Effects of Mindfulness Meditation on Psychoneuroendocrinoimmunology in Nursing Students
Phase: NA
Conditions: Stress Reaction, Nurse's Role
Sponsor: Jordan University of Science and Technology

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The Effects of Mindfulness Meditation on Psychoneuroendocrinoimmunology in 
Nursing Students 
Study Protocol 
Date: July 30, 2019 
NCT number: Not yet issued  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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Introduction 
Stress has been recognized worldwide as a prevalent health issue in nursing education 
(1). Like nursing students in other countries, nursing students in Jordan have reported 
moderate to high levels of stress, sometimes higher than the levels reported by students from 
other disciplines (2, 3). Although acute stress works to sustain human hemostasis, repeated 
exposure to stress can influence students’ health, academic performance, attrition, and ability 
to care for patients and themselves (4). 
Previous studies have shown that stress can negatively impact the body. Specifically, 
the immune system can be negatively impacted by the activation of the hypothalamic-
pituitary-adrenal (HPA) system (e.g. cortisol) (5). Because of stress, the hypothalamus 
releases a corticotrophin-releasing factor (CRF) that stimulates the release of 
adrenocorticotropic hormone (ACTH) from the anterior areas of the pituitary gland. ACTH 
stimulates the adrenal cortex to secrete cortisol, described as a stress hormone that mainly 
affects metabolic processes, and an elevated cortisol level suppresses the immune system and 
inflammatory functions (5). Further, an elevated cortisol level increases the release of pro-
inflammatory factors such as C-reactive protein (CRP), which is the most widely used 
proinflammatory biomarker in clinical practice and which has been found to be associated 
with a variety of chronic illnesses such as major depression, coronary artery diseases, cancer, 
and diabetes mellitus (6, 7).  
It has been reported that when dealing with stress, Jordanian nursing students mostly 
use inefficient, harmful coping methods such as avoidance and smoking. These methods have 
short-lived benefits but are harmful in the long run, resulting in a variety of physical and 
psychological health problems (8, 9). Therefore, nursing students in Jordan may need to learn 
to use more effective coping strategies.  

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There are several potentially beneficial stress-reduction methods which have been 
found to help students worldwide cope effectively with stress and its adverse health 
consequences (10). Mind-body therapies are being more widely used in Jordan, as they are 
easily accessible, easy to learn, and inexpensive (11). Specifically, mindfulness meditation is 
a mind-body therapy that has been gaining increasing attention in the recent literature and has 
demonstrated promising results across different populations and settings (12, 13). The target 
groups for mindfulness meditation include people with chronic physical pain, illnesses such 
as cancer, or mental illnesses, such as stress, anxiety, depression, or burnout (12). In addition, 
this mind-body therapy has been used among non-clinical populations, including students, 
therapists, and prisoners (14).  
Whilst mindfulness meditation has been shown by a growing body of evidence to 
improve several health and psychological well-being measures in university students, its 
mechanism of action and how it improves stress and its related health responses remain 
debated in the literature. Garland et al. (2009) proposed a hypothetical causal model that 
argues for the role of mindfulness meditation in positive reappraisal coping, explaining that 
attending repeatedly in a mindful way evokes a transitory metacognitive state of mindfulness 
that remains for as long as that form of attention is sustained. With repeated practices, 
individuals, including students, can cultivate their predisposition to be mindful in daily life, 
which is known as trait mindfulness (15). Trait mindfulness is described as the cognitive 
ability to non-judgmentally observe sensations, thoughts, emotions, and the environment 
while simultaneously encouraging openness, curiosity, and acceptance (16). Previous studies 
among university students have supported this theoretical claim. A recent randomized 
controlled trial showed that four weekly sessions of mindfulness meditation improved trait 
mindfulness among university students and staff (N=561) (17), and another recent RCT 

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showed that three daily sessions of mindfulness meditation significantly improved state 
mindfulness among university students (N=40) (18). 
Based on the mindful coping model (15), positive reappraisal is a cognitive coping 
strategy that enables people to adapt successfully to perceived stress, which is defined as the 
degree to which events are appraised as stressful and uncontrollable (19). For example, a 
student who perceives a given event or situation, such as an exam, as stressful (e.g. risk of 
threat, harm, or loss) and exceeding their abilities may practice mindfulness meditation to 
induce an adaptive response by decentring from this stress appraisal into a mode of 
mindfulness. In turn, this mode allows the student to pay attention to the dynamic process of 
consciousness itself rather than its contents, which enhances attentional flexibility and raises 
awareness. Based on this broadened, metacognitive awareness, the student can then 
reappraise the given event in a positive way by giving it a new meaning, which may evolve 
either through a conscious process of reflection or a more automatic process. The reappraisal 
of the event then leads to positive emotions such as compassion, trust, and confidence that 
ultimately decrease stress and its related physiological reactions, such as cortisol and CRP 
(15).  
  Previous studies have also supported the claims of this model regarding the effects 
of mindfulness meditation on perceived stress among university students. A previous RCT 
showed that 8 weeks of mindfulness meditation reduced study-related stress among 
university students (20). In addition to long-term interventions, RCTs using brief mindfulness 
meditation, with sessions ranging between 3 daily sessions to 4 weekly sessions, showed that 
these brief mindfulness meditation interventions decreased perceived stress among university 
students [21, 22, 23, 24].  
In addition to its psychological effects, mindfulness meditation has been found to 
improve physiological indices of stress. It is hypothesized that mindfulness meditation 

