Introduction
Caring for patients at the end of life is one of the most challenging experiences in a nurse’s professional journey (Espejo‐fernández and Martínez‐angulo Reference Espejo‐fernández and Martínez‐angulo2025; Li et al. Reference Li, Kongsuwan and Barry2025; Palmryd et al. Reference Palmryd, Rejnö and Alvariza2025). For nursing interns, their first encounters with dying patients often evoke intense emotions such as empathy, sadness, fear, and anxiety about death. These emotional responses can influence their confidence, hinder effective communication with patients and families, and potentially affect the quality of care they provide (Yang and Zhou Reference Yang and Zhou2025; Ye et al. Reference Ye, Huang and Yang2025). However, these experiences also represent important opportunities for professional and personal growth. When properly supported and guided, nursing interns can learn to manage these emotions, developing both clinical competence and emotional resilience, and ultimately becoming compassionate and skilled caregivers in palliative and end-of-life care (Jiajia and Jiawen Reference Jiajia and Jiawen2022; Ju et al. Reference Ju, Liu and Soh2026).
Palliative care is more than just medical knowledge. It requires nurses to be emotionally resilient, ethical, and fully present for patients and families facing the end of life (Alodhialah et al. Reference Alodhialah, Almutairi and Almutairi2024; Ibrahim et al. Reference Ibrahim, Zaghamir and Ramadan Abdel-aziz2024; Stenman et al. Reference Stenman, Rönngren and Näppä2026). Nursing interns must balance learning complex clinical skills with managing their own stress and anxiety (Xiong and Zhu Reference Xiong and Zhu2023; Luo et al. Reference Luo, Wang and Li2025). Research shows that high levels of death anxiety and stress among nursing students can make them less comfortable caring for dying patients and less willing to support families during terminal illness (Kaygısı Reference Kaygısı2016; Wang Reference Wang2019). These challenges can affect both the individual nurse and the overall quality of palliative care, especially in cultures where talking about death is difficult (Zahran et al. Reference Zahran, Hamdan and Hamdan‐mansour2022; Ceyhan et al. Reference Ceyhan, Sürme and Kaçmaz2026).
Mindfulness-Based Stress Reduction (MBSR), developed by Kabat-Zinn (Reference Kabat-Zinn1982, Reference Kabat-Zinn1990), teaches people to focus on the present, accept their thoughts and feelings without judgment, and respond to stress calmly. MBSR has been shown to reduce stress and improve well-being among nurses (Consorte et al. Reference Consorte, Morotti and Nanni2026; Raana et al. Reference Raana, Fatima and Zaheer2026; Sapp et al. Reference Sapp, Schwartz-mette and Strout2026), but few studies have looked at its effects on nursing interns during palliative care rotations.
This study explores how an 8-week MBSR program affects death anxiety (DAP-R), stress (PSS-10), and attitudes toward caring for dying patients (FATCOD-B) among nursing interns at Prince Sattam Bin Abdulaziz University. The goal is to see whether mindfulness training can help interns build emotional strength and confidence when caring for dying patients, preparing them to provide compassionate and human-centered palliative care.
Methods
Study design
This quasi-experimental pre–post study evaluated the effects of an 8-week MBSR program on death anxiety, perceived stress, and attitudes toward care of the dying among nursing interns. A single-group design with pre- and post-intervention assessments was chosen to assess feasibility and effect sizes within the constraints of real-world clinical training, without a control group.
Setting
The study was conducted at the College of Nursing, Prince Sattam Bin Abdulaziz University, Al Kharj, Saudi Arabia. Data collection coincided with nursing interns’ mandatory palliative care and oncology clinical rotations (January–March 2026), ensuring direct relevance to end-of-life care competencies.
Participants and recruitment
Final-year Bachelor of Science in nursing interns completing their clinical internship were the target population. Participants were recruited from approximately 350 eligible interns across 3 cohorts using learning management system announcements, clinical preceptor referrals, and orientation sessions. Sample size was calculated using G*Power 3.1 for a paired-samples t-test. Assuming a medium effect size (d = 0.50), power of 0.95, and a correlation between repeated measures (r = 0.50), the minimum required sample was 120. A 20% buffer for attrition set a recruitment target of 150. A total of 120 participants completed the study (response rate = 34%).
