Nursing students are constantly exposed to different stressors during their education and training, which may directly or indirectly hinder their education and performance. Clinical education has its own set of difficulties that might lead to stress among students . Clinical training stress impairs psychological well-being, which interferes with students’ learning, limits their academic performance and productivity, and increases suicidal thoughts and lowers their quality of life .
Many studies have shown that mindfulness reduces stress symptoms, enhances attention and cognitive skills, and promotes emotional balance [26, 27]. Therefore, utilizing a mindfulness-based approach to address the clinical and academic stressors of nursing students as they navigate the requirements of their nursing education may help them cope with stressors by improving their level of mindfulness awareness and attention.
According to the findings of the current study, more than three-quarters of the participants were female. This might be owing to due to Egyptians’ belief that nursing is a female-dominated profession, resulting in the admission of more women to nursing schools and faculties. The age of studied students ranged from 21 to 23 years. This is because this study was carried out among first-year Technical Institute of Nursing students, and this is a suitable age for them. This goes online with Dhanpal and Paul who revealed that the majority of the nursing students were females (80%), and their average age was 21 years . Also, an Egyptian study indicated that the majority of nursing students (81.2%) were female, and about two-thirds of them (66%) were between the ages of 21 and 23 .
The current study revealed that the most stressful events during clinical training among studied students were open wounds, seeing patients die, being unable to save specific patient lives, and performing cardiopulmonary resuscitation. It may be because students did not complete the prerequisite courses before beginning their clinical training, and they did not receive adequate preparation for clinical training. Additionally, those students are being exposed to a highly technological clinical environment for the first time. Their inexperience and limited professional skills prevent them from handling sophisticated technological equipment. In addition, they are afraid of making mistakes, and they lack confidence in their abilities to care for patients.
This is in agreement with an Egyptian study in which emergency undergraduate nursing students face a variety of stressors. They described seeing patients’ deaths, feeling overworked, and suffering trauma-related injuries were the most stressful events in their clinical experience . Similarly, Adriaenssens, de Gucht, and Maes’s study in the Netherland indicated that emergency nurses are exposed to many traumatic events. These events are commonly related to patients presenting with severe injuries, suicide, violent behavior, death of a patient, particularly a child, abuse from physicians, patients or family members, and resource exhaustion. These events also contribute to the development of PTSD when combined with what one would consider being routine nursing care .
In the same context, a study by Han and Yoo that was conducted in South Korea revealed that the most common traumatic events reported by emergency nurses were resuscitation attempts, child death, and physical/verbal violence .
The findings of this study indicated that the highest mean score of PTSS according to the Impact of Event Scale was a symptom of intrusion or re-experienced trauma, followed by symptoms related to avoidance and hyperarousal at the pre-intervention period. This was supported by the study of nursing interventions for PTSD, which revealed that PTSS appear sequentially, with intrusion symptoms appearing first, followed by avoidance behavior symptoms. Avoidance behavior typically leads to hyperarousal symptoms, including angry outbursts, difficulty falling asleep, hypervigilance, concentration problems, irresponsible behavior and carelessness, and excessive reactivity to unexpected loud noises .
This partially goes online with a Chinese study which revealed that in the emergency room, approximately 53.0% of the healthcare professionals reported having at least one PTSD criterion. Re-experiencing a traumatic event was the most prevalent PTSD symptom (45.1%), followed by hyperarousal (37.8%) and avoidance (35.1%) . This is contradictory with Machado’s study of secondary traumatic stress among emergency department nurses who revealed that arousal symptoms had the highest mean score of PTSD symptoms, followed by avoidance, while intrusion symptoms had the lowest mean score . Furthermore, an Egyptian study revealed that avoidance had the highest score in the three PTSS dimensions, followed by re-experiencing and hyperarousal .
The results of the current study confirmed the first hypothesis as more than one-third of the study sample experienced symptoms that suggested a diagnosis of PTSD, and about one-fifth of them had a partial diagnosis of PTSD at the pre-intervention period. This means that the level of PTSS was high among the study sample at the pre-intervention period. It might be because the studied students are still young and may be seeing critically ill patients for the first time. They lack the necessary experience to deal with these patients. Moreover, they may use highly technical equipment and may undertake procedures that could result in serious injury to their patients. Furthermore, discrepancies in stress perceptions across people are most likely due to differences in personal aspects such as coping abilities and level of companionship during clinical practice.
This is consistent with Asfour and Ramadan, who indicated that more than half of students they studied had a low (PTSS) score, while more than one-third had a high (PTSS) score. Nurse students might have a low (PTSS) score due to their clinical teachers closely observing, supervising, and supporting them in the clinical areas. The high (PTSS) scores of some students might be a result of individual differences among nursing students; students differ in their identification of stressors, particularly in the complex and rapidly changing healthcare environment of emergency departments and intensive care units .
Similarly, an Egyptian study indicated that the total PTSD score was high among 40% of the studied emergency medical trainees . Similarly, Carmassi et al.  found that emergency care personnel trainees are more likely to develop PTSD as a result of being exposed to a new environment, their young age, the lack of expertise in their field, and the added strain of academic evaluation. Additionally, the emergency nurses who worked with more traumatized and emergency patients were more likely to develop anxiety disorders, including PTSD, and the prevalence of PTSD was higher among nurses with less education and less work experience .
