Psychological Empowerment as a Moderator in the Pathway from Attitudes Toward Care of the Dying to Palliative Care Competency among Nursing Students: A Serial Mediation Model of Self-efficacy and Resilience

Psychological Empowerment as a Moderator in the Pathway from Attitudes Toward Care of the Dying to Palliative Care Competency among Nursing Students: A Serial Mediation Model of Self-efficacy and 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 Psychological Empowerment as a Moderator in the Pathway from Attitudes Toward Care of the Dying to Palliative Care Competency among Nursing Students: A Serial Mediation Model of Self-efficacy and Resilience HUI LIN, Zhaojie Fu, Jinyang Zhao, Xia Xu, Li Ba, Xiaoli Hu This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8716003/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Background As the global population continues to age rapidly, the growing demand for end-of-life care highlights the urgent need to enhance nursing students' palliative care competencies. Attitudes toward care of the dying constitute a critical cognitive and emotional foundation that directly influences nursing students’ willingness to engage in palliative care practice. However, the underlying mechanisms through which these attitudes affect palliative care competencies remain unclear. Research aim This study aims to examine a moderated chain mediation model to investigate the sequential mediating role of attitudes toward care of the dying on the influence of self-efficacy and psychological resilience on nursing students' palliative care competence, and to examine the moderating effect of psychological empowerment between attitudes toward care of the dying and self-efficacy. Research design A cross-sectional survey design. Participants completed an online questionnaire. The questionnaire incorporated the Frommelt Attitudes Toward Care of the Dying Scale, Psychological Empowerment Scale, Palliative Care Self-Efficacy Scale, Psychological Resilience Scale, and Palliative Care Competence Scale to assess nursing students' professional attitudes toward end-of-life care, psychological empowerment, palliative care self-efficacy, psychological resilience, and palliative care competence. Participants and research context This study recruited 996 nursing interns from 42 teaching hospitals across China. Ethical considerations This study was approved by the Ethics Committee of Shandong Xiehe University. All participants signed informed consent forms. Results Attitudes toward care of the dying had a significant positive effect on palliative care competence (β = 0.594). Psychological empowerment demonstrated a significant moderating effect on the relationship between attitudes toward the care of the dying and self-efficacy (β = 0.076; P = 0.002). Self-efficacy and psychological resilience functioned as sequential mediators, with a chained indirect effect value of 0.045. The indirect effect accounted for 60.1%. Conclusion Attitudes toward care of the dying enhance nursing students' palliative care competencies through multiple pathways. Psychological empowerment functioning as a moderating variable enhances the mediating effects of self-efficacy and psychological resilience, thereby facilitating enhancement in nursing students' palliative care competencies. Clinical trial number not applicable. Palliative Care Competency Attitudes toward Care of the Dying Psychological Empowerment Serial Mediation Self-efficacy Resilience Nursing Students Figures Figure 1 Introduction With the rapid aging of the global population [ 1 ], the number of patients in the terminal phase is increasing [ 2 ], hence intensifying the urgent need for high-quality palliative care services in healthcare systems [ 3 ]. Palliative care competency, the integrated manifestation of knowledge, skills, and attitudes essential for end-of-life care delivery, has become a core objective in nursing education [ 4 ]. However, existing research demonstrates that nursing students, as the future backbone of the nursing workforce, continue to exhibit inadequate knowledge and practical skills in palliative care, hindering their ability to effectively meet clinical end-of-life care demands [ 5 , 6 ]. The professional attitude of healthcare providers regarding end-of-life care, particularly their cognitive and emotional perspective toward death, the dying process, and their caregiving capabilities[ 7 ]., is a crucial factor influencing the development of their palliative care competencies [ 8 – 10 ]. A positive end-of-life care attitude correlates with lower death anxiety and higher levels of professional identity [ 11 – 13 ], signifying that such attitudes function as essential psychological resources for nursing students facing terminal situations. Although the association between attitudes toward care and palliative care competence is widely acknowledged [ 14 ], the underlying psychological mechanisms that facilitate the translation of positive attitudes into palliative care competence remain unclear. Specifically, it is unclear which psychological variables mediate this process, whether a chained mediation pathway exists, and which resource conditions may moderate these translational mechanisms. Addressing these questions is essential for advancing nursing education from the “cognitive guidance” model to the “mechanism-based intervention.” This study adopted the Resource Conservation Theory (RCT) as its research framework to elucidate the previously indicated conversion mechanism [ 15 ]. This theory asserts that individuals endeavor to obtain, maintain, and enhance valuable resources. The aggregation of resources can create a “value-added spiral,” enhancing an individual's adaptive capacity and overall performance in managing stressful situations [ 16 ]. A positive attitude toward end-of-life care constitutes a cognitive-emotional resource [ 17 ]. The study hypothesizes that this resource may enhance nursing students' self-efficacy in palliative care, specifically, their confidence in executing tasks such as end-of-life communication and symptom management [ 18 ], which can foster the development of psychological resilience, characterized as the ability for rapid adaptation and prompt recovery when facing adversity [ 19 ]. This forms a resource enhancement chain from self-efficacy to psychological resilience, enhancing their palliative care competencies. Furthermore, psychological empowerment—characterized by an individual's perceived work meaning, autonomy, and self-efficacy [ 20 ]—may function as a stable internal psychological resource that plays a crucial boundary-modulating role within this mechanism. Resource conservation theory posits that individuals possessing abundant resources are more inclined to acquire additional resources [ 15 , 16 ]. Therefore, nursing students with high psychological empowerment may be more equipped to transform positive end-of-life care into steadfast professional confidence, thereby more effectively initiating subsequent resource-gain processes. Although previous studies have investigated the effect of attitudes toward end-of-life care on palliative care competence, empirical evidence remains insufficient regarding the specific mechanism by which this influence occurs through the sequential mediating pathway of “self-efficacy → psychological resilience” and the moderating role of psychological empowerment at the initial stage of this pathway. Consequently, this study aimed to develop and evaluate a moderated sequential mediation model to investigate the influence of nursing students' attitudes toward care of the dying on palliative care competence, mediated sequentially by self-efficacy and psychological resilience, and to determine whether psychological empowerment moderates the association between “attitudes toward care of the dying → self-efficacy.” By clarifying these psychological mechanisms, the study seeks to provide theoretical and empirical foundations for developing more targeted and mechanism-based nursing education intervention strategies. Aim This study aims to examine the correlations among nursing students' attitudes toward care of the dying, psychological empowerment, palliative care self-efficacy, psychological resilience, and palliative care competence. Specifically, this study hypothesizes that nursing students' attitudes toward care of the dying improve palliative care competence through the mediating effects of self-efficacy and psychological resilience, whereas psychological empowerment moderates the relationship between these attitudes and self-efficacy. The primary aim is to clarify the fundamental psychological mechanisms by evaluating this model. Methods Design and setting This multicenter cross-sectional study enrolled nursing interns from 42 tertiary-level Class A hospitals across China between September and December 2025. Participants and sampling This study employed convenience sampling to select participants. The inclusion criteria were as follows: (a) Full-time nursing students currently undergoing clinical internships; (b) full-time nursing students with ≥ 3 months in the internship program; (c) full-time nursing students who provided informed consent and volunteered to participate in this study. The exclusion criteria were as follows: (a) Participants on academic leave or those with interrupted internships; (b) full-time nursing students on internships without critical care, emergency, or oncology department rotations. To ensure statistical power, G*Power 3.1 software [ 21 ] was utilized for pre-test calculations. Based on preliminary research, a multiple linear regression model was selected with a medium effect size (f² = 0.15), α = 0.05, and a statistical power = 0.80, resulting in a minimum required sample size of 129 participants. Additionally, following psychometric guidelines [ 22 ], to ensure the validity of factor analysis, the minimum sample size was set at 10 times the number of items in the scale with the largest number of items. The Frommelt Attitudes Toward Care of the Dying (FATCOD) scale, which contained 30 items, therefore required a minimum sample size of 300 participants. Electronic questionnaires were distributed to nursing students across 42 selected tertiary hospitals in China after obtaining informed consent. In total, 996 valid questionnaires were collected. Post-hoc sample size analysis indicated moderate effect detection, with the study's statistical power exceeding 0.99, which is significantly higher than the conventional standard of 0.80 [ 23 ], thereby providing robust support for subsequent data analyses. Measures Instruments Demographic information. The study collected sociodemographic data from nursing students, including demographic data (age, gender, geographic origin, and only child status); educational and professional history (highest level of education, reasons for choosing nursing major, and willingness to care for terminally ill patients); cultural and personal experiences (religious beliefs, hospice care education background, experience in caring for terminal patients and their families); and bereavement experiences (bereavement within the past year and current circumstance). Frommelt Attitudes Toward Care of Dying Scale (FATCOD Scale) . Developed by Frommelt in 1991 [ 24 ], the Chinese version has been widely utilized and verified among nursing students in China [ 25 ]. The scale comprises 30 items, each scored on a 5-point Likert scale ranging from “Strongly Disagree” (1 point) to “Strongly Agree” (5 points). Total scores range from 30 to 150 points, with higher scores signifying more positive attitudes toward care of the dying among nursing students. The scale exhibits a Cronbach's α coefficient of 0.983. Psychological Empowerment Scale (PES). This scale was developed by Spreitzer in 1995 [ 26 ]. Chinese scholars, including Li Chao et al., translated it into Chinese [ 27 ]. The scale has exhibited good construct validity and reliability among Chinese nursing students [ 28 ]. It comprises four dimensions: work meaning, work autonomy, work self-efficacy, and work influence, totaling 12 items. Each item uses a 5-point Likert scale ranging from “strongly disagree” to “strongly agree,” scored 1–5, respectively. The total score ranges from 12 to 60, with higher scores signifying greater psychological empowerment. The Cronbach's α coefficient for the PES is 0.959. Elderly Palliative Care Self-Efficacy Scale (EPCS) . Developed by Chinese scholars, including Zou Zhijie [ 29 ], this 21-item scale utilizes a 1–5 point rating system ranging from “Strongly Disagree” to “Strongly Agree,” scored as 1–5 points, respectively, yielding a total score range of 21–105 points. Higher scores signify stronger self-efficacy in palliative care among participants. The overall Cronbach’s α coefficient for this scale is 0.972. Psychological Resilience Scale (CD-RISC) . This scale was created and utilized by Kenneth M. Connor and Jonathan R. T. Davidson in 2001 [ 30 ]. This study utilized the Chinese version of the Connor-Davidson Resilience Scale (CD-RISC) for assessment [ 31 ]. The scale has demonstrated good construct validity and reliability among Chinese nursing students [ 32 ]. The scale comprises three dimensions and 25 items, rated on a five-point Likert scale ranging from 1 (“Never”) to 5 (“Always”), resulting in total scores between 25 and 125. Higher scores signify enhanced psychological resilience. The Chinese version exhibits an internal consistency coefficient of 0.982. Palliative Care Competency Assessment Questionnaire (PCCQ) . Developed by a Chinese scholar, Zhao Jing [ 33 ], this questionnaire is the sole palliative care competency assessment tool in China that has been carefully validated for reliability and validity and specifically designed for nursing students. Consequently, although initially designed for undergraduate nursing students, this study was extended to encompass nursing students across all academic levels. The questionnaire comprises three dimensions: effective care skills, cultural and ethical