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buffers stress reactivity, resulting in decreased cortisol responses and proinflammatory 
markers such as CRP. In a systematic review of 45 RCTs (25), the authors identified strong 
evidence of mindfulness meditation leading to reductions in serum cortisol and C-reactive 
protein. Similarly, another systematic review of RCTs concluded that mindfulness meditation 
has been found to reduce pro-inflammatory cytokines, including CRP, which is associated 
with the reduction of perceived stress and cortisol (26).  
Although an increasing number of studies have demonstrated the effectiveness of 
mindfulness meditation in improving wellbeing and reducing stress among ill and healthy 
populations such as university students, these studies have been conducted only in western 
countries. Therefore, any generalization of these study findings to other populations of 
different cultures is limited due to these cultures’ differing belief systems and self-care 
practices. Also, there have been in these previous studies variations in the operationalization 
and standardized delivery of mindfulness meditation, limiting the generalizability of the 
findings related to the distinct effects of this therapy on stress and health. In Jordan, there is a 
lack of evidence related to the effectiveness of mindfulness meditation on stress and its 
physiological indices in Jordanian people generally and nursing students specifically. Thus, 
this study aimed to examine the effects of a standardized version of mindfulness meditation 
on trait mindfulness, perceived stress, serum cortisol, and serum CRP in Jordanian nursing 
students.  
The current study is the first to report findings related to the effects of mindfulness 
meditation on psychoneuroendocrinoimmunolgy among the target population. Practically, the 
findings of this study may guide nursing faculties in adopting mindfulness meditation in 
nursing colleges. Theoretically, the current study also extends the body of nursing knowledge 
and fills a gap in the literature regarding the effects of mindfulness meditation on 
psychoneuroendocrinoimmunolgy in nursing students outside the United States and Europe.  

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Methods 
Design and Participants  
The study used randomized controlled design (pre-posttest, two-group, randomized, 
blinded design). The study sample included undergraduate nursing students who were 
selected using convenience sampling from Jordan University of Science and Technology 
(JUST). Students were included if they were aged 18 years or over and taking a clinical 
course. Meanwhile, students were excluded if they were practicing any type of relaxation 
techniques or taking hypnotics, sedatives, anxiolytics, anti-depressants, or anti-hypertensive 
drugs.  
Sample Size Calculation 
G* Power software 3.1 was used to calculate the required sample size, given a 
MANOVA test, an alpha of .05, power of 0.95, number of dependent variables of 4, number 
of groups of 2, and effect size of 0.25 (18). A sample size of 80 was calculated, and an 
attrition rate of 35% was added based on a previous study with variables similar to those of 
the present study (27). Therefore, this resulted in a final total sample size of 108 participants.  
Instruments 
The study data were collected using self-reported and physical measures. For the self-
reported variables, a self-report questionnaire was used. The first part of the questionnaire 
included questions related to the behaviors and demographic characteristics of the 
participants, including age, religion, gender, marital status, daily consumption of cigarettes, 
general health status, nutritional status, coping behaviors, and sleeping hours and quality. 
Meanwhile, the second part included scales used to measure trait mindfulness and perceived 
stress. As for the physical variables, the enzyme-linked immunosorbent assay (ELISA) 
procedure was used to measure serum biomarkers such as serum cortisol and serum CRP. 

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Trait Mindfulness. Trait mindfulness was measured using the Arabic version of the Mindful 
Attention Awareness Scale (MAAS) (28), which is a one-dimensional scale that includes 15 items 
measured on a six-point Likert-type scale ranging from 1 (almost always) to 6 (almost never). The 
total possible score ranges between 15 and 90, with higher scores indicating higher levels of trait 
mindfulness. The original scale has been shown to have strong psychometric properties when 
validated among college students (28). Further, the Arabic version of this scale has been shown to 
have excellent internal consistency and convergent validity for use among Arab populations (29). In 
the current study, the Cronbach’s alpha for the Arabic version of the MAAS was .79, indicating good 
internal consistency. 
Perceived Stress. The Perceived Stress Scale (PSS) (30) is used to measure the 
degree to which situations in one’s life are appraised as stressful (unpredictable, 
uncontrollable, and overloaded). The scale comprises 10 items which are measured on a 5-
point Likert scale (0=never, 4= very often) and which are relatively free of content specific to 
any subpopulation group. The total possible score ranges from 0 to 40, with higher scores 
indicating higher levels of perceived stress (30). The PSS has been validated for use among 
college students, with internal consistency coefficients ranging from .84 to 36 and a test-
retest reliability of .85 (30). The Arabic version of the PSS, which was used in the present 
study, has been shown to have adequate reliability and validity and is considered a suitable 
instrument for assessing perceived stress among Arab populations (31). In the current study, 
the Cronbach’s alpha for the Arabic version of the PSS was .81, indicating good internal 
consistency.  
Biomedical Markers.  
The ELISA method has been found to be accurate, sensitive, specific, and precise in 
terms of determining the plasma concentration of cortisol and proinflammatory  markers (32). 
In the current study, the ELISA kit and protocols were used to analyze the blood sample for 
the serum cortisol (CEA462Ge) and serum CRP (Cat no: SEA821Hu) . Three research 

