsp;0.86\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e\u003cp\u003e5.64\u0026thinsp;\u0026plusmn;\u0026thinsp;0.91\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e9.879\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e1,721\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.002\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e0.014\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"10\"\u003eNote: RN\u0026thinsp;=\u0026thinsp;Registered Nurse, ANCT\u0026thinsp;=\u0026thinsp;Auxiliary Nursing Care Technician, ICU\u0026thinsp;=\u0026thinsp;Intensive Care Units\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eFear-of-Death: Resilience completely mediated the relationship between professional level and Fear-of-Death (proportion mediated: 245.9%), with ANCT showing higher Fear-of-Death through lower resilience. This large percentage indicates a suppression effect, where the indirect effect through resilience is stronger than the original direct effect. Similarly, resilience completely mediated the relationship between prior training and Fear-of-Death (proportion mediated: 104.0%), with trained professionals experiencing less fear through enhanced resilience.\u003c/p\u003e\u003cp\u003eDeath-Avoidance: Resilience partially mediated the relationship between prior training and Death-Avoidance (proportion mediated: 13.0%).\u003c/p\u003e\u003cp\u003eNeutral-Acceptance: Resilience completely mediated the relationship between professional level and Neutral-Acceptance (proportion mediated: -201.2%), with ANCT showing lower Neutral-Acceptance through reduced resilience. The negative percentage indicates that the mediating effect works in the opposite direction to the direct effect. Resilience also completely mediated the relationship between prior training and Neutral-Acceptance (proportion mediated: 22.4%).\u003c/p\u003e\u003cp\u003eNo significant mediating effects of resilience were found for Approach-Acceptance or Escape-Acceptance.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eModerating role of resilience\u003c/h2\u003e\u003cp\u003eModeration analyses examined whether relationships between personal/occupational factors and attitudes toward death varied depending on resilience levels. Only one significant moderation effect was identified: resilience moderated the relationship between professional level (ANCT) and Escape-Acceptance, although the effect size was minimal. Simple slope analysis showed the relationship between being an ANCT and Escape-Acceptance was slightly stronger for nurses with high resilience (B\u0026thinsp;=\u0026thinsp;1.94) compared to those with low resilience (B\u0026thinsp;=\u0026thinsp;1.93).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003ePrincipal component analysis of death attitudes\u003c/h2\u003e\u003cp\u003ePrincipal Component Analysis identified two main components explaining 67.27% of variance in death attitudes (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). The first component (38.91% of variance) was heavily loaded with Fear-of Death (.857) and Death-Avoidance (.797), with negative loading for Neutral-Acceptance (-.619), representing negative/avoidant orientation toward death. The second component (28.35% of variance) was primarily loaded with Escape-Acceptance (.830) and Approach-Acceptance (.734), representing a transcendence-oriented perspective viewing death as either escape from suffering or gateway to afterlife.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eNeutral-Acceptance was the predominant ATD among nursing professionals, implying that most professionals in high emotional healthcare settings consider death a natural part of life, accepting it without welcoming nor rejecting it, emphasizing motivation to live meaningfully (\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e). However, considering ATD as a complex pattern (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e), findings suggest that alongside Neutral-Acceptance, avoiding death was also commonly practiced. This combination suggests that although nurses face death daily, they opt for cognitive approaches while leaving aside emotional processing by avoiding feelings about death. Such approach may act as a self-preservation mechanism protecting them from the deep impact of accompanying suffering individuals at end-of-life.\u003c/p\u003e\u003cp\u003eNonetheless, Cybulska et al. (2022) (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) found nurses showed high Neutral-Acceptance and Fear-of-Death levels with low avoidance. A feasible explanation comes from Approach-Acceptance's key role, as proposed through Meaning Management Theory (MMT) (\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e) and Terror-Management Theory (TMT) (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e). MMT focuses on building meaningful life goals despite death's reality, while TMT establishes that humans use avoidance and denial to protect themselves from mortality awareness terror. Approach-Acceptance would offer, according to TMT, better afterlife alternatives to reinforce symbolic immortality. However, such focus contributes to emphasizing death rather than life. Kraitenberger et al. (2021) (\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e)concluded that believing in happier afterlife could be unsuccessful at avoiding anxious death thoughts, increasing rather than reducing fear responses.