values, and interprofessional teamwork. The scale has 16 items scored using a 5-point Likert scale, with 1 signifying no competency and 5 denoting full competency. The total score ranges from 16 to 80 points. The Cronbach’s α coefficient for this scale is 0.974. Data collection The online survey was administered using Wenjuanxing, a popular Chinese online survey platform. Researchers provided comprehensive explanations to the heads of the Education and Training Departments at each internship hospital regarding the study's aims, significance, survey process, and confidentiality principles. After the nursing students signed the informed consent forms, the internship team leaders at each hospital forwarded the survey poster to their respective internship group WeChat or QQ groups. The survey was anonymized and included a standardized introductory statement to clearly explain the research significance and process to participating nursing students. To ensure data integrity, researchers mandated a minimum completion duration of 5 min. Questionnaires were considered invalid if all answer options were identical or if the completion duration was less than 5 min. After screening, 36 invalid questionnaires were excluded, yielding 996 valid responses. The effective response rate reached 96.51%. Statistical analysis The Statistical Package for the Social Sciences software (SPSS; version 26.0) was utilized for data analysis. Continuous variables meeting normal distribution are expressed as mean ± standard deviation (M ± SD); categorical variables are presented as frequency and percentage (*n*, %). Pearson correlation analysis was utilized to examine correlations among primary variables. To test the moderated chained mediation model, the PROCESS macro (version 3.4, Model 6) in SPSS was utilized for analysis. PROCESS utilizes a path analysis framework based on ordinary least squares regression. The importance of all indirect effects and conditional indirect effects in the model was evaluated utilizing nonparametric percentile bootstrap sampling, repeated 5000 times, with 95% bias-corrected confidence intervals reported. Effects were considered statistically significant if their confidence intervals excluded zero. Ethical considerations This study was approved by the Ethics Review Committee of Shandong Xiehe University (No.: LLSC-KY03-2005038). All research procedures complied with the ethical principles established by the Declaration of Helsinki [ 34 ]. Results Demographic characteristics of the participants The study included 996 nursing students. The results revealed no statistically significant differences in palliative care competency scores based on gender or whether students were only children (all P > 0.05). Significant differences were observed in the subsequent variables: age ( P = 0.019), place of origin ( P = 0.003), highest educational attainment, motivation for choosing the nursing major, willingness to care for terminally ill patients, religious beliefs, exposure to death education, previous experience caring for terminally ill patients, bereavement experience within the past year, and current family status (all P < 0.001). Older students from urban areas possessed higher educational qualifications, chose their major based on personal motivation, demonstrated a willingness to care for terminally ill patients, held religious beliefs, had received death-related education, had previous experience caring for terminally ill patients, or had experienced bereavement within the past year, and demonstrated higher levels of palliative care competency. Table 1 presents detailed results. Descriptive analysis Table 2 presents the specific scores. The mean score for nursing students’ attitudes toward care of the dying (FATCOD) was 89.90 ± 22.06. Psychological empowerment (PES) had a mean score of 35.97 ± 9.00. The mean score for palliative care self-efficacy (EPCS) was 63.12 ± 15.13. Psychological resilience had a mean score of 74.88 ± 18.88. The mean palliative care competency score was 47.93 ± 12.24. Correlation analysis Significant positive correlations were observed among all major variables ( P < 0.01; Table 3 ). Nursing students' attitudes toward care of the dying exhibited a significant positive correlation with psychological empowerment (r = 0.170), with stronger correlations observed for self-efficacy (r = 0.541), psychological resilience (r = 0.592), and palliative care competence (r = 0.607). Self-efficacy demonstrated strong positive correlations with psychological resilience (r = 0.616) and palliative care competence (r = 0.597). Psychological resilience exhibited the strongest correlation with palliative care competence (r = 0.708). Common method bias test To assess potential common method bias, several procedural controls were implemented during data collection, including assurances of anonymity and confidentiality, randomizing item order, and the inclusion of reverse-scored items. During statistical analysis, latent method factor techniques were applied. The results indicated that the inclusion of a method factor led to only minimal changes in model fit indices (ΔCFI = 0.008, ΔTLI = 0.005). Additionally, the method factor accounted for 12.7% of the variance, which was well below the 40% critical threshold [ 35 ]. These findings indicate that common method bias did not pose a significant threat to the validity of the data. Mediation and Moderating Effects A moderated chain mediation model was developed, using nursing students' attitudes toward care of the dying as the independent variable, palliative care competence as the dependent variable, self-efficacy and psychological resilience as chain mediators, and psychological empowerment as the moderator. Model evaluation utilized the bootstrap method with 5,000 repeated samples. The results demonstrated that all hypothesized paths achieved statistical significance (Table 4 ). Nursing students' attitudes toward care of the dying directly and positively predicted palliative care competence (β = 0.237, P < 0.001) and indirectly enhanced competence through an increase in self-efficacy (β = 0.507, P < 0.001) and psychological resilience (β = 0.365, P < 0.001). Self-efficacy positively predicted psychological resilience (β = 0.420, P < 0.001) and palliative care competence (β = 0.191, P < 0.001). Additionally, psychological resilience directly and positively predicted palliative care competence (β = 0.450, P < 0.001). Moderation analysis further revealed that psychological empowerment significantly moderated the relationship between nursing students' attitudes toward care of the dying and self-efficacy (interaction term β = 0.076, P = 0.002) (Table 5 ). All model fit indices fell within acceptable ranges. Figure 1 depicts the mediation and effect model. Decomposition of Total, Direct, and Indirect Effects Table 6 presents the decomposition of the effect of nursing students' attitudes toward care of the dying on palliative care competence. The total effect value was 0.594, comprising a direct effect of 0.237 (39.9%) and an indirect effect of 0.357 (60.1%). The indirect effect was mediated through four pathways: (1) “Attitudes toward care of the dying → Self-Efficacy → Palliative Care Competence” pathway, effect size 0.046; (2) “Attitudes toward care of the dying → Psychological Resilience → Palliative Care Competence” pathway, effect size 0.077; (3) “Attitudes toward care of the dying → Self-Efficacy → Psychological Resilience → Palliative Care Competence” chained mediation pathway, effect size 0.045; (4) “Attitudes toward care of the dying → Self-Efficacy → Psychological Resilience” pathway, effect size 0.100. The confidence intervals for all indirect pathways excluded zero, signifying significant mediating effects. Furthermore, psychological resilience significantly mediated the association between self-efficacy and palliative care competence, with an effect size of 0.089. Table 1 Demographic characteristics and univariate analysis of variables related to PCCQ (n = 996) Variable n (%) M ± SD t/F P Age (years) t = 3.987 0.019 18–20 240 (25.1) 52.83 ± 8.56 21–22 612 (61.4) 49.37 ± 7.82 23–24 144 (14.5) 54.12 ± 9.13 Gender t = 1.873 0.061 Male 194 (19.5) 49.72 ± 8.35 Female 802 (80.5) 51.26 ± 8.18 Geographic Origin t = 2.937 0.003 Rural 770 (77.3) 50.17 ± 8.32 Urban 226 (22.7) 51.83 ± 8.05 Only-child Status t = 1.246 1.246 Yes 178 (17.9) 50.52 ± 8.27 No 818 (82.1) 51.18 ± 8.19 Highest Education Level F = 7.563 < 0.001 Diploma 360 (36.1) 53.51 ± 7.93 Bachelor’s degree 632 (63.5) 53.51 ± 7.93 Master's Students 4 (0.4) 55.38 ± 7.62 Choice of Nursing Major t = 5.328 < 0.001 Based on my own 778 (78.1) 51.63 ± 8.02 Not based on my own 218 (21.9) 48.27 ± 8.56 Willingness to Care for Terminally Ill Patients t = 9.873 < 0.001 Yes 730 (73.3) 52.87 ± 7.69 No 266 (26.7) 47.32 ± 8.85 Religious Affiliation F = 13.892 < 0.001 None 962 (96.6) 50.12 ± 8.25 Buddhism 20 (2) 53.76 ± 7.58 Christianity 4 (0.4) 54.21 ± 7.36 Others 10 (1.0) 52.35 ± 8.11 Previous Education on End-of-Life Care F = 48.915 < 0.001 Completed a dedicated course on death 462 (46.4) 56.32 ± 6.85 Covered related content within other courses 440 (44.2) 51.28 ± 7.63 Never encountered any knowledge on death 94 (9.4) 46.05 ± 8.27 Prior Experience in Caring for Terminal Patients and Their Families t = 13.268 < 0.001 Yes 304 (30.5) 53.17 ± 7.52 No 692 (69.5) 46.05 ± 8.27 Experience of Bereavement within the Past Year F = 8.973 < 0.001 Lost one closely related person 284 (28.5) 52.83 ± 7.65 Lost an immediate family member 50 (5) 53.56 ± 7.42 Lost a non-immediate family member 56 (5.6) 50.12 ± 8.03 Lost multiple closely related persons 46 (4.6) 54.27 ± 7.18 No bereavement experience 560 (56.2) 47.69 ± 8.35 Current Circumstance F = 11.476 < 0.001 No bereavement experience 794 (79.7) 49.23 ± 8.21 Recently experienced the death of an immediate family member 170 (17.1) 55.12 ± 6.93 Currently have an immediate family member in a terminal stage 32 (3.2) 53.76 ± 7.28 Table 2 Descriptive results for FATCOD-B, PES, EPCS, CD-RISC, and PCCQ (n = 996) Variables Scores (M ± SD) Boot LLCI Boot ULCI FATCOD 89.90 ± 22.06 88.53 91.27 PES 35.97 ± 9.00 35.41 36.53 EPCS 63.12 ± 15.13 62.18 64.06 CD-RISC 74.88 ± 18.88 73.7 76.05 PCCQ 47.93 ± 12.24 47.17 48.69 Note: M, mean; SD, standard deviation; FATCOD, Frommelt Attitudes Toward Care of the Dying Scale; PES, Psychological Empowerment Scale; EPCS, End-of-life Professional Caregiver Survey; CD-RISC, Connor-Davidson Resilience Scale; PCCQ, Palliative Care Competence Questionnaire. Table 3 Multiple stepwise linear regression analysis of variables related to PCCQ Variables FATCOD PES EPCS CD-RISC PCCQ FATCOD 1 PES .170* 1 EPCS .541* .268* 1 CD-RISC .592* .111* .616* 1 PCCQ .607* .075* .597* .708* 1 Note:* indicates significance at the 0.01 level. Table 4 Mediation analysis between FATCOD-B, EPCS, CD-RISC, and PCCQ Pathway β SE t P FATCOD - EPCS 0.507 0.024 21.329 < .001 EPCS - CD-RISC 0.420 0.027 15.630 < .001 CD-RISC - PCCQ 0.450 0.029 15.787 < .001 FATCOD - CD-RISC 0.365 0.027 13.509 < .001 EPCS - CD-RISC 0.420 0.027 15.630 < .001 EPCS - PCCQ 0.191 0.028 6.913 < .001 FATCOD-B - PCCQ 0.237 0.027 8.828 < .001 Table 5 Results of Moderation Effect Analysis Pathway β S.E T P FATCOD-B - EPCS 0.507 0.024 21.329 0.000 PES - EPCS 0.190 0.026 7.379 0.000 PES - FATCOD-B - EPCS 0.076 0.026 2.963 0.002 Table 6 Total, direct, and indirect effects of FATCOD-B on PCCQ Variables Effect SE 95% CI P Percentage of effect (%) Total effect 0.594 0.021 0.559 ~ 0.627 0.000 ~ Direct effect 0.237 0.027 0.194 ~ 0.283 0.000 39.9 Indirect effect 0.357 0.018 0.327 ~ 0.387 0.000 60.1 FATCOD - CD-RISC - PCCQ 0.077 0.016 0.139 ~ 0.191 0.000 13.0 EPCS - CD-RISC - PCCQ 0.089 0.017 0.161 ~ 0.218 0.000 15.0 FATCOD - EPCS - PCCQ 0.046 0.015 0.072 ~ 0.121 0.000 7.7 FATCOD - EPCS - CD-RISC - PCCQ 0.045 0.009 0.081 ~ 0.112 0.000 7.6 FATCOD - EPCS - CD-RISC 0.100 0.017 0.186 ~ 0.242 0.000 16.9 Discussion The study confirmed the theoretical hypothesis, illustrating that psychological empowerment, palliative care self-efficacy, and psychological resilience constitute a moderated sequential mediating model between nursing students' professional attitudes toward end-of-life care and their palliative care competencies. Nursing students' attitudes toward care of the dying directly enhance their palliative care competencies and indirectly foster these competencies by activating sequential psychological resources—specifically, palliative care self-efficacy and psychological resilience. Simultaneously, psychological empowerment, as an internal resource, positively moderates the activation effect of professional attitudes on palliative care self-efficacy, indicating that educational outcomes differ based on students' psychological empowerment. Current Status and Implications of Nursing Students' Palliative Care Competency This study revealed that nursing students' palliative care competency scores (47.93 ± 12.24) were similar to findings from multiple domestic surveys of nursing student cohorts [ 36 – 37 ], but markedly lower than levels reported by clinical nurses [ 38 ]. These disparities highlight a significant “competency chasm” persisting between nursing students and qualified palliative care practitioners. Conventional nursing education frequently prioritizes knowledge transmission and skill acquisition [ 39 , 40 ], but cognitive input is insufficient for fostering robust professional competence in the highly emotionally intense domain of end-of-life care [ 6 ]. Findings reveal that competency discrepancies transcend numerical scores, being deeply rooted in the effective activation of psychological resource systems underpinning competency development, which are adequately activated and cultivated. Resource-Enhancing Spiral Effect of the Core Mediator “Attitudes toward care of the dying → Self-Efficacy → Psychological Resilience” One of the core findings of this study is the marked chain-mediated pathway from “self-efficacy → psychological resilience.” This pathway is comprehensively explained through the perspective of the