Inclusion criteria: enrolment in the final-semester nursing internship at Prince Sattam Bin Abdulaziz University; currently completing ≥4 weeks of palliative care/oncology rotation; age 21–25 years; ability to read Arabic or English; and willingness to participate in the 8-week MBSR program.
Exclusion criteria: prior formal MBSR/mindfulness training (>4 sessions); current psychiatric diagnosis requiring medication; regular use of anxiolytics or sedatives; severe acute illness; or planned internship interruption.
Data were collected anonymously using Google Forms, distributed via university email and WhatsApp groups. Pre-intervention surveys (T1) occurred during internship Week 1, and post-intervention surveys (T2) at Week 9. Forms included all instruments, required completion of all fields, and had a completion time of 25–30 minutes. From 142 initial responses, 22 incomplete forms were excluded, resulting in n = 120.
Data collection tools
Demographic Characteristics Questionnaire. A researcher-developed demographic questionnaire was used to characterize the study sample of nursing interns. This standard instrument, commonly employed in palliative care education research, collected data on age (categorized as 21–23 vs. 24–25 years), sex (male/female), marital status (single/married), prior palliative care training (yes/no), and previous oncology exposure (yes/no). These variables were selected based on their established relevance to palliative care competencies and attitudes among nursing students. Responses were categorical, analyzed using frequencies and percentages. Content validity was established through expert review and alignment with similar instruments used in nursing education studies, demonstrating face validity for the Saudi nursing intern population.
Death Attitude Profile-Revised (DAP-R). Developed by Wong et al. (Reference Wong, Reker, Gesser and Neimeyer1994), the DAP-R is a multidimensional instrument designed to assess attitudes toward death, particularly relevant for healthcare professionals in palliative and end-of-life care settings. It comprises 32 items organized into 5–6 subscales, including Fear of Death (7 items: 1, 2, 7, 18, 20, 21, 32), Death Acceptance, Approach Acceptance, Death Avoidance, and Escape Acceptance. Participants respond on a 7-point Likert scale (1 = Strongly Disagree to 7 = Strongly Agree), with subscale scores obtained by direct summation (no reverse scoring for Fear subscale). Higher scores on the Fear of Death subscale indicate greater death anxiety. The scale demonstrates well-to-excellent internal consistency (Cronbach’s α = 0.72–0.94 across subscales) and convergent validity with Templer’s Death Anxiety Scale (r = 0.45–0.65). Confirmatory factor analysis supports its multidimensional structure in nursing samples (CFI > 0.90), with reliable cross-cultural application including healthcare professionals.
Perceived Stress Scale (PSS-10). The PSS-10, developed by Cohen et al. (Reference Cohen, Kamarck and Mermelstein1983), measures the degree to which individuals perceive life situations as stressful and their sense of control over them, making it ideal for evaluating stress reduction interventions among nursing students. It consists of 10 items assessing stress over the past month, with 4 positively worded items (4, 5, 7, 8) requiring reverse scoring (0 = Never to 4 = Very Often becomes 4 = Never to 0 = Very Often). Total scores range from 0 to 40, categorized as low (0–13), moderate (14–26), or high stress (27–40), with higher scores indicating greater perceived stress. The scale exhibits excellent psychometric properties, including internal consistency (α = 0.78–0.90) and convergent validity with measures of depression and anxiety (r = 0.39–0.62). A 2-factor structure (perceived helplessness vs. self-efficacy) is well-supported (CFI > 0.95), and the Arabic version is validated among Saudi populations (α = 0.67–0.86).
Frommelt Attitude Toward Care of the Dying Scale Form B (FATCOD-B). The FATCOD-B, authored by Frommelt (Reference Frommelt1991), evaluates nurses’ and nursing students’ attitudes toward caring for terminally ill patients and their families, focusing on comfort with death discussions, family involvement, and emotional support in palliative contexts. It includes 30 items, with 15 positively keyed statements and 15 negatively keyed items requiring reverse scoring (items 3, 5, 6, 7, 8, 9, 11, 13, 14, 15, 17, 19, 25, 26, 28, 29). Responses use a 5-point Likert scale (1 = Strongly Disagree to 5 = Strongly Agree), yielding a total score range of 30–150 after reversing negatives (higher scores reflect more positive attitudes). Psychometric evaluation confirms good internal consistency (α = 0.79–0.88) and a 2-factor structure distinguishing patient and family attitudes (CFI = 0.85–0.92). Convergent validity with palliative care knowledge is moderate (r = 0.35–0.50), and it discriminates effectively by training level.