\u003c/p\u003e\u003cp\u003eBoth in this study and Xu et al. (2019) (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e), participants reported lowest Approach-Acceptance levels, while Cybulska's study (2022) (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) showed similar levels to Fear-of-Death and Neutral-Acceptance, creating different overall ATD. When nurses avoid thinking about death, fear-driven responses may arise; however, they remain lower than when viewing death as transition to desirable afterlife. Results, similar to Kraitenberger et al. (2021) (\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e), suggest that as Fear-of-Death grows, attempts to avoid death thoughts and construct meaningful-afterlife versions increase. Higher Neutral-Acceptance indicates lower Fear-of-Death, enabling higher quality patient-focused care and more efficient emotional management (\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eNeither sex nor working at oncology-related settings influenced how nurses face death. However, nurses at ICU showed comparatively higher avoidance attitudes than those at Palliative Care Units. Palliative Care correlated inversely with Fear-of-Death and Death-Avoidance, implying that establishing working cultures promoting compassionate approaches to patient suffering would improve nurses' coping cognitive and affective skills (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e), regardless of death-exposure time. Years of professional experience did not influence different ATD usage. However, older nurses showed higher Approach and Escape-Acceptance levels, suggesting that life experience itself, not work experience, promotes reflection processes around non-quality life or life-after-death sense. Results align with Gama et al. (2013) (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e) and Cybulska et al. (2022) (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e), who reported higher Escape-Acceptance in older nurses, showing nurses opt for higher life quality rather than longevity, perhaps related to personal death experiences both in and outside workplace (\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eBoth professional level and prior death training relate to ATD changes. Professionals without nursing bachelor's degrees show higher Death-Avoidance than Registered Nurses, same as professionals without prior death training. This aligns with Xu et al. (2019) (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e) where nursing trainees receiving specific death training showed higher Neutral-Acceptance levels. Results reinforce that death training should be included as core curriculum part on ongoing basis throughout careers. This is supported by Cheong et al. (2020) (\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e), who found Fear-of-Death and Death-Avoidance significantly decreased after 6-week death coping workshops.\u003c/p\u003e\u003cp\u003ePrior training implies directly discussing end-of-life, involving reflection on its meaning, promoting greater emotional contact and encouraging deeper empathic insight. Confronting these mental processes makes not thinking about death nearly impossible, but not necessarily more pleasant. Although results show lower Approach-Acceptance in Registered Nurses, this approach increases with specific death-training. This could imply that nurses without work experience think of death rationally as events occurring with illness; however, comprehensive on-job training may push them toward constructing meaningful life approaches helping shape less negative ATD, aligning with previous research (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eResilience plays a key role in developing positive ATD through adaptation processes under stress or trauma, where negative events transform into opportunities for cultivating strengths and self-growth (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). Highly resilient nursing staff showed lower Fear-of-Death and Death-Avoidance levels, and higher Neutral-Acceptance. While sociodemographic variables such as sex or age, and professional variables like professional level, prior training, healthcare setting or seniority showed no interaction effects or significant relationships with Neutral-Acceptance, resilience correlated positively with Neutral-Acceptance, supporting its nature as protective mechanism in palliative healthcare professionals (\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eFindings support the Psychological-Immunity/Psychological-Elasticity model (PI-PE) (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e), proposing that tolerance and narrative construction are crucial elements enhancing adaptive coping outcomes with stressors such as death and dying patients. As tolerance is acquired resistance response, it can be developed through trained exposure to specific stressors; therefore, tolerance can be specific to some stressors but not others. The ability to incorporate stressful experiences into self-narrative, or create new narratives making sense of negative experiences, is reminiscent of Meaning Management Theory. Linked to Neutral-Acceptance, resilient nurses would build positive life views despite sickness or death proximity, making each moment worthy of living (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e).