conservation of resources theory [ 15 , 16 ]. A positive attitude toward the care of the dying constitutes a valuable cognitive-emotional resource. When nursing students hold such an attitude, they are more likely to perceive end-of-life care as meaningful professional work rather than a stressful task, thereby initiating a resource-enhancing process. First, this attitudinal resource is translated into palliative care self-efficacy. According to social cognitive theory, self-efficacy functions as a central motivational mechanism for transforming knowledge into action [ 18 ]. Herein, professional attitudes toward end-of-life care significantly predicted palliative care self-efficacy (β = 0.507), consistent with the perspective of Petrongolo et al. (2021) [ 41 , 42 ] that positive cognitive appraisals of end-of-life care provide a foundation for coping with related stressors. The “mastery experiences” acquired by nursing students through simulation training, role-playing, and reflective practice represent effective pathways for strengthening palliative care self-efficacy belief [ 43 ]. Second, high self-efficacy further promotes the development of more trait-like psychological resilience. This effect (β = 0.420) reflects a progression from situational confidence (“I can handle this specific challenge”) to a broader and more stable psychological trait (“I can recover from various adversities”). When nursing students with high self-efficacy encounter end-of-life challenges, repeated experiences of successful emotional regulation and effective communication serve as “resilience training,” helping them accumulate more stable and protective psychological capital [ 44 , 45 ]. These findings are consistent with those of Liang's[ 44 ], indicating that confidence in managing specific occupational stressors serves as a critical catalyst for the cultivation of broad psychological resilience. Moderating Role of Psychological Empowerment in the Relationship Between Attitudes Toward Care of the Dying and Self-Efficacy This study confirmed the moderating influence of psychological empowerment. Nursing students with elevated psychological empowerment exhibited a stronger promotion effect of attitudes toward care of the dying on palliative care self-efficacy (interaction term β = 0.076). This finding aligns with the fundamental tenet of resource conservation theory, which asserts that individuals possessing ample resources are more inclined to acquire additional resources [ 15 , 16 ]. Psychological empowerment, defined as an individual's impression of work significance, autonomy, and self-efficacy [ 20 ], constitutes a stable reservoir of internal resources. Studies demonstrate that nursing students with elevated psychological empowerment exhibit more proactive and intrinsically driven learning behaviors. They internalize end-of-life care attitudes as “my work is meaningful, and I can make a positive impact,” promoting deep role identification [ 46 ]. This enables them to more efficiently transform positive attitudes toward care of the dying into robust professional confidence. Conversely, nursing students with low empowerment may struggle to translate positive attitudes into strong action beliefs due to occupational alienation or feelings of helplessness [ 47 ]. This elucidates why identical educational treatments produce varying outcomes across different students and highlights the need for proactive attention to enhance students' psychological empowerment in educational design to optimize the benefits of educational investment. Constructing a Moderated Mediated Model to Achieve Transformation from Knowledge Transmission to Resource Cultivation The moderated chain-mediated model developed in this study provides a dynamic “resource-cognition-trait-competence” framework for understanding the development of palliative care competencies. This model demonstrates that developing palliative care professional competence transcends the mere accumulation of knowledge. The process commences with an individual's resource foundation—psychological empowerment—and advances through stimulating situational cognitive motivation, namely self-efficacy [ 48 ]. This process subsequently internalizes into stable psychological traits, particularly psychological resilience, integrating into comprehensive professional performance—palliative care competence—as a coherent psychological transformation. This framework holds significant implications. It advocates for a transformation in nursing education from “what we teach” to “what students internalize and how they internalize it.” Educators' duties should evolve from knowledge transmitters to catalysts and integrators of psychological resources. Practical Implications and Educational Recommendations This study offers insights into the psychological development mechanisms of nursing students' palliative care competencies. The findings offer the following insights for nursing educators and clinical administrators: Optimizing Curriculum Design. Developing an integrated teaching design combining “empowerment-experience-reflection.” Before palliative care-related courses, students' psychological empowerment should be enhanced through narrative medicine and professional value seminars, laying a resource foundation for future learning. Improving Teaching Methods. Extensively employing high-fidelity end-of-life scenario simulations, standardized patient exercises, and reflective narrative writing to facilitate “mastery experiences” [ 49 , 50 ]. The curriculum material includes symptom management, end-of-life communication, family support, ethical decision-making, and spiritual care scenarios [ 51 ], aimed at fostering self-efficacy. Building Support Systems. Implementing support mechanisms. Identifying nursing students exhibiting low psychological empowerment and self-efficacy through pre-course assessments, offering organized peer support, graduated skill training, and prompting positive feedback to facilitate completion. Enhancing Clinical Internships. During clinical rotations, supervised, structured exposure should be arranged for terminally ill patients, and nursing students should be guided in reflective discussions to enhance psychological resilience through practical experience [ 52 ]. Research Limitations and Future Directions First, the cross-sectional design limited the strength of causal inference. Future studies should utilize longitudinal tracking or experimental interventions to better validate the causal direction of the model. Second, all data were derived from nursing students' subjective self-reports, which may introduce common method bias. Future research could integrate multi-source data, including third-party evaluations and objective behavioral observations, to enable a more comprehensive analysis. Finally, the selected samples were exclusively drawn from Chinese teaching hospitals, and the generalizability of these findings to other cultural contexts remains to be established. Furthermore, future research should examine potential mediators, including empathy and professional identity, or examine moderating variables, including social support and organizational climate, to further refine this proposed psychological mechanism model. Conclusion The study demonstrated that nursing students' palliative care competence is influenced by their attitudes toward care of the dying, psychological empowerment, palliative care self-efficacy, and psychological resilience, hence developing a moderated chain-sequence mediation model. A positive attitude toward care of the dying indirectly enhances palliative care competency by fostering a resource-enhancing chain from self-efficacy in palliative care to psychological resilience. Psychological empowerment, as a key internal resource, moderates the initial stage of transforming attitudes toward care of the dying into confidence. The study suggests that palliative care education should extend beyond the mere transmission of knowledge and skills. Instead, it should cultivate an ecosystem that systematically enhances nursing students’ psychological resources, fostering their self-efficacy and psychological resilience. This approach facilitates the effective transformation from cognition to competency, thereby optimizing educational outcomes. Future educational practices should account for individual differences in students' psychological resources. By implementing empowerment-oriented curriculum design, student-centered teaching strategies, and tiered clinical placement arrangements, the sustained development of professional competence can be effectively promoted. Abbreviations FATCOD, Frommelt Attitudes Toward Care of the Dying Scale; PES, Psychological Empowerment Scale; EPCS, End-of-life Professional Caregiver Survey; CD-RISC, Connor-Davidson Resilience Scale; PCCQ, Palliative Care Competence Questionnaire. Declarations Acknowledgements We extend our gratitude to all nursing students and researchers who participated in this study. Author contributions Hui Lin: Conceptualization, Methodology, Investigation, Data Curation, Formal Analysis, Writing – Original Draft, Project Administration. Zhaojie Fu: Methodology, Investigation, Software, Formal Analysis, Visualization. Jinyang Zhao: Investigation, Formal Analysis, Visualization. Xia Xu: Conceptualization, Investigation, Methodology, Resources. Li Ba: Software, Validation, Data Curation. Xiaoli Hu: Conceptualization, Methodology, Supervision, Writing – Review & Editing. All authors have read and finally approved the submitted manuscript. Funding No funding Data availability To protect the privacy of research participants, the data supporting the conclusions of this study are not publicly stored. However, the data may be obtained from the corresponding author upon reasonable request and in compliance with the ethical protocol. Ethical approval and informed consent statements This study has been approved by the Ethics Committee of Shandong Xiehe University. All nursing students participating in the study have signed informed consent forms. Consent for publication Not applicable. Competing interests The authors declare no competing interests. Author details ¹ School of Nursing, Shandong Xiehe University, Jinan, Shandong Province, 250109, China 2 Department of Gastrointestinal Surgery, Affiliated Tumor Hospital of Shandong First Medical University, Jinan, Shandong Province, 250117, China 3 School of Nursing, Shandong Medical College, Jinan, Shandong Province, 250002, China References Chen C, Lim J, Koh J, Beard J, Rowe JW; Research Network on an Aging Society. A global analysis of adaptation to societal aging across low-, middle- and high-income countries using the Global Aging Society Index. Nat Aging. 2025;5(1):113-121. doi:10.1038/s43587-024-00772-3 Kukimoto Y RN, Maeda K PT, Yasui N RN, Nakamura M OT. 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A study on the relationship between spiritual care competency, ethical sensitivity, and empathy ability of palliative care nurses. J Nurs Adm. 2023;23(5):340-344. doi:10.3969/j.issn.1671-315x.2023.05.005. Malya RM, Mahande MJ, Urstad KH, Rogathi JJ, Bø B. Perception of simulation-based education among nursing and midwifery students in Tanzania: a qualitative study. Adv Simul (Lond). 2025;10(1):8. Published 2025 Mar 8. doi:10.1186/s41077-025-00339-1 Zhang S, Jiang J, Guan C, Li J, Hu X. Latent profile analysis of resilience and its relationship with social support, coping style, and death attitude among Chinese palliative nurses. BMC Nurs. 2025;25(1):2. Published 2025 Nov 29. doi:10.1186/s12912-025-04115-4 Petrongolo M, Toothaker R. Nursing students perceptions of death and dying: A descriptive quantitative study. Nurse Educ Today. 2021;104:104993. doi:10.1016/j.nedt.2021.104993 Pierce B, Allen J, Mortel TV. Undergraduate nursing students' self-efficacy in clinical teaching: a cross-sectional study. BMC Nurs. 2025;24(1):1519. Published 2025 Nov 27. doi:10.1186/s12912-025-04165-8 Gül Ş, Demir Karabulut S, Eren H, et al. Nursing Students' Experiences With Death and Terminal Patients During Clinical Education. Omega (Westport). 2022;85(3):628-649. doi:10.1177/0030222820950510 Liang SY. The relationship between physical exercise and occupational burnout among primary and secondary school young teachers [master's thesis]. Bohai University; 2023. doi:10.27190/d.cnki.gjzsc.2023.000698. Du Y, Qiao L, Dong L, Wan C, Yang X, Liu H. The relationship between self-efficacy, resilience, and job burnout in pediatric residents: a cross-sectional study in Western China. BMC Med Educ. 2024;24(1):787. Published 2024 Jul 23. doi:10.1186/s12909-024-05700-y Grealish A, Tai S, Hunter A, Emsley R, Murrells T, Morrison AP. Does empowerment mediate the effects of psychological factors on mental health, well-being, and recovery in young people?. Psychol Psychother. 2017;90(3):314-335. doi:10.1111/papt.12111 Moore SC, Ward KS. Nursing Student Perceptions of Structural Empowerment. Nurs Educ Perspect. 2017;38(1):32-33. doi:10.1097/01.NEP.0000000000000096 Zhou Y, Wu Y, Deng X, Wang S, Shi L. Analysis Model of the Influence of Self-Efficacy on Professional Toughness of Preschool Teachers under the Condition of Ensuring Children's Mental Health and Healthy Family Environment [retracted in: J Environ Public Health. 2023 Jun 28;2023:9786498. doi: 10.1155/2023/9786498.]. J Environ Public Health. 2022;2022:3737690. Published 2022 Sep 27. doi:10.1155/2022/3737690 Testoni I, Ronconi L, Orkibi H, et al. Death education for Palliative care: a european project for University students. BMC Palliat Care. 2023;22(1):47. Published 2023 Apr 21. doi:10.1186/s12904-023-01169-6 Clark SB, Lippe MP. Vicarious learning and communication self-efficacy: A pediatric end-of-life simulation for pre-licensure nursing students. J Prof Nurs. 2022;43:107-116. doi:10.1016/j.profnurs.2022.09.008 Pyke-Grimm KA, Fisher B, Haskamp A, Bell CJ, Newman AR. Providing Palliative and Hospice Care to Children, Adolescents and Young Adults with Cancer. Semin Oncol Nurs. 2021;37(3):151166. doi:10.1016/j.soncn.2021.151166 Jeffers S, Black S, Alessi G. End-of-Life Nursing Education in US Baccalaureate Degree Nursing Programs. Nurs Educ Perspect. 