Intervention: mindfulness-based stress reduction program
Program Structure and Fidelity. Participants completed the standardized 8-week MBSR program based on the original protocol by Kabat-Zinn (Reference Kabat-Zinn1982, Reference Kabat-Zinn1990), delivered by 2 certified instructors. The intervention comprised 8 weekly 2-hour group sessions (n = 15–20 per group), one 6-hour silent retreat (Week 6), and daily 45-minute home practice, achieving 84% mean attendance (range: 78–91%). Sessions occurred in dedicated university seminar rooms at the College of Nursing, Prince Sattam Bin Abdulaziz University during non-clinical evening hours (6–8 PM). Fidelity was maintained through instructor checklists, 10% session recordings (audited), and verified participant practice logs (mean: 32 hours total).
Delivery Method. Sessions utilized a standard classroom arrangement with chairs in circles, portable meditation cushions, and audio equipment. Digital support included Google Classroom for guided practice files and reflection prompts. Daily home practice utilized the Insight Timer app with instructor-recorded Arabic/English sessions. WhatsApp groups facilitated attendance tracking and peer support.
Weekly session content
Week 1: Present Moment Awareness (Attendance: 92%)
• Mindful eating (raisin exercise), 20-minute body scan meditation
• Introduction to automatic stress reactivity in nursing
• Home practice: Daily 30-minute body scan
Week 2: Breath Awareness and Perception (Attendance: 89%)
• Sitting meditation with breath focus, mindful listening pairs
• Discussion: recognizing clinical stress triggers (patient deterioration)
• Home practice: 35-minute body scan + 10-minute breath awareness
Week 3: Mindful Movement (Attendance: 87%)
• Gentle seated stretches and standing yoga (classroom-adapted)
• Walking meditation (corridor practice)
• Home practice: 20-minute mindful movement + body scan
Week 4: Working with Thoughts (Attendance: 85%)
• 30-minute sitting meditation, cognitive defusion (“thought labeling”)
• Group processing of difficult patient scenarios
• Home practice: 45-minute formal sitting meditation
Week 5: Acceptance of Difficult Emotions (Attendance: 83%)
• “Turning toward” practice for challenging feelings
• Mindful communication exercises (dyadic practice)
• Home practice: 45-minute meditation + informal shift practice
Week 6: Silent Retreat (Attendance: 79%)
• 6-hour intensive: body scan, sitting/walking meditation, gentle yoga
• Noble silence (10 AM–4 PM); campus cafeteria lunch provided
• Compassion fatigue prevention discussion
Week 7: Loving-Kindness Practice (Attendance: 82%)
• Metta meditation for self, patients, colleagues
• Role-play: end-of-life family communication
• Home practice: 45-minute loving-kindness meditation
Week 8: Integration and Maintenance (Attendance: 88%)
• Full practice sequence (45 minutes), relapse prevention strategies
• Certificates awarded; peer support group established
• Post-intervention assessment
Home Practice Protocol. Daily guided audio files (Arabic/English) delivered via Google Drive followed the MBSR core practices: body scan (Weeks 1–3), sitting meditation (Weeks 4–6), loving-kindness (Weeks 7–8). Weekly Google Forms logs verified practice time against audio timestamps. Informal practices integrated into clinical shifts included mindful handwashing and patient assessments.
Nursing-Specific Adaptations
• Weekly discussions applied mindfulness to palliative/oncology scenarios
• Shift-compatible 2-hour sessions (vs. traditional 2.5 hours)
• Bilingual delivery for Saudi nursing interns
• 2 academic credit hours toward nursing electives
Instructor Qualifications. Lead instructor held 500+ hours of MBSR teaching experience (PhD, Psychology); co-instructor completed an MSN with MBSR certification (2024). Both fluent in Arabic/English with healthcare training experience.