The second hypothesis was confirmed after implementing the mindfulness-based intervention because PTSS improved among the studied students. These improvements appear to be attributed to changes in intrusive thoughts and hyperarousal symptoms, rather than avoidance. The difference between the pre- and post-intervention periods was statistically significant. Moreover, the number of students who do not have PTSS has increased, and those who are fully diagnosed with PTSS have decreased at the post-intervention period. This improvement could be attributed to the effect of the mindfulness intervention. Perhaps, this is due to the fact that mindfulness improves awareness of the present moment. Awareness allows one to be more sensitive to emotions and thoughts in different situations, which may help in the early identification of stress . Early stress identification through improved self-awareness has been demonstrated to be effective for stress management in nursing students who practice mindfulness .
Increasing awareness predicts stronger perceived self-efficacy in dealing with daily stressful events since awareness expands the range of available responses. Furthermore, increasing awareness was claimed to improve an individual’s executive control, reducing the impact of perceived stress on mental health .
In addition, the present study results are in harmony with another study conducted in Canada which revealed that increased attention control or the ability to shift attention away from trauma-related stimuli and to remain in the present moment is thought to improve intrusive and hyperarousal symptoms. Mindfulness-based approaches may also reduce avoidance symptoms (by encouraging openness to new experiences), negative mood states, and cognitive changes (e.g., negative beliefs about oneself, the world, and others by enhancing nonjudgmental acceptance of current and past experiences) .
This is congruent with Kim et al.  who demonstrated that participating in an 8-week mindfulness-based exercise program was associated with a significant reduction in PTSD symptoms. As well, educational programs on PTSD helped emergency medical personnel who treat critically ill patients to be better equipped to cope with environmental factors that might contribute to behavioral disorders and recover faster .
The findings of this study indicated that there was a statistically significant negative correlation between PTSS and students’ age, which may be caused by inadequate clinical skills of young students to deal with critically ill patients. Increasing age may help students recognize their professional accountability for the job, and training for a long period helps them to predict possible circumstances that cause stress among nurses. This is in line with the Canadian study of Lavoie, Talbot, and Mathieu who showed that the prevalence of PTSD symptoms reduced with age, although exposure to traumatic experiences increased with years of nursing experience . In the same context, d'Ettorre et al.  found that young age, female gender, little job experience, and insufficiency of training were found to be associated with a high risk of PTSS. Additionally, an Egyptian study by Madian, Abdelaziz, and Ahmed reported significant differences between perceived stress levels and demographic variables, such as age and gender, among nursing students .
The present study’s multivariate analysis identified that the number of training hours was a positive predictor of PTSS. Perhaps this is because with an increasing number of clinical training, the students are more exposed to traumatic experiences. This is supported by Vance et al.  in the USA who showed that a higher number of working hours was the only work-related factor that associated significantly with trauma exposure. This is because working for longer hours causes more stress and presents a longer time for exposure to work-related trauma . Similarly, Mitrović and Romić found that symptoms of PTSD vary according to educational level, working duration, job position, and gender . Moreover, work experience and the number of working hours were predictors of secondary traumatic stress symptoms .
Mother occupation and education were negative predictors of PTSS as indicated in the multivariate analysis of this study. It may be because the educated mother is open-minded, uses a raising style that enhances coping skills in her children, provides them with social support, and teaches them how to cope with stressful situations. This is congruent with an Egyptian study in which education and occupation of the nursing students’ mothers were strongly correlated with their stress level, as the students whose mothers are housewives and less educated experience more stress than those whose mothers are working and highly educated. Furthermore, it was shown that better education of mothers and their employment outside the home, as well as good adaptability and management of stress, resulted in reduced stress on their daughters .
Similarly, Kalavathi, Indira, and Rejeswari showed that there was a statistically significant relationship between the stress level among first-year BSc nursing students and their sociodemographic characteristics, such as their father’s and mother’s educational backgrounds . Clinical perceived stress was lower among students whose parents had an academic education, which is not surprising given that talking to parents can be beneficial for managing clinical stress. It is anticipated that educated parents provide better effective support than less educated parents .
The result of the current study indicated that there was an improvement in all dimensions of mindfulness at the post-intervention period. As well as, the total level of mindfulness has been improved as more than one-third of the study participants have good mindfulness after implementing the intervention. The difference was statistically significant in all areas except for non-judging. This finding was supported by a study in which a mindfulness-based meditation program was applied to nursing students, the mindfulness levels improved following the program . In another study, students’ levels of awareness and acceptance were positively improved by a mindfulness-based intervention .
In agreement with Dearholt’s study of improving nurse well-being through a mindfulness-based education strategy, it is indicated that mindfulness-based education programs improve skills and knowledge for inexperienced nurses, enabling them to practice mindfulness in a short time. At the end of the program, all participants reported using meditation as a form of mindfulness practice . In the same context, Yuksel and Bahadir Yilmaz’s study in Turkey revealed that group mindfulness-based cognitive therapy programs had a positive effect on students’ mindful attention awareness levels .
The results of this study contradict those of de Vibe et al.  in a study conducted with medical and psychology students who found that mindfulness-based stress reduction education had no effect on the students’ levels of mindfulness .
The results of the present study demonstrated that mindfulness was a negative predictor of PTSS. This may be because the acting with awareness dimension of mindfulness allows for the identification of signs of stress, promotes self-regulation capacity, and supports adaptive responsiveness to distressing and negative situations. As a result, persons with a greater capability to behave with awareness may be able to raise the awareness of low-level stress-related symptoms, thereby increasing access to coping resources and buffering against the harmful effects of stress . Similarly, this was supported by the study of Gibert et al. (2021) who found that higher levels of mindfulness were related to lower levels of PTSD symptoms [56, 57].