2022;43(6):E88-E90. doi:10.1097/01.NEP.0000000000000940 Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8716003","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":612320271,"identity":"727e26a4-3efa-47e1-a2b8-f423fd4ab895","order_by":0,"name":"HUI LIN","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA1klEQVRIiWNgGAWjYBACPmYGNgYGAxsGhgOMDcxgoQMEtLBBtKSRogWMGA6DVRKphZ332GOegvP2fDeSGx8XVDDI8d1IYPxcgNdhfOnGPAa3E2eeOdhsPOMMg7HkjQRm6Rl4tfCYSQO1JBgcb2yT5m1jSNxwIwEoSFjLOXuDw4ztv3n/MdQTq+UA4wagLcy8DQwJBsRokZxjkAz2izTPMQnDmWceAhl4tPDznzGTePPHDhhi6Q8/89TYyPMdTz74GZ8WdCABxIwNJGgYBaNgFIyCUYANAAB8rkKmF4IjnwAAAABJRU5ErkJggg==","orcid":"","institution":"Shandong Xiehe University","correspondingAuthor":true,"prefix":"","firstName":"HUI","middleName":"","lastName":"LIN","suffix":""},{"id":612320272,"identity":"7d2a2bb0-2e3d-486d-9e88-03782d857ed0","order_by":1,"name":"Zhaojie Fu","email":"","orcid":"","institution":"Shandong Xiehe University","correspondingAuthor":false,"prefix":"","firstName":"Zhaojie","middleName":"","lastName":"Fu","suffix":""},{"id":612320273,"identity":"5ea91bd0-7190-4ff6-89ab-6f25d21b71ee","order_by":2,"name":"Jinyang Zhao","email":"","orcid":"","institution":"Shandong Xiehe University","correspondingAuthor":false,"prefix":"","firstName":"Jinyang","middleName":"","lastName":"Zhao","suffix":""},{"id":612320274,"identity":"1374dee5-7aff-41b1-914f-20981b5a48b4","order_by":3,"name":"Xia Xu","email":"","orcid":"","institution":"Shandong Xiehe University","correspondingAuthor":false,"prefix":"","firstName":"Xia","middleName":"","lastName":"Xu","suffix":""},{"id":612320275,"identity":"19972ec8-794d-4e47-a2b4-645dd7a3cd6b","order_by":4,"name":"Li Ba","email":"","orcid":"","institution":"Shandong Xiehe University","correspondingAuthor":false,"prefix":"","firstName":"Li","middleName":"","lastName":"Ba","suffix":""},{"id":612320276,"identity":"c9b131ec-2b7e-4348-8fa2-4309fd40fb4d","order_by":5,"name":"Xiaoli Hu","email":"","orcid":"","institution":"Shandong Medical College","correspondingAuthor":false,"prefix":"","firstName":"Xiaoli","middleName":"","lastName":"Hu","suffix":""}],"badges":[],"createdAt":"2026-01-28 03:55:13","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8716003/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8716003/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":105641257,"identity":"e799e551-dd8f-47a6-b1ca-cf605be64ea9","added_by":"auto","created_at":"2026-03-28 16:27:53","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":162901,"visible":true,"origin":"","legend":"\u003cp\u003eModerated serial mediation model of FATCOD, PES, EPCS, CD-RISC, and PCCQamong nursing students.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-8716003/v1/e9df5952b54e0e07b1571b3c.png"},{"id":105728913,"identity":"301fdbce-03ec-4101-a7e5-369974491fff","added_by":"auto","created_at":"2026-03-30 11:12:58","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1719776,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8716003/v1/36503f31-8cc6-4efc-9641-f93938ec83e9.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Psychological Empowerment as a Moderator in the Pathway from Attitudes Toward Care of the Dying to Palliative Care Competency among Nursing Students: A Serial Mediation Model of Self-efficacy and Resilience","fulltext":[{"header":"Introduction","content":"\u003cp\u003eWith the rapid aging of the global population [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e], the number of patients in the terminal phase is increasing [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e], hence intensifying the urgent need for high-quality palliative care services in healthcare systems [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Palliative care competency, the integrated manifestation of knowledge, skills, and attitudes essential for end-of-life care delivery, has become a core objective in nursing education [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. However, existing research demonstrates that nursing students, as the future backbone of the nursing workforce, continue to exhibit inadequate knowledge and practical skills in palliative care, hindering their ability to effectively meet clinical end-of-life care demands [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe professional attitude of healthcare providers regarding end-of-life care, particularly their cognitive and emotional perspective toward death, the dying process, and their caregiving capabilities[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]., is a crucial factor influencing the development of their palliative care competencies [\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. A positive end-of-life care attitude correlates with lower death anxiety and higher levels of professional identity [\u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], signifying that such attitudes function as essential psychological resources for nursing students facing terminal situations. Although the association between attitudes toward care and palliative care competence is widely acknowledged [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], the underlying psychological mechanisms that facilitate the translation of positive attitudes into palliative care competence remain unclear. Specifically, it is unclear which psychological variables mediate this process, whether a chained mediation pathway exists, and which resource conditions may moderate these translational mechanisms. Addressing these questions is essential for advancing nursing education from the \u0026ldquo;cognitive guidance\u0026rdquo; model to the \u0026ldquo;mechanism-based intervention.\u0026rdquo;\u003c/p\u003e \u003cp\u003eThis study adopted the Resource Conservation Theory (RCT) as its research framework to elucidate the previously indicated conversion mechanism [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. This theory asserts that individuals endeavor to obtain, maintain, and enhance valuable resources. The aggregation of resources can create a \u0026ldquo;value-added spiral,\u0026rdquo; enhancing an individual's adaptive capacity and overall performance in managing stressful situations [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. A positive attitude toward end-of-life care constitutes a cognitive-emotional resource [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. The study hypothesizes that this resource may enhance nursing students' self-efficacy in palliative care, specifically, their confidence in executing tasks such as end-of-life communication and symptom management [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], which can foster the development of psychological resilience, characterized as the ability for rapid adaptation and prompt recovery when facing adversity [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. This forms a resource enhancement chain from self-efficacy to psychological resilience, enhancing their palliative care competencies. Furthermore, psychological empowerment\u0026mdash;characterized by an individual's perceived work meaning, autonomy, and self-efficacy [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]\u0026mdash;may function as a stable internal psychological resource that plays a crucial boundary-modulating role within this mechanism. Resource conservation theory posits that individuals possessing abundant resources are more inclined to acquire additional resources [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Therefore, nursing students with high psychological empowerment may be more equipped to transform positive end-of-life care into steadfast professional confidence, thereby more effectively initiating subsequent resource-gain processes.\u003c/p\u003e \u003cp\u003eAlthough previous studies have investigated the effect of attitudes toward end-of-life care on palliative care competence, empirical evidence remains insufficient regarding the specific mechanism by which this influence occurs through the sequential mediating pathway of \u0026ldquo;self-efficacy \u0026rarr; psychological resilience\u0026rdquo; and the moderating role of psychological empowerment at the initial stage of this pathway. Consequently, this study aimed to develop and evaluate a moderated sequential mediation model to investigate the influence of nursing students' attitudes toward care of the dying on palliative care competence, mediated sequentially by self-efficacy and psychological resilience, and to determine whether psychological empowerment moderates the association between \u0026ldquo;attitudes toward care of the dying \u0026rarr; self-efficacy.\u0026rdquo; By clarifying these psychological mechanisms, the study seeks to provide theoretical and empirical foundations for developing more targeted and mechanism-based nursing education intervention strategies.\u003c/p\u003e\n\u003ch3\u003eAim\u003c/h3\u003e\n\u003cp\u003eThis study aims to examine the correlations among nursing students' attitudes toward care of the dying, psychological empowerment, palliative care self-efficacy, psychological resilience, and palliative care competence. Specifically, this study hypothesizes that nursing students' attitudes toward care of the dying improve palliative care competence through the mediating effects of self-efficacy and psychological resilience, whereas psychological empowerment moderates the relationship between these attitudes and self-efficacy. The primary aim is to clarify the fundamental psychological mechanisms by evaluating this model.\u003c/p\u003e "},{"header":"Methods","content":"\u003ch2\u003eDesign and setting\u003c/h2\u003e\u003cp\u003eThis multicenter cross-sectional study enrolled nursing interns from 42 tertiary-level Class A hospitals across China between September and December 2025.\u003c/p\u003e\n\u003ch3\u003eParticipants and sampling\u003c/h3\u003e\n\u003cp\u003eThis study employed convenience sampling to select participants. The inclusion criteria were as follows: (a) Full-time nursing students currently undergoing clinical internships; (b) full-time nursing students with \u0026ge;\u0026thinsp;3 months in the internship program; (c) full-time nursing students who provided informed consent and volunteered to participate in this study. The exclusion criteria were as follows: (a) Participants on academic leave or those with interrupted internships; (b) full-time nursing students on internships without critical care, emergency, or oncology department rotations. To ensure statistical power, G*Power 3.1 software [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] was utilized for pre-test calculations. Based on preliminary research, a multiple linear regression model was selected with a medium effect size (f\u0026sup2; = 0.15), α\u0026thinsp;=\u0026thinsp;0.05, and a statistical power\u0026thinsp;=\u0026thinsp;0.80, resulting in a minimum required sample size of 129 participants. Additionally, following psychometric guidelines [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], to ensure the validity of factor analysis, the minimum sample size was set at 10 times the number of items in the scale with the largest number of items. The Frommelt Attitudes Toward Care of the Dying (FATCOD) scale, which contained 30 items, therefore required a minimum sample size of 300 participants.\u003c/p\u003e \u003cp\u003eElectronic questionnaires were distributed to nursing students across 42 selected tertiary hospitals in China after obtaining informed consent. In total, 996 valid questionnaires were collected. Post-hoc sample size analysis indicated moderate effect detection, with the study's statistical power exceeding 0.99, which is significantly higher than the conventional standard of 0.80 [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e], thereby providing robust support for subsequent data analyses.\u003c/p\u003e\n\u003ch3\u003eMeasures\u003c/h3\u003e\n\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eInstruments\u003c/h2\u003e \u003cp\u003e \u003cb\u003eDemographic information.\u003c/b\u003e The study collected sociodemographic data from nursing students, including demographic data (age, gender, geographic origin, and only child status); educational and professional history (highest level of education, reasons for choosing nursing major, and willingness to care for terminally ill patients); cultural and personal experiences (religious beliefs, hospice care education background, experience in caring for terminal patients and their families); and bereavement experiences (bereavement within the past year and current circumstance).\u003c/p\u003e \u003cp\u003e \u003cb\u003eFrommelt Attitudes Toward Care of Dying Scale (FATCOD Scale)\u003c/b\u003e. Developed by Frommelt in 1991 [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e], the Chinese version has been widely utilized and verified among nursing students in China [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. The scale comprises 30 items, each scored on a 5-point Likert scale ranging from \u0026ldquo;Strongly Disagree\u0026rdquo; (1 point) to \u0026ldquo;Strongly Agree\u0026rdquo; (5 points). Total scores range from 30 to 150 points, with higher scores signifying more positive attitudes toward care of the dying among nursing students. The scale exhibits a Cronbach's α coefficient of 0.983.\u003c/p\u003e \u003cp\u003e \u003cb\u003ePsychological Empowerment Scale (PES).\u003c/b\u003e This scale was developed by Spreitzer in 1995 [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Chinese scholars, including Li Chao et al., translated it into Chinese [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. The scale has exhibited good construct validity and reliability among Chinese nursing students [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. It comprises four dimensions: work meaning, work autonomy, work self-efficacy, and work influence, totaling 12 items. Each item uses a 5-point Likert scale ranging from \u0026ldquo;strongly disagree\u0026rdquo; to \u0026ldquo;strongly agree,\u0026rdquo; scored 1\u0026ndash;5, respectively. The total score ranges from 12 to 60, with higher scores signifying greater psychological empowerment. The Cronbach's α coefficient for the PES is 0.959.