Compliance and Fidelity Monitoring. Automated practice logs and instructor check-ins achieved 85% adherence. Participants missing >3 sessions were excluded (n = 8). Session fidelity matched published MBSR protocols (Khoury et al. Reference Khoury, Sharma and Rush2015).
Statistical analysis
Data were analyzed using IBM SPSS Statistics version 26.0. Descriptive statistics including means, standard deviations, frequencies, and percentages characterized the sample and scale scores. Normality of difference scores was confirmed using Shapiro–Wilk tests for each scale (all p > 0.05). Paired samples t-tests compared pre- and post-MBSR scores for DAP-R, PSS-10, and FATCOD-B, with paired variables entered as (Pre, Post) for each scale. Effect sizes (Cohen’s d) were calculated using the formula d = t/√n for paired designs. Bivariate relationships between scale scores were examined using Pearson correlation coefficients. Multiple linear regression with stepwise entry assessed predictors of post-intervention FATCOD-B scores, including demographic variables (age category, sex, marital status, prior palliative training, and previous oncology exposure) and baseline/post-intervention DAP-R and PSS scores. Statistical significance was set at α = 0.05 (2-tailed), with Bonferroni correction applied for multiple comparisons where appropriate.
Results
Participant characteristics
A total of 120 nursing interns participated in the study. As shown in Table 1, more than half of the participants were aged 21–23 years (57.5%), while 42.5% were aged 24–25 years. Females represented 56.7% (n = 68) of the sample, whereas 43.3% (n = 52) were males. The majority of interns were single (83.3%), while 16.7% were married. Most participants reported no prior palliative care training (75.0%) and no previous oncology clinical exposure (75.8%), indicating limited previous experience in end-of-life care settings.
Demographic characteristics of the studied group (n = 120)
Table 1 Long description
Demographic breakdown for 120 participants across age, sex, marital status, prior palliative training, and previous oncology exposure. Ages clustered in the early twenties, with 69 participants aged 21 to 23 (57.5%) and 51 aged 24 to 25 (42.5%). Sex distribution was 68 female (56.7%) and 52 male (43.3%). Marital status was predominantly single, with 100 single (83.3%) and 20 married (16.7%). Prior palliative training was reported by 30 participants (25.0%), while 90 (75.0%) reported none. Previous oncology exposure was similarly uncommon, with 29 yes (24.2%) and 91 no (75.8%). Percentages reflect the full sample and may not generalize beyond this group.
Effects of the MBSR intervention
Changes in death anxiety, perceived stress, and attitudes toward caring for dying patients following the intervention are presented in Table 2. A significant reduction in death anxiety (DAP-R) was observed following the intervention. Mean scores decreased from 134.67 ± 6.70 at baseline to 118.46 ± 7.85 post-intervention (t (119) = 33.39, p < 0.001). The mean difference was 16.21 (95% CI: 15.25–17.17), indicating a large effect size (Cohen’s d = 3.05). Similarly, perceived stress (PSS) scores significantly decreased from 20.29 ± 2.94 at pre-test to 19.41 ± 3.36 post-test (t(119) = 4.25, p < 0.001), with a mean difference of 0.88 (95% CI: 0.47–1.29) and a small-to-moderate effect size (d = 0.39). In contrast, attitudes toward care of the dying (FATCOD-B) significantly improved following the intervention. Mean scores increased from 84.10 ± 4.99 to 90.01 ± 5.64 (t (119) = +16.95, p < 0.001), with a mean difference of 5.91 (95% CI: 5.22–6.60) and a large effect size (d = 1.55), confirming MBSR’s comprehensive impact across all primary outcomes.