\u003c/p\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003eStrengths and limitations\u003c/h2\u003e\u003cp\u003eThis study contributes to existing literature given the paucity of publications on ATD and resilience's role in nursing staff. The large sample size, including professionals from different healthcare settings in different hospitals, with diversity in professional levels and death training degrees, ensures findings' generalizability. Rigorous statistical analyses performed allow robust conclusions about how resilience plays major roles in nurses' coping with patient death. Importantly, the study was conducted before COVID-19 pandemic outbreak, allowing ATD exploration prior to negative impacts caused by huge death numbers and subsequent frustration and helplessness experienced during pandemic times.\u003c/p\u003e\u003cp\u003eHowever, limitations exist. First, cross-sectional design prevents causal inferences. Second, other factors such as religious beliefs, trait-anxiety or death exposure could affect nurses' attitudes toward death and were not included. Third, convenience sampling may have affected findings. Fourth, information obtained through self-reported questionnaires could include social desirability bias.\u003c/p\u003e\u003cp\u003eAfter living through COVID-19 pandemic, replicating this study is essential to explore direct pandemic impacts on nurses, not only on ATD, but also on resilience building processes and compare findings with current state of nurses' everyday routines. Adding randomized sampling and including nurses from services where death is less prevalent may allow further findings replication. Furthermore, longitudinal designs will enable analysis of potential influences that specific death training may have over ATD, as well as natural ATD evolution over time due to professional and personal experiences. Incorporating instruments measuring dimensions such as nurses' personal and professional wellbeing, empathy, social support perception, and religious beliefs will allow obtaining more complete profiles of nurses' weaknesses and strengths. Based on these, tailored training and support strategies can be designed to guarantee not only professionals' emotional well-being, but also care quality provided to patients.\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe findings provide greater insight about interactions between sociodemographic and professional variables and attitudes towards death in nursing staff working at high-emotional-impact units. Results reinforce death attitudes' complexity, showcasing use of neutral death approaches combined with avoidance and fear-driven responses. Furthermore, findings support resilience's key role, as resilient professionals are more prone to show higher Neutral-Acceptance and experience fewer negative attitudes. Finally, specific on-job death training should be included as core theme in healthcare professionals' training, as it assists nursing staff with confronting death and dying people in more adaptive ways, improving care quality and self-well-being.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eANCT\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eAuxiliary Nursing Care Technician\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eATD\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eAttitude toward death\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eICU\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eIntensive Care Units\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eMMT\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eMeaning Management Theory\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePI-PE\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ePsychological Immunity \u0026ndash; Psychological Elasticity\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eRN\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eRegistered Nurse\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eTMT\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eTerror Management Theory\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved by the Research and Ethics Committee of the Basque Ethics Committee for Research (CEIm-E PI2018066) and conducted according to the 1964 Declaration of Helsinki and subsequent amendments. Informed consent was obtained from all participants. Participant anonymity and confidentiality were ensured.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data that support the findings of this study are available from the corresponding author, S.A-G., upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe present research has not received specific support from public sector agencies, commercial sector, or non-profit entities.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors´contributions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eS.A-G., E.P., J.J., T.S-G., I.M. and S.D. made substantial contributions to the work.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eS.A-G.: conceptualization (lead); investigation – data collection; writing – original draft (lead); interpretation of data; writing- review and editing.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eE.P.: project administration; writing – original draft (lead).\u003c/p\u003e\n\u003cp\u003eJ.J.: conceptualization (lead); writing – original draft (supporting).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eT.S-G.: project administration; writing – original draft (lead).\u003c/p\u003e\n\u003cp\u003eI.M.: writing – original draft (supporting); writing- review and editing.\u003c/p\u003e\n\u003cp\u003eS.D.: design and methodology; formal analysis; writing- review and editing; preparation of tables and figures and visualization.