\u003c/p\u003e \u003cp\u003e \u003cb\u003eElderly Palliative Care Self-Efficacy Scale (EPCS)\u003c/b\u003e. Developed by Chinese scholars, including Zou Zhijie [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e], this 21-item scale utilizes a 1\u0026ndash;5 point rating system ranging from \u0026ldquo;Strongly Disagree\u0026rdquo; to \u0026ldquo;Strongly Agree,\u0026rdquo; scored as 1\u0026ndash;5 points, respectively, yielding a total score range of 21\u0026ndash;105 points. Higher scores signify stronger self-efficacy in palliative care among participants. The overall Cronbach\u0026rsquo;s α coefficient for this scale is 0.972.\u003c/p\u003e \u003cp\u003e \u003cb\u003ePsychological Resilience Scale (CD-RISC)\u003c/b\u003e. This scale was created and utilized by Kenneth M. Connor and Jonathan R. T. Davidson in 2001 [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. This study utilized the Chinese version of the Connor-Davidson Resilience Scale (CD-RISC) for assessment [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. The scale has demonstrated good construct validity and reliability among Chinese nursing students [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. The scale comprises three dimensions and 25 items, rated on a five-point Likert scale ranging from 1 (\u0026ldquo;Never\u0026rdquo;) to 5 (\u0026ldquo;Always\u0026rdquo;), resulting in total scores between 25 and 125. Higher scores signify enhanced psychological resilience. The Chinese version exhibits an internal consistency coefficient of 0.982.\u003c/p\u003e \u003cp\u003e \u003cb\u003ePalliative Care Competency Assessment Questionnaire (PCCQ)\u003c/b\u003e. Developed by a Chinese scholar, Zhao Jing [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e], this questionnaire is the sole palliative care competency assessment tool in China that has been carefully validated for reliability and validity and specifically designed for nursing students. Consequently, although initially designed for undergraduate nursing students, this study was extended to encompass nursing students across all academic levels. The questionnaire comprises three dimensions: effective care skills, cultural and ethical values, and interprofessional teamwork. The scale has 16 items scored using a 5-point Likert scale, with 1 signifying no competency and 5 denoting full competency. The total score ranges from 16 to 80 points. The Cronbach\u0026rsquo;s α coefficient for this scale is 0.974.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eData collection\u003c/h2\u003e \u003cp\u003eThe online survey was administered using Wenjuanxing, a popular Chinese online survey platform. Researchers provided comprehensive explanations to the heads of the Education and Training Departments at each internship hospital regarding the study's aims, significance, survey process, and confidentiality principles. After the nursing students signed the informed consent forms, the internship team leaders at each hospital forwarded the survey poster to their respective internship group WeChat or QQ groups. The survey was anonymized and included a standardized introductory statement to clearly explain the research significance and process to participating nursing students. To ensure data integrity, researchers mandated a minimum completion duration of 5 min. Questionnaires were considered invalid if all answer options were identical or if the completion duration was less than 5 min. After screening, 36 invalid questionnaires were excluded, yielding 996 valid responses. The effective response rate reached 96.51%.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eThe Statistical Package for the Social Sciences software (SPSS; version 26.0) was utilized for data analysis. Continuous variables meeting normal distribution are expressed as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (M\u0026thinsp;\u0026plusmn;\u0026thinsp;SD); categorical variables are presented as frequency and percentage (*n*, %). Pearson correlation analysis was utilized to examine correlations among primary variables. To test the moderated chained mediation model, the PROCESS macro (version 3.4, Model 6) in SPSS was utilized for analysis. PROCESS utilizes a path analysis framework based on ordinary least squares regression. The importance of all indirect effects and conditional indirect effects in the model was evaluated utilizing nonparametric percentile bootstrap sampling, repeated 5000 times, with 95% bias-corrected confidence intervals reported. Effects were considered statistically significant if their confidence intervals excluded zero.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eEthical considerations\u003c/h3\u003e\n\u003cp\u003e This study was approved by the Ethics Review Committee of Shandong Xiehe University (No.: LLSC-KY03-2005038). All research procedures complied with the ethical principles established by the Declaration of Helsinki [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e].\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eDemographic characteristics of the participants\u003c/h2\u003e \u003cp\u003eThe study included 996 nursing students. The results revealed no statistically significant differences in palliative care competency scores based on gender or whether students were only children (all \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05). Significant differences were observed in the subsequent variables: age (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.019), place of origin (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.003), highest educational attainment, motivation for choosing the nursing major, willingness to care for terminally ill patients, religious beliefs, exposure to death education, previous experience caring for terminally ill patients, bereavement experience within the past year, and current family status (all \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Older students from urban areas possessed higher educational qualifications, chose their major based on personal motivation, demonstrated a willingness to care for terminally ill patients, held religious beliefs, had received death-related education, had previous experience caring for terminally ill patients, or had experienced bereavement within the past year, and demonstrated higher levels of palliative care competency. Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e presents detailed results.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eDescriptive analysis\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e presents the specific scores. The mean score for nursing students\u0026rsquo; attitudes toward care of the dying (FATCOD) was 89.90\u0026thinsp;\u0026plusmn;\u0026thinsp;22.06. Psychological empowerment (PES) had a mean score of 35.97\u0026thinsp;\u0026plusmn;\u0026thinsp;9.00. The mean score for palliative care self-efficacy (EPCS) was 63.12\u0026thinsp;\u0026plusmn;\u0026thinsp;15.13. Psychological resilience had a mean score of 74.88\u0026thinsp;\u0026plusmn;\u0026thinsp;18.88. The mean palliative care competency score was 47.93\u0026thinsp;\u0026plusmn;\u0026thinsp;12.24.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eCorrelation analysis\u003c/h2\u003e \u003cp\u003eSignificant positive correlations were observed among all major variables (\u003cem\u003eP\u0026thinsp;\u0026lt;\u003c/em\u003e\u0026thinsp;0.01; Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Nursing students' attitudes toward care of the dying exhibited a significant positive correlation with psychological empowerment (r\u0026thinsp;=\u0026thinsp;0.170), with stronger correlations observed for self-efficacy (r\u0026thinsp;=\u0026thinsp;0.541), psychological resilience (r\u0026thinsp;=\u0026thinsp;0.592), and palliative care competence (r\u0026thinsp;=\u0026thinsp;0.607). Self-efficacy demonstrated strong positive correlations with psychological resilience (r\u0026thinsp;=\u0026thinsp;0.616) and palliative care competence (r\u0026thinsp;=\u0026thinsp;0.597). Psychological resilience exhibited the strongest correlation with palliative care competence (r\u0026thinsp;=\u0026thinsp;0.708).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eCommon method bias test\u003c/h2\u003e \u003cp\u003eTo assess potential common method bias, several procedural controls were implemented during data collection, including assurances of anonymity and confidentiality, randomizing item order, and the inclusion of reverse-scored items. During statistical analysis, latent method factor techniques were applied. The results indicated that the inclusion of a method factor led to only minimal changes in model fit indices (ΔCFI\u0026thinsp;=\u0026thinsp;0.008, ΔTLI\u0026thinsp;=\u0026thinsp;0.005). Additionally, the method factor accounted for 12.7% of the variance, which was well below the 40% critical threshold [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. These findings indicate that common method bias did not pose a significant threat to the validity of the data.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eMediation and Moderating Effects\u003c/h2\u003e \u003cp\u003eA moderated chain mediation model was developed, using nursing students' attitudes toward care of the dying as the independent variable, palliative care competence as the dependent variable, self-efficacy and psychological resilience as chain mediators, and psychological empowerment as the moderator. Model evaluation utilized the bootstrap method with 5,000 repeated samples. The results demonstrated that all hypothesized paths achieved statistical significance (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). Nursing students' attitudes toward care of the dying directly and positively predicted palliative care competence (β\u0026thinsp;=\u0026thinsp;0.237, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and indirectly enhanced competence through an increase in self-efficacy (β\u0026thinsp;=\u0026thinsp;0.507, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and psychological resilience (β\u0026thinsp;=\u0026thinsp;0.365, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Self-efficacy positively predicted psychological resilience (β\u0026thinsp;=\u0026thinsp;0.420, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and palliative care competence (β\u0026thinsp;=\u0026thinsp;0.191, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Additionally, psychological resilience directly and positively predicted palliative care competence (β\u0026thinsp;=\u0026thinsp;0.450, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Moderation analysis further revealed that psychological empowerment significantly moderated the relationship between nursing students' attitudes toward care of the dying and self-efficacy (interaction term β\u0026thinsp;=\u0026thinsp;0.076, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.002) (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). All model fit indices fell within acceptable ranges. Figure\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e depicts the mediation and effect model.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eDecomposition of Total, Direct, and Indirect Effects\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e presents the decomposition of the effect of nursing students' attitudes toward care of the dying on palliative care competence. The total effect value was 0.594, comprising a direct effect of 0.237 (39.9%) and an indirect effect of 0.357 (60.1%). The indirect effect was mediated through four pathways: (1) \u0026ldquo;Attitudes toward care of the dying \u0026rarr; Self-Efficacy \u0026rarr; Palliative Care Competence\u0026rdquo; pathway, effect size 0.046; (2) \u0026ldquo;Attitudes toward care of the dying \u0026rarr; Psychological Resilience \u0026rarr; Palliative Care Competence\u0026rdquo; pathway, effect size 0.077; (3) \u0026ldquo;Attitudes toward care of the dying \u0026rarr; Self-Efficacy \u0026rarr; Psychological Resilience \u0026rarr; Palliative Care Competence\u0026rdquo; chained mediation pathway, effect size 0.045; (4) \u0026ldquo;Attitudes toward care of the dying \u0026rarr; Self-Efficacy \u0026rarr; Psychological Resilience\u0026rdquo; pathway, effect size 0.100. The confidence intervals for all indirect pathways excluded zero, signifying significant mediating effects. Furthermore, psychological resilience significantly mediated the association between self-efficacy and palliative care competence, with an effect size of 0.089.\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\u003eDemographic characteristics and univariate analysis of variables related to PCCQ (n\u0026thinsp;=\u0026thinsp;996)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\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=\"\u0026plusmn;\" 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=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\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\u003e\u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eM\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003et/F\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge (years)\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 \u003cp\u003et\u0026thinsp;=\u0026thinsp;3.987\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.019\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e18\u0026ndash;20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e240 (25.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e52.83\u0026thinsp;\u0026plusmn;\u0026thinsp;8.56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e21\u0026ndash;22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e612 (61.