Pre/post DAP-R, PSS, and FATCOD-B scores among nursing interns (n = 120)
Table 2 Long description
Pre- and post-test scores are reported for 120 nursing interns on death anxiety, perceived stress, and attitudes toward caring for dying patients, with mean and standard deviation plus paired-test results. Death anxiety decreased from 134.67 plus or minus 6.70 to 118.46 plus or minus 7.85, a mean reduction of 16.21 with a 95 percent confidence interval from 15.25 to 17.17; the p-value is below 0.001 and the effect size is very large at 3.05. Perceived stress decreased from 20.29 plus or minus 2.94 to 19.41 plus or minus 3.36, a mean reduction of 0.88 with a 95 percent confidence interval from 0.47 to 1.29; the p-value is below 0.001 and the effect size is small to moderate at 0.39. Attitude toward care of the dying increased from 84.10 plus or minus 4.99 to 90.01 plus or minus 5.64, a mean increase of 5.91 with a 95 percent confidence interval from 5.22 to 6.60; the p-value is below 0.001 and the effect size is large at 1.55. All tests use 119 degrees of freedom, consistent with paired comparisons in the same participants. Results indicate statistically significant improvements across all three measures, with the largest change in death anxiety and the smallest change in perceived stress; statistical significance does not by itself establish clinical importance.
Correlation analysis
Pearson correlation analysis was conducted to examine associations between pre- and post-intervention scores (Table 3). Strong positive correlations were observed between pre- and post-scores for each scale (DAP-R r = 0.744; PSS r = 0.747; FATCOD-B r = 0.748; p < 0.01), indicating consistency between measurements over time. Correlations between different constructs were weak and statistically non-significant (r ranging from −0.111 to 0.034), suggesting that death anxiety, perceived stress, and attitudes toward caring for dying patients represent distinct psychological constructs.
Pearson correlations between pre- and post-intervention scores of DAP-R, PSS, and FATCOD-B (n = 120)
Table 3 Long description
Pearson correlations compare pre- and post-intervention total scores for DAP-R, PSS, and FATCOD-B in a sample of 120. Each measure shows a strong positive association between its own pre and post totals: DAP-R about 0.74, PSS about 0.75, and FATCOD-B about 0.75, indicating stable rank ordering over time. Correlations between different measures are small and close to zero overall. DAP-R has weak negative correlations with PSS at both time points, ranging roughly from minus 0.07 to minus 0.12. DAP-R and FATCOD-B are essentially uncorrelated, around minus 0.03 to minus 0.01. PSS and FATCOD-B are also near zero, from about plus 0.03 down to minus 0.07. Statistical significance markers appear only on the within-scale pre to post correlations; correlation size does not imply causation.
Correlation is significant at the 0.01 level (2-tailed).
Predictors of post-intervention attitudes toward care of the dying
Multiple linear regression analysis was performed to identify predictors of post-intervention FATCOD-B scores (Table 4). The overall regression model was statistically significant (F (10,109) = 15.553, p < 0.001) and explained 58.8% of the variance in post-intervention attitudes (R 2 = 0.588; Adjusted R 2 = 0.550). Among all predictors included in the model, baseline FATCOD-B score was the only statistically significant predictor of post-intervention attitudes (β = 0.778, t = 12.311, p < 0.001). None of the demographic variables (age, sex, marital status), previous clinical exposure variables (prior palliative training or oncology experience), or psychological variables (DAP-R and PSS scores) significantly predicted post-intervention FATCOD-B scores (p > 0.05). These findings indicate that initial attitudes toward caring for dying patients were the strongest determinant of post-intervention attitudes, while participant characteristics and other psychological variables showed limited predictive influence.
Multiple linear regression predicting post-intervention attitudes toward care of the dying (FATCOD-B) (n = 120)
Table 4 Long description
Multiple linear regression results estimate how demographic factors, prior training and exposure, and pre and post measures predict post-intervention FATCOD-B attitudes in a sample of 120. The strongest predictor is the pre-intervention FATCOD total, with a large positive standardized effect and a highly significant p value below 0.001. All other predictors have small standardized effects and p values above 0.05, including age category, sex, marital status, prior palliative training, and previous oncology exposure. Pre and post DAPR totals show near-zero effects and are not significant. Pre and post PSS totals also are not significant, with the post PSS estimate negative but not statistically reliable. Overall, the pattern suggests baseline attitudes toward care of the dying account for most of the explained variation, and the remaining variables do not add clear independent predictive value in this model.
Model statistics:
R = 0.767.
R 2 = 0.588.
Adjusted R 2 = 0.550.
F(10,109) = 15.553, p < 0.001.