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll authors are in agreement with the submitted manuscript. All the authors agree to be personally accountable for the authors´ own contributions and ensure the accuracy and integrity of any part of the work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to thank all the participants who shared some of their time to help us make this study possible.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eGarc\u0026iacute;a-Avenda\u0026ntilde;o DJ, Ochoa-Estrada MC, Brice\u0026ntilde;o-Rodr\u0026iacute;guez II. Attitude of nursing staff at the death of the person in the intensive care unit: Quantitative study. Duazary. 2018;15(3):281\u0026ndash;93.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRu\u0026iacute;z-Fern\u0026aacute;ndez MD, Fern\u0026aacute;ndez-Medina IM, Granero-Molina J, Hern\u0026aacute;ndez-Padilla JM, Correa-Casado M, Fern\u0026aacute;ndez-Sola C. 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Resilience in palliative healthcare professionals: A systematic review. Support Care Cancer. 2020;28(3):971\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-palliative-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pcar","sideBox":"Learn more about [BMC Palliative Care](http://bmcpalliatcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pcar/default.aspx","title":"BMC Palliative Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"death attitudes, inservice training, nursing, psychological resilience","lastPublishedDoi":"10.21203/rs.3.rs-7808208/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7808208/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eNurses are not always prepared to deal with strong emotions evoked when caring for suffering patients. Their attitudes-towards-death affect care quality provided to dying patients and their own well-being. This study examined resilience's role on attitudes-towards-death and personal/occupational factors related to each attitude before pandemic impact.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003e This observational, cross-sectional study included 743 nursing professionals from Intensive-Care, Palliative-Care and Oncology units in seven public Spanish hospitals. Participants completed the Death-Attitude-Profile-Revised-Scale, Connor-Davidson-Resilience-Scale and an ad-hoc questionnaire between June 2018 and April 2019. MANOVA tests, correlation analyses, mediation analyses, and Principal Component Analysis were performed.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eNeutral-Acceptance was the predominant attitude (M\u0026thinsp;=\u0026thinsp;5.68, SD\u0026thinsp;=\u0026thinsp;0.90), followed by Death-Avoidance (M\u0026thinsp;=\u0026thinsp;4.54, SD\u0026thinsp;=\u0026thinsp;1.79). Professional level, age, prior death training, healthcare setting, and resilience significantly affected attitudes (all p\u0026thinsp;\u0026lt;\u0026thinsp;.05). Resilience correlated positively with Neutral-Acceptance and inversely with Fear-of-Death and Death-Avoidance. Mediation analyses revealed complete mediation effects of resilience on relationships between professional factors and key attitudes, with some suppression effects indicated by mediation percentages\u0026thinsp;\u0026gt;\u0026thinsp;100%.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eBoth resilience and prior death training play key roles in attitudes-towards-death; therefore, both should be included as core elements in academic and on-the-job nursing training.\u003c/p\u003e","manuscriptTitle":"Attitudes towards death in nursing staff: The role of resilience","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-30 11:54:10","doi":"10.21203/rs.3.rs-7808208/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-10-30T10:40:47+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-25T06:49:52+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-21T18:31:17+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"178670429675760595766509828380130587742","date":"2025-10-17T03:53:59+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"105937945807875999257124328778737569056","date":"2025-10-16T11:18:57+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-10-16T10:11:09+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-10-14T05:41:47+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-10-14T04:11:21+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-10-14T04:10:18+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Palliative Care","date":"2025-10-08T12:59:13+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-palliative-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pcar","sideBox":"Learn more about [BMC Palliative Care](http://bmcpalliatcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pcar/default.aspx","title":"BMC Palliative Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"3cdd0f75-61a3-4932-bc18-64eb7cdd25f3","owner":[],"postedDate":"October 30th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-03-23T16:08:14+00:00","versionOfRecord":{"articleIdentity":"rs-7808208","link":"https://doi.org/10.1186/s12904-026-02062-8","journal":{"identity":"bmc-palliative-care","isVorOnly":false,"title":"BMC Palliative Care"},"publishedOn":"2026-03-18 15:58:49","publishedOnDateReadable":"March 18th, 2026"},"versionCreatedAt":"2025-10-30 11:54:10","video":"","vorDoi":"10.1186/s12904-026-02062-8","vorDoiUrl":"https://doi.org/10.1186/s12904-026-02062-8","workflowStages":[]},"version":"v1","identity":"rs-7808208","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7808208","identity":"rs-7808208","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}