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e49.37\u0026thinsp;\u0026plusmn;\u0026thinsp;7.82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e23\u0026ndash;24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e144 (14.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e54.12\u0026thinsp;\u0026plusmn;\u0026thinsp;9.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGender\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 \u003cp\u003et\u0026thinsp;=\u0026thinsp;1.873\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.061\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e194 (19.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e49.72\u0026thinsp;\u0026plusmn;\u0026thinsp;8.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e802 (80.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e51.26\u0026thinsp;\u0026plusmn;\u0026thinsp;8.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGeographic Origin\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 \u003cp\u003et\u0026thinsp;=\u0026thinsp;2.937\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.003\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e770 (77.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e50.17\u0026thinsp;\u0026plusmn;\u0026thinsp;8.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrban\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e226 (22.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e51.83\u0026thinsp;\u0026plusmn;\u0026thinsp;8.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOnly-child Status\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 \u003cp\u003et\u0026thinsp;=\u0026thinsp;1.246\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.246\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e178 (17.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e50.52\u0026thinsp;\u0026plusmn;\u0026thinsp;8.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e818 (82.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e51.18\u0026thinsp;\u0026plusmn;\u0026thinsp;8.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHighest Education 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 \u003cp\u003eF\u0026thinsp;=\u0026thinsp;7.563\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiploma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e360 (36.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e53.51\u0026thinsp;\u0026plusmn;\u0026thinsp;7.93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBachelor\u0026rsquo;s degree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e632 (63.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e53.51\u0026thinsp;\u0026plusmn;\u0026thinsp;7.93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMaster's Students\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (0.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e55.38\u0026thinsp;\u0026plusmn;\u0026thinsp;7.62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eChoice of Nursing Major\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 \u003cp\u003et\u0026thinsp;=\u0026thinsp;5.328\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBased on my own\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e778 (78.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e51.63\u0026thinsp;\u0026plusmn;\u0026thinsp;8.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNot based on my own\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e218 (21.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e48.27\u0026thinsp;\u0026plusmn;\u0026thinsp;8.56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWillingness to Care for Terminally Ill Patients\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 \u003cp\u003et\u0026thinsp;=\u0026thinsp;9.873\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e730 (73.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e52.87\u0026thinsp;\u0026plusmn;\u0026thinsp;7.69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e266 (26.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e47.32\u0026thinsp;\u0026plusmn;\u0026thinsp;8.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eReligious Affiliation\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 \u003cp\u003eF\u0026thinsp;=\u0026thinsp;13.892\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e962 (96.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e50.12\u0026thinsp;\u0026plusmn;\u0026thinsp;8.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBuddhism\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20 (2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e53.76\u0026thinsp;\u0026plusmn;\u0026thinsp;7.58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChristianity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (0.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e54.21\u0026thinsp;\u0026plusmn;\u0026thinsp;7.36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOthers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (1.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e52.35\u0026thinsp;\u0026plusmn;\u0026thinsp;8.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePrevious Education on End-of-Life Care\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 \u003cp\u003eF\u0026thinsp;=\u0026thinsp;48.915\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCompleted a dedicated course on death\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e462 (46.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e56.32\u0026thinsp;\u0026plusmn;\u0026thinsp;6.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCovered related content within other courses\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e440 (44.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e51.28\u0026thinsp;\u0026plusmn;\u0026thinsp;7.63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNever encountered any knowledge on death\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e94 (9.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e46.05\u0026thinsp;\u0026plusmn;\u0026thinsp;8.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePrior Experience in Caring for Terminal Patients and Their Families\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 \u003cp\u003et\u0026thinsp;=\u0026thinsp;13.268\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e304 (30.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e53.17\u0026thinsp;\u0026plusmn;\u0026thinsp;7.52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e692 (69.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e46.05\u0026thinsp;\u0026plusmn;\u0026thinsp;8.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eExperience of Bereavement within the Past Year\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 \u003cp\u003eF\u0026thinsp;=\u0026thinsp;8.973\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLost one closely related person\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e284 (28.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e52.83\u0026thinsp;\u0026plusmn;\u0026thinsp;7.65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLost an immediate family member\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e50 (5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e53.56\u0026thinsp;\u0026plusmn;\u0026thinsp;7.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLost a non-immediate family member\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e56 (5.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e50.12\u0026thinsp;\u0026plusmn;\u0026thinsp;8.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLost multiple closely related persons\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e46 (4.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e54.27\u0026thinsp;\u0026plusmn;\u0026thinsp;7.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo bereavement experience\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e560 (56.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e47.69\u0026thinsp;\u0026plusmn;\u0026thinsp;8.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCurrent Circumstance\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 \u003cp\u003eF\u0026thinsp;=\u0026thinsp;11.476\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo bereavement experience\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e794 (79.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e49.23\u0026thinsp;\u0026plusmn;\u0026thinsp;8.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRecently experienced the death of an immediate family member\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e170 (17.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e55.12\u0026thinsp;\u0026plusmn;\u0026thinsp;6.93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCurrently have an immediate family member in a terminal stage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32 (3.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e53.76\u0026thinsp;\u0026plusmn;\u0026thinsp;7.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \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\u003eDescriptive results for FATCOD-B, PES, EPCS, CD-RISC, and PCCQ (n\u0026thinsp;=\u0026thinsp;996)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" 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 \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eScores\u003c/p\u003e \u003cp\u003e(M\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eBoot LLCI\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBoot ULCI\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFATCOD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e89.90\u0026thinsp;\u0026plusmn;\u0026thinsp;22.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e88.53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e91.27\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePES\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e35.97\u0026thinsp;\u0026plusmn;\u0026thinsp;9.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e35.41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e36.53\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEPCS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e63.12\u0026thinsp;\u0026plusmn;\u0026thinsp;15.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e62.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e64.06\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCD-RISC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e74.88\u0026thinsp;\u0026plusmn;\u0026thinsp;18.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e73.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e76.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePCCQ\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e47.93\u0026thinsp;\u0026plusmn;\u0026thinsp;12.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e47.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e48.69\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eNote: M, mean; SD, standard deviation;\u003c/p\u003e \u003cp\u003eFATCOD, Frommelt Attitudes Toward Care of the Dying Scale;\u003c/p\u003e \u003cp\u003ePES, Psychological Empowerment Scale;\u003c/p\u003e \u003cp\u003eEPCS, End-of-life Professional Caregiver Survey;\u003c/p\u003e \u003cp\u003eCD-RISC, Connor-Davidson Resilience Scale;\u003c/p\u003e \u003cp\u003ePCCQ, Palliative Care Competence Questionnaire.\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\u003eMultiple stepwise linear regression analysis of variables related to PCCQ\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\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=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFATCOD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePES\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eEPCS\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCD-RISC\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003ePCCQ\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFATCOD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \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 \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePES\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.170*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \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 \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEPCS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.541*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.268*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCD-RISC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.592*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.111*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.616*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePCCQ\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.607*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.075*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.597*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.708*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eNote:* indicates significance at the 0.01 level.