Discussion
Participant characteristics
In this study, 120 nursing interns with limited prior exposure to palliative care and oncology were included. The predominance of young, relatively inexperienced participants highlights a common educational gap in preparation for end-of-life care, underscoring the need for interventions that support both emotional readiness and clinical competence in palliative settings. This aligns with systematic evidence indicating that nursing students often feel underprepared for patient death and palliative care, experiencing emotional and educational challenges that impact their clinical confidence and coping resources. A recent meta-synthesis of nursing students’ experiences with patient death and palliative care emphasizes the importance of structured support and curriculum integration to address these learning needs (Yoong et al. Reference Yoong, Wang and Seah2023).
Effects of the MBSR intervention
Death anxiety
Following the 8-week MBSR intervention, death anxiety was significantly reduced (DAP-R scores: 134.67 ± 6.70 → 118.46 ± 7.85, p < 0.001, d = 3.05). From the researchers’ perspective, this large effect suggests that mindfulness training helped interns develop emotional regulation and acceptance when confronted with mortality, reducing fear-based reactions that typically accompany early clinical encounters with dying patients. These findings are supported by research showing that mindfulness-based and preparatory educational interventions can mitigate death anxiety among healthcare learners. For example, Zhang et al. (Reference Zhang, Zhao and Cao2023) reported that participation in an MBSR program significantly decreased perceived stress among intern nursing students, suggesting that structured mindfulness training can strengthen coping mechanisms during demanding clinical placements. Similarly, Alsaqer et al. (Reference Alsaqer, Al-maghaireh and Kawafha2025) found that undergraduate nursing students who participated in an MBSR program during psychiatric clinical practice experienced significant reductions in depression, anxiety, and stress, alongside improvements in mindfulness levels. These findings highlight how mindfulness interventions can enhance emotional stability and psychological resilience in challenging clinical environments.
Furthermore, a meta-analysis conducted by Li et al. (Reference Li, Sun and Sun2020) synthesizing randomized controlled trials involving nursing students concluded that mindfulness meditation significantly reduces anxiety, depression, and stress while improving mindfulness levels. Such evidence supports the theoretical framework that mindfulness training enhances self-awareness and adaptive coping strategies, which are particularly important when healthcare learners confront emotionally demanding situations such as caring for dying patients. In the context of end-of-life care education, these results also align with studies focusing specifically on death-related attitudes. For example, Ibrahim (Reference Ibrahim2025) demonstrated that a structured palliative care education program significantly improved nursing students’ attitudes toward death and their readiness to care for dying patients.
Perceived stress
Perceived stress declined significantly following MBSR (PSS: 20.29 ± 2.94 → 19.41 ± 3.36, p < 0.001, d = 0.39). Although the effect size was smaller than for death anxiety, the reduction remains meaningful in the demanding context of internship stress. Mindfulness fosters attentional control and cognitive flexibility, helping interns manage daily stressors associated with clinical rotations. This effect is consistent with other recent findings showing that MBSR significantly reduces stress and psychological distress in nursing student populations. A quasi-experimental study among university nursing students demonstrated improvements in perceived stress and mindfulness following an 8-week intervention, highlighting the robustness of mindfulness approaches for stress management in educational settings (Liu et al. Reference Liu, Lee and Wu2024).
These findings are consistent with previous research demonstrating the effectiveness of mindfulness-based interventions in reducing stress among nursing students. For instance, Liu et al. (Reference Liu, Lee and Wu2024) conducted a quasi-experimental study among university nursing students and found that mindfulness-based intervention significantly improved mindfulness levels while reducing perceived stress. Their results support the growing evidence that mindfulness training can be a practical and accessible strategy for stress management in academic and clinical training environments. Similarly, Ksiksou et al. (Reference Ksiksou, Maskour and El Batri2022) reported that a mindfulness training program implemented among nursing students in Morocco significantly reduced perceived stress while also improving emotional intelligence. The authors suggested that mindfulness practices help students become more aware of their emotional responses and develop better emotional regulation skills, which are essential when dealing with demanding patient care situations. Enhanced emotional intelligence may further support effective communication with patients and healthcare teams, contributing to better overall clinical performance.
Similarly, research on nursing students during the COVID-19 pandemic found that MBSR significantly improved mental health outcomes, including reductions in stress and anxiety, further supporting the utility of mindfulness training during challenging clinical or public health environments (Eslamimoghadam et al. Reference Eslamimoghadam, Abedini and Khoramirad2024).