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assistants with at least 10 years of experience collected 10 mL blood samples via 
venipuncture both at baseline and next day morning after the last session, between 8:30-9:30 
AM. The results were read using a SYNERGY (HTZ) multi-mode reader, connected to a 
computer which showed each reading value. The participants were asked to avoid caffeine 
consumption on the days of data collection. To decrease venipuncture-related pain during 
blood sampling, the EMLA cream was used, as it has been found effective in decreasing 
venipuncture-related pain among different populations (33).  
Interventions 
In the current study, the ABC standardized version of mindfulness meditation was 
used, which includes 5 30-minute weekly sessions of mindfulness meditation and which has 
been found effective in improving stress and its responses (34). An additional 3-hour 
educational workshop about the intervention was provided before the actual training sessions 
to enhance the participants’ understanding of the intervention. In the initial educational 
session, the principal investigator (PI) held a PowerPoint presentation for the participants in 
each experimental group, which included an explanation of the intervention rationale and 
procedures and a demonstration of the entire intervention protocol. The PI is an experienced 
practitioner who received stress-management training at the Psychology Department at Kent 
State University over 7 years ago and who has, since then, been practicing stress-
management techniques, especially those used in the current study, on a daily basis. The 
participants were asked to briefly practice the intervention, and their performance was then 
evaluated by the PI to make sure that the intervention had been conducted correctly. The PI 
gave the participants the opportunity to ask questions during the educational session.  
During the actual training sessions, the intervention was introduced to the participants 
in the experimental groups by the PI based on Smith’s (2005) guidelines and protocols. The 
participants were divided into 6 groups, with 10 to 11 participants in each group. The 

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subgroups met separately in different classrooms, where the interventions were conducted, 
and provided with identical instructions. Each participant sat in a hard chair behind a desk. 
The classrooms had tiled floors, and the lights were dimmed during the relaxation phases and 
turned up when the participants were completing the study questionnaires. A trained research 
assistant with a master’s degree in psychiatric health nursing randomly selected sessions to 
evaluate the delivery of the interventions using checklists produced according to Smith’s 
protocols.  
Smith’s version of the mindfulness meditation intervention was used in the current 
study. The participants were asked to sit upright in a comfortable position, place their feet on 
the floor, and quietly observe and reflect on internal and external stimuli such as breathing, 
thought, feeling, physical sensation, and sound, without reactions, judgments, or evaluations. 
They were asked to quietly attend to, note, and let go of all internal and external stimuli. They 
were reminded that they should not try to think about, push away, or do anything with these 
stimuli, and that they should not focus on figuring out the connections between the stimuli. 
They were asked to simply let each stimulus come and go and wait for the next stimulus. 
Finally, the participants were told that they should not concern themselves with distractions 
and that if faced with a distraction, they should note it as yet another passing stimulus (e.g., 
“Ah, a distraction… how interesting") (34).  
Control Group 
Each of the control group subgroups had 10 participants. The participants were 
instructed to sit with their eyes closed and relax during the intervention sessions, in order to 
control for the nonspecific effects of trainer interaction, social interaction, attention, 
environment, time, and closed eyes (35). The timings of the control group interventions were 
similar to those of the experimental groups, whereby if a given experimental group 

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intervention lasted for 30 minutes, the control group participants would be asked to sit with 
their eyes closed and relax for 30 minutes also.  
Procedure 
First, approval from the institutional review board at JUST was obtained. After 
obtaining permission from the dean of the nursing college at JUST and the students’ 
instructors, the PI visited the students in their classrooms. After the students’ lecture had 
finished, the PI made an announcement explaining the study title and objectives and asked 
any students who were interested in participating to contact him either on the phone number 
assigned for the purposes of the study or via email. The PI arranged an initial meeting to meet 
with students who were interested in participating, which was to be held on another day in a 
private room at the university. At this meeting, the PI informed the students of the study 
objectives, risks, and benefits, in addition to answering the students’ questions and assuring 
them that all collected data would be kept confidential. The students were also assured that 
they had the full right to refuse or discontinue participation at any time and that such refusal 
or discontinuation would not affect their academic achievement in any way. At the same 
meeting, informed consent was obtained from participants who agreed to participate and who 
met the eligibility criteria. After that, the participants were randomly assigned equally to the 
study groups using a computerized random numbers procedure carried out by a research 
assistant who was not involved in any other parts of the study. Finally, the dates and times of 
the sessions were determined.  
In the 2-hour educational session, baseline measurements of the study variables were 
taken. Then, the PI delivered a PowerPoint presentation for the