\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\u003eMediation analysis between FATCOD-B, EPCS, CD-RISC, and PCCQ\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\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=\"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=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePathway\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eβ\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSE\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003et\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFATCOD - EPCS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.507\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.024\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e21.329\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEPCS - CD-RISC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.420\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.027\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e15.630\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCD-RISC - PCCQ\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.450\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.029\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e15.787\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFATCOD - CD-RISC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.365\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.027\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e13.509\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEPCS - CD-RISC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.420\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.027\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e15.630\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEPCS - PCCQ\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.191\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.028\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6.913\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFATCOD-B - PCCQ\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.237\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.027\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8.828\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eResults of Moderation Effect Analysis\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\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=\"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 \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePathway\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eβ\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eS.E\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eT\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFATCOD-B - EPCS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.507\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.024\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e21.329\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePES - EPCS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.190\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.026\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e7.379\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePES - FATCOD-B - EPCS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.076\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.026\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.963\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eTotal, direct, and indirect effects of FATCOD-B on PCCQ\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\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=\"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=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEffect\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSE\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003ePercentage of effect (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal effect\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.594\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.559\u0026thinsp;~\u0026thinsp;0.627\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e~\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDirect effect\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.237\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.027\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.194\u0026thinsp;~\u0026thinsp;0.283\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e39.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIndirect effect\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.357\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.018\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.327\u0026thinsp;~\u0026thinsp;0.387\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e60.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFATCOD - CD-RISC - PCCQ\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.077\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.016\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.139\u0026thinsp;~\u0026thinsp;0.191\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e13.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEPCS - CD-RISC - PCCQ\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.089\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.017\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.161\u0026thinsp;~\u0026thinsp;0.218\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e15.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFATCOD - EPCS - PCCQ\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.046\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.015\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.072\u0026thinsp;~\u0026thinsp;0.121\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e7.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFATCOD - EPCS - CD-RISC - PCCQ\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.045\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.009\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.081\u0026thinsp;~\u0026thinsp;0.112\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e7.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFATCOD - EPCS - CD-RISC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.017\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.186\u0026thinsp;~\u0026thinsp;0.242\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e16.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe study confirmed the theoretical hypothesis, illustrating that psychological empowerment, palliative care self-efficacy, and psychological resilience constitute a moderated sequential mediating model between nursing students' professional attitudes toward end-of-life care and their palliative care competencies. Nursing students' attitudes toward care of the dying directly enhance their palliative care competencies and indirectly foster these competencies by activating sequential psychological resources\u0026mdash;specifically, palliative care self-efficacy and psychological resilience. Simultaneously, psychological empowerment, as an internal resource, positively moderates the activation effect of professional attitudes on palliative care self-efficacy, indicating that educational outcomes differ based on students' psychological empowerment.\u003c/p\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eCurrent Status and Implications of Nursing Students' Palliative Care Competency\u003c/h2\u003e \u003cp\u003eThis study revealed that nursing students' palliative care competency scores (47.93\u0026thinsp;\u0026plusmn;\u0026thinsp;12.24) were similar to findings from multiple domestic surveys of nursing student cohorts [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e], but markedly lower than levels reported by clinical nurses [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. These disparities highlight a significant \u0026ldquo;competency chasm\u0026rdquo; persisting between nursing students and qualified palliative care practitioners. Conventional nursing education frequently prioritizes knowledge transmission and skill acquisition [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e], but cognitive input is insufficient for fostering robust professional competence in the highly emotionally intense domain of end-of-life care [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Findings reveal that competency discrepancies transcend numerical scores, being deeply rooted in the effective activation of psychological resource systems underpinning competency development, which are adequately activated and cultivated.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eResource-Enhancing Spiral Effect of the Core Mediator\u003c/h2\u003e \u003cp\u003e\u0026ldquo;Attitudes toward care of the dying \u0026rarr; Self-Efficacy \u0026rarr; Psychological Resilience\u0026rdquo; One of the core findings of this study is the marked chain-mediated pathway from \u0026ldquo;self-efficacy \u0026rarr; psychological resilience.\u0026rdquo; This pathway is comprehensively explained through the perspective of the conservation of resources theory [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. A positive attitude toward the care of the dying constitutes a valuable cognitive-emotional resource. When nursing students hold such an attitude, they are more likely to perceive end-of-life care as meaningful professional work rather than a stressful task, thereby initiating a resource-enhancing process. First, this attitudinal resource is translated into palliative care self-efficacy. According to social cognitive theory, self-efficacy functions as a central motivational mechanism for transforming knowledge into action [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Herein, professional attitudes toward end-of-life care significantly predicted palliative care self-efficacy (β\u0026thinsp;=\u0026thinsp;0.507), consistent with the perspective of Petrongolo et al. (2021) [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e] that positive cognitive appraisals of end-of-life care provide a foundation for coping with related stressors. The \u0026ldquo;mastery experiences\u0026rdquo; acquired by nursing students through simulation training, role-playing, and reflective practice represent effective pathways for strengthening palliative care self-efficacy belief [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. Second, high self-efficacy further promotes the development of more trait-like psychological resilience. This effect (β\u0026thinsp;=\u0026thinsp;0.420) reflects a progression from situational confidence (\u0026ldquo;I can handle this specific challenge\u0026rdquo;) to a broader and more stable psychological trait (\u0026ldquo;I can recover from various adversities\u0026rdquo;). When nursing students with high self-efficacy encounter end-of-life challenges, repeated experiences of successful emotional regulation and effective communication serve as \u0026ldquo;resilience training,\u0026rdquo; helping them accumulate more stable and protective psychological capital [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. These findings are consistent with those of Liang's[\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e], indicating that confidence in managing specific occupational stressors serves as a critical catalyst for the cultivation of broad psychological resilience.\u003c/p\u003e \u003cp\u003e \u003cb\u003eModerating Role of Psychological Empowerment in the Relationship Between Attitudes Toward Care of the Dying and Self-Efficacy\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThis study confirmed the moderating influence of psychological empowerment. Nursing students with elevated psychological empowerment exhibited a stronger promotion effect of attitudes toward care of the dying on palliative care self-efficacy (interaction term β\u0026thinsp;=\u0026thinsp;0.076). This finding aligns with the fundamental tenet of resource conservation theory, which asserts that individuals possessing ample resources are more inclined to acquire additional resources [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePsychological empowerment, defined as an individual's impression of work significance, autonomy, and self-efficacy [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e], constitutes a stable reservoir of internal resources. Studies demonstrate that nursing students with elevated psychological empowerment exhibit more proactive and intrinsically driven learning behaviors. They internalize end-of-life care attitudes as \u0026ldquo;my work is meaningful, and I can make a positive impact,\u0026rdquo; promoting deep role identification [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. This enables them to more efficiently transform positive attitudes toward care of the dying into robust professional confidence. Conversely, nursing students with low empowerment may struggle to translate positive attitudes into strong action beliefs due to occupational alienation or feelings of helplessness [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]. This elucidates why identical educational treatments produce varying outcomes across different students and highlights the need for proactive attention to enhance students' psychological empowerment in educational design to optimize the benefits of educational investment.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eConstructing a Moderated Mediated Model to Achieve Transformation from Knowledge Transmission to Resource Cultivation\u003c/h2\u003e \u003cp\u003eThe moderated chain-mediated model developed in this study provides a dynamic \u0026ldquo;resource-cognition-trait-competence\u0026rdquo; framework for understanding the development of palliative care competencies. This model demonstrates that developing palliative care professional competence transcends the mere accumulation of knowledge. The process commences with an individual's resource foundation\u0026mdash;psychological empowerment\u0026mdash;and advances through stimulating situational cognitive motivation, namely self-efficacy [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e]. This process subsequently internalizes into stable psychological traits, particularly psychological resilience, integrating into comprehensive professional performance\u0026mdash;palliative care competence\u0026mdash;as a coherent psychological transformation. This framework holds significant implications. It advocates for a transformation in nursing education from \u0026ldquo;what we teach\u0026rdquo; to \u0026ldquo;what students internalize and how they internalize it.\u0026rdquo; Educators' duties should evolve from knowledge transmitters to catalysts and integrators of psychological resources.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003ePractical Implications and Educational Recommendations\u003c/h2\u003e \u003cp\u003eThis study offers insights into the psychological development mechanisms of nursing students' palliative care competencies. The findings offer the following insights for nursing educators and clinical administrators:\u003c/p\u003e \u003cp\u003e \u003cb\u003eOptimizing Curriculum Design.