Attitudes toward care of the dying
Interns’ attitudes toward caring for dying patients improved significantly after the intervention (FATCOD-B: 84.10 ± 4.99 → 90.01 ± 5.64, p < 0.001, d = 1.55). From the researchers’ perspective, this notable improvement indicates that the MBSR program not only reduced psychological distress but also enhanced interns’ professional orientation toward compassionate end-of-life care. Mindfulness practices encourage non-judgmental awareness, emotional openness, and empathetic presence, which may help nursing interns engage more comfortably with dying patients and their families rather than avoiding emotionally difficult interactions. As a result, interns may develop greater confidence, empathy, and willingness to provide holistic care during the final stages of life.
These findings are consistent with previous studies demonstrating that structured educational or psychological interventions can positively influence attitudes toward caring for dying patients. For instance, Öcalan et al. (Reference Öcalan, Bilgin and Duru2026) conducted a randomized controlled trial examining an end-of-life care preparedness program for senior nursing students in Türkiye and reported significant improvements in both attitudes toward end-of-life care and self-efficacy in providing such care. The authors concluded that targeted training programs help students approach dying patients with greater competence and emotional readiness.
Similarly, Hou et al. (Reference Hou, Li and Guo2024) found that an educational intervention among oncology nurses significantly improved their attitudes and behaviors toward caring for dying patients. The study highlighted that structured learning experiences focusing on communication, emotional awareness, and palliative care principles can strengthen nurses’ professional commitment to compassionate end-of-life care.
Comparable findings were also reported by Ozpulat et al. (Reference Ozpulat, Tasdelen Bas and Molu2023), who examined the effects of an intervention designed to enhance compassion and attitudes toward death among nursing students in Türkiye. Their results showed that students who participated in the intervention demonstrated improved compassion levels and more positive attitudes toward caring for dying individuals, suggesting that experiential and reflective educational strategies can effectively address emotional barriers related to death and dying.
Support for these findings also comes from Ibrahim (Reference Ibrahim2025), whose broader research on palliative care education demonstrated that structured educational programs significantly improved nursing students’ attitudes toward death and their preparedness to care for dying patients. Ibrahim emphasized that effective palliative care training should address both cognitive knowledge and emotional preparedness, enabling future nurses to provide compassionate and patient-centered care.
Correlation analysis
Strong correlations between pre- and post-scores within each measure (DAP-R r = 0.744; PSS r = 0.747; FATCOD-B r = 0.748; p < 0.01) indicate high stability of these constructs over time and consistent responsiveness to the intervention. The weak and non-significant correlations between different constructs (r ranging from −0.111 to 0.034) suggest that death anxiety, perceived stress, and attitudes toward care of dying patients are distinct psychological domains, rather than overlapping outcomes. This supports theoretical models in palliative care that treat emotional distress, stress perception, and professional attitudes as separate aspects of psychological functioning, each requiring targeted approaches within educational interventions (Yoong et al. Reference Yoong, Wang and Seah2023). Indeed, research exploring the psychological experience of nursing students facing patient death has emphasized that variables such as emotional distress, resilience, and moral courage may correlate differently and independently influence outcomes, stressing the importance of multifaceted interventions (Mohammadi et al. Reference Mohammadi, Masoumi and Oshvandi2022).
Predictors of post-intervention attitudes
Multiple regression revealed that baseline attitudes toward care of the dying were the only significant predictor of post-intervention FATCOD-B scores (β = 0.778, p < 0.001), explaining nearly 59% of variance. Demographic variables, prior palliative training or oncology exposure, and psychological measures (DAP-R and PSS) were not significant predictors. This indicates that interns’ pre-existing orientation toward end-of-life care strongly influenced how they benefited from mindfulness training. From our perspective, this suggests that intrinsic professional attitudes and personal engagement with palliative care principles play a critical role in how learners integrate emotional and reflective practices. It also highlights the value of early cultivation of positive attitudes-potentially through targeted palliative education which could enhance responsiveness to interventions like MBSR. This emphasis on baseline attitudes resonates with broader educational research showing that learners’ initial emotional and professional dispositions influence the impact of training programs, particularly in emotionally demanding areas such as death care. Integrating attitude-building components into curricula may therefore strengthen subsequent training outcomes.