\u003c/b\u003e Developing an integrated teaching design combining \u0026ldquo;empowerment-experience-reflection.\u0026rdquo; Before palliative care-related courses, students' psychological empowerment should be enhanced through narrative medicine and professional value seminars, laying a resource foundation for future learning.\u003c/p\u003e \u003cp\u003e \u003cb\u003eImproving Teaching Methods.\u003c/b\u003e Extensively employing high-fidelity end-of-life scenario simulations, standardized patient exercises, and reflective narrative writing to facilitate \u0026ldquo;mastery experiences\u0026rdquo; [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e]. The curriculum material includes symptom management, end-of-life communication, family support, ethical decision-making, and spiritual care scenarios [\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e], aimed at fostering self-efficacy.\u003c/p\u003e \u003cp\u003e \u003cb\u003eBuilding Support Systems.\u003c/b\u003e Implementing support mechanisms. Identifying nursing students exhibiting low psychological empowerment and self-efficacy through pre-course assessments, offering organized peer support, graduated skill training, and prompting positive feedback to facilitate completion.\u003c/p\u003e \u003cp\u003e \u003cb\u003eEnhancing Clinical Internships.\u003c/b\u003e During clinical rotations, supervised, structured exposure should be arranged for terminally ill patients, and nursing students should be guided in reflective discussions to enhance psychological resilience through practical experience [\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e \u003ch2\u003eResearch Limitations and Future Directions\u003c/h2\u003e \u003cp\u003eFirst, the cross-sectional design limited the strength of causal inference. Future studies should utilize longitudinal tracking or experimental interventions to better validate the causal direction of the model. Second, all data were derived from nursing students' subjective self-reports, which may introduce common method bias. Future research could integrate multi-source data, including third-party evaluations and objective behavioral observations, to enable a more comprehensive analysis. Finally, the selected samples were exclusively drawn from Chinese teaching hospitals, and the generalizability of these findings to other cultural contexts remains to be established. Furthermore, future research should examine potential mediators, including empathy and professional identity, or examine moderating variables, including social support and organizational climate, to further refine this proposed psychological mechanism model.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe study demonstrated that nursing students' palliative care competence is influenced by their attitudes toward care of the dying, psychological empowerment, palliative care self-efficacy, and psychological resilience, hence developing a moderated chain-sequence mediation model. A positive attitude toward care of the dying indirectly enhances palliative care competency by fostering a resource-enhancing chain from self-efficacy in palliative care to psychological resilience. Psychological empowerment, as a key internal resource, moderates the initial stage of transforming attitudes toward care of the dying into confidence. The study suggests that palliative care education should extend beyond the mere transmission of knowledge and skills. Instead, it should cultivate an ecosystem that systematically enhances nursing students\u0026rsquo; psychological resources, fostering their self-efficacy and psychological resilience. This approach facilitates the effective transformation from cognition to competency, thereby optimizing educational outcomes. Future educational practices should account for individual differences in students' psychological resources. By implementing empowerment-oriented curriculum design, student-centered teaching strategies, and tiered clinical placement arrangements, the sustained development of professional competence can be effectively promoted.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eFATCOD, Frommelt Attitudes Toward Care of the Dying Scale;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePES, Psychological Empowerment Scale;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEPCS, End-of-life Professional Caregiver Survey;\u003c/p\u003e\n\u003cp\u003eCD-RISC, Connor-Davidson Resilience Scale;\u003c/p\u003e\n\u003cp\u003ePCCQ, Palliative Care Competence Questionnaire.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe extend our gratitude to all nursing students and researchers who participated in this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHui Lin: Conceptualization, Methodology, Investigation, Data Curation, Formal Analysis, Writing \u0026ndash; Original Draft, Project Administration.\u003c/p\u003e\n\u003cp\u003eZhaojie Fu: Methodology, Investigation, Software, Formal Analysis, Visualization.\u003c/p\u003e\n\u003cp\u003eJinyang Zhao:\u0026nbsp;Investigation, Formal Analysis, Visualization.\u003c/p\u003e\n\u003cp\u003eXia Xu: Conceptualization, Investigation, Methodology, Resources.\u003c/p\u003e\n\u003cp\u003eLi Ba: Software, Validation, Data Curation.\u003c/p\u003e\n\u003cp\u003eXiaoli Hu: Conceptualization, Methodology, Supervision, Writing \u0026ndash; Review \u0026amp; Editing.\u003c/p\u003e\n\u003cp\u003eAll authors have read and finally approved the submitted manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo protect the privacy of research participants, the data supporting the conclusions of this study are not publicly stored. However, the data may be obtained from the corresponding author upon reasonable request and in compliance with the ethical protocol.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical approval and informed consent statements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study has been approved by the Ethics Committee of Shandong Xiehe University. All nursing students participating in the study have signed informed consent forms.\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\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor details\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026sup1; School of Nursing, Shandong Xiehe University, Jinan, Shandong Province, 250109, China\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e2\u0026nbsp;\u003c/sup\u003eDepartment of Gastrointestinal Surgery, Affiliated Tumor Hospital of Shandong First Medical University, Jinan, Shandong Province, 250117, China\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e3\u003c/sup\u003e School of Nursing, Shandong Medical College, Jinan, Shandong Province, 250002, China\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eChen C, Lim J, Koh J, Beard J, Rowe JW; Research Network on an Aging Society. 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Published 2024 Jul 23. doi:10.1186/s12909-024-05700-y\u003c/li\u003e\n\u003cli\u003eGrealish A, Tai S, Hunter A, Emsley R, Murrells T, Morrison AP. Does empowerment mediate the effects of psychological factors on mental health, well-being, and recovery in young people?. Psychol Psychother. 2017;90(3):314-335. doi:10.1111/papt.12111\u003c/li\u003e\n\u003cli\u003eMoore SC, Ward KS. Nursing Student Perceptions of Structural Empowerment. Nurs Educ Perspect. 2017;38(1):32-33. doi:10.1097/01.NEP.0000000000000096\u003c/li\u003e\n\u003cli\u003eZhou Y, Wu Y, Deng X, Wang S, Shi L. Analysis Model of the Influence of Self-Efficacy on Professional Toughness of Preschool Teachers under the Condition of Ensuring Children\u0026apos;s Mental Health and Healthy Family Environment [retracted in: J Environ Public Health. 2023 Jun 28;2023:9786498. doi: 10.1155/2023/9786498.]. J Environ Public Health. 2022;2022:3737690. Published 2022 Sep 27. doi:10.1155/2022/3737690\u003c/li\u003e\n\u003cli\u003eTestoni I, Ronconi L, Orkibi H, et al. Death education for Palliative care: a european project for University students. BMC Palliat Care. 2023;22(1):47. Published 2023 Apr 21. doi:10.1186/s12904-023-01169-6\u003c/li\u003e\n\u003cli\u003eClark SB, Lippe MP. Vicarious learning and communication self-efficacy: A pediatric end-of-life simulation for pre-licensure nursing students. J Prof Nurs. 2022;43:107-116. doi:10.1016/j.profnurs.2022.09.008\u003c/li\u003e\n\u003cli\u003ePyke-Grimm KA, Fisher B, Haskamp A, Bell CJ, Newman AR. Providing Palliative and Hospice Care to Children, Adolescents and Young Adults with Cancer. Semin Oncol Nurs. 2021;37(3):151166. doi:10.1016/j.soncn.2021.151166\u003c/li\u003e\n\u003cli\u003eJeffers S, Black S, Alessi G. End-of-Life Nursing Education in US Baccalaureate Degree Nursing Programs. Nurs Educ Perspect. 2022;43(6):E88-E90. doi:10.1097/01.NEP.0000000000000940\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-nursing","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurs","sideBox":"Learn more about [BMC Nursing](http://bmcnurs.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurs/default.aspx","title":"BMC Nursing","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Palliative Care Competency, Attitudes toward Care of the Dying, Psychological Empowerment, Serial Mediation, Self-efficacy, Resilience, Nursing Students","lastPublishedDoi":"10.21203/rs.3.rs-8716003/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8716003/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eAs the global population continues to age rapidly, the growing demand for end-of-life care highlights the urgent need to enhance nursing students' palliative care competencies. Attitudes toward care of the dying constitute a critical cognitive and emotional foundation that directly influences nursing students\u0026rsquo; willingness to engage in palliative care practice. However, the underlying mechanisms through which these attitudes affect palliative care competencies remain unclear.\u003c/p\u003e\u003ch2\u003eResearch aim\u003c/h2\u003e \u003cp\u003eThis study aims to examine a moderated chain mediation model to investigate the sequential mediating role of attitudes toward care of the dying on the influence of self-efficacy and psychological resilience on nursing students' palliative care competence, and to examine the moderating effect of psychological empowerment between attitudes toward care of the dying and self-efficacy.\u003c/p\u003e\u003ch2\u003eResearch design\u003c/h2\u003e \u003cp\u003eA cross-sectional survey design. Participants completed an online questionnaire. The questionnaire incorporated the Frommelt Attitudes Toward Care of the Dying Scale, Psychological Empowerment Scale, Palliative Care Self-Efficacy Scale, Psychological Resilience Scale, and Palliative Care Competence Scale to assess nursing students' professional attitudes toward end-of-life care, psychological empowerment, palliative care self-efficacy, psychological resilience, and palliative care competence.\u003c/p\u003e\u003ch2\u003eParticipants and research context\u003c/h2\u003e \u003cp\u003eThis study recruited 996 nursing interns from 42 teaching hospitals across China.\u003c/p\u003e\u003ch2\u003eEthical considerations\u003c/h2\u003e \u003cp\u003e This study was approved by the Ethics Committee of Shandong Xiehe University. All participants signed informed consent forms.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eAttitudes toward care of the dying had a significant positive effect on palliative care competence (β\u0026thinsp;=\u0026thinsp;0.594). Psychological empowerment demonstrated a significant moderating effect on the relationship between attitudes toward the care of the dying and self-efficacy (β\u0026thinsp;=\u0026thinsp;0.076; \u003cem\u003eP\u0026thinsp;=\u003c/em\u003e\u0026thinsp;0.002). Self-efficacy and psychological resilience functioned as sequential mediators, with a chained indirect effect value of 0.045. The indirect effect accounted for 60.1%.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eAttitudes toward care of the dying enhance nursing students' palliative care competencies through multiple pathways. Psychological empowerment functioning as a moderating variable enhances the mediating effects of self-efficacy and psychological resilience, thereby facilitating enhancement in nursing students' palliative care competencies.\u003c/p\u003e\u003ch2\u003eClinical trial number\u003c/h2\u003e \u003cp\u003enot applicable.\u003c/p\u003e","manuscriptTitle":"Psychological Empowerment as a Moderator in the Pathway from Attitudes Toward Care of the Dying to Palliative Care Competency among Nursing Students: A Serial Mediation Model of Self-efficacy and Resilience","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-28 16:27:49","doi":"10.21203/rs.3.rs-8716003/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-04-16T03:21:25+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"336839020546327252894923862178625937231","date":"2026-04-02T00:28:20+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-03-25T12:49:02+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-02-02T04:18:20+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-30T09:11:50+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-30T09:05:52+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Nursing","date":"2026-01-28T03:41:55+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-nursing","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurs","sideBox":"Learn more about [BMC Nursing](http://bmcnurs.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurs/default.aspx","title":"BMC Nursing","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"3c4317b3-1d16-4b0b-9377-3b653d6e4270","owner":[],"postedDate":"March 28th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-03-28T16:27:49+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-28 16:27:49","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8716003","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8716003","identity":"rs-8716003","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}