This interpretation is consistent with previous research indicating that students’ initial attitudes toward death and dying significantly influence their readiness to provide end-of-life care. For example, Frommelt (Reference Frommelt2003) demonstrated that nursing students with more positive baseline attitudes toward caring for dying patients showed greater improvement following educational interventions focused on death and palliative care. Similarly, Mallory (Reference Mallory2003) reported that nursing students’ comfort with death prior to training significantly predicted their post-training attitudes and willingness to care for dying patients, suggesting that personal beliefs and emotional readiness play a critical role in learning outcomes in palliative care education.
Further evidence comes from Berndtsson et al. (Reference Berndtsson, Karlsson and Rejnö2019), who found that nursing students’ pre-existing perceptions of death and personal reflections about mortality influenced their ability to engage in end-of-life care education and develop professional confidence in caring for dying patients. Likewise, Henoch et al. (Reference Henoch, Melin-johansson and Bergh2017) reported that attitudes toward death and dying among healthcare students were strongly associated with their preparedness for palliative care practice, emphasizing that educational interventions may be more effective when learners already possess a constructive orientation toward death care.
Conclusion
This study demonstrates that an 8-week MBSR intervention can significantly improve the psychological preparedness of nursing interns for end-of-life care. The intervention produced a substantial reduction in death anxiety and a meaningful decrease in perceived stress, while significantly enhancing attitudes toward caring for dying patients. These findings suggest that mindfulness training supports emotional regulation, reflective awareness, and empathetic engagement when interns encounter death in clinical settings. The results also indicate that baseline attitudes toward caring for dying patients strongly influence post-intervention outcomes, highlighting the importance of early development of positive professional perspectives toward end-of-life care. Overall, integrating mindfulness practices within nursing education may strengthen both the emotional resilience and compassionate orientation of future nurses working in palliative and oncology settings.
Recommendations
Based on these findings, nursing education programs should consider integrating structured mindfulness-based interventions such as MBSR into undergraduate and internship training to enhance students’ emotional preparedness for end-of-life care. Educational curricula should also incorporate early palliative care exposure, reflective learning activities, and communication training related to death and dying to foster positive attitudes toward caring for terminally ill patients. Healthcare institutions and nursing educators may further support interns through mentorship programs, psychological support services, and experiential learning opportunities in palliative care settings. Future research should employ randomized controlled designs with larger and more diverse samples, as well as long-term follow-up assessments, to further examine the sustainability of mindfulness interventions and their impact on clinical practice and patient care outcomes.
Limitations
Despite its contributions, this study has several limitations that should be considered when interpreting the findings. The use of a single-group pre–post quasi-experimental design without a control group limits the ability to attribute observed changes solely to the MBSR intervention. The study was conducted among nursing interns from a single educational context, which may limit the generalizability of the results to other institutions or healthcare systems. Additionally, the reliance on self-reported measures may introduce response bias or social desirability effects. The relatively short follow-up period also prevented evaluation of the long-term sustainability of the observed improvements. Future studies should address these limitations by including randomized controlled designs, multi-site samples, and longitudinal follow-up assessments to provide stronger evidence regarding the effectiveness of mindfulness-based interventions in nursing education and palliative care preparation.
Data availability statement
The original contributions presented in this study are available within the manuscript. For additional inquiries, please contact the corresponding author.
Funding
The authors extend their appreciation to Prince Sattam Bin Abdulaziz University for funding this research (Project number: PSU/2025/03/37413).
Competing interests
The authors affirm that the methods employed in the data analyses are appropriately applied to the data within the study’s design and context, and the statistical findings have been accurately implemented and interpreted. Additionally, the authors agree to assume responsibility for verifying that the selected statistical approach is suitable and that it is conducted and interpreted correctly.
Ethical approval
Prince Sattam Bin Abdulaziz University IRB approved the study (SCBR/267/2025/). Electronic informed consent detailed voluntary participation, anonymity, withdrawal rights, and MBSR benefits/risks. Data remained encrypted on secure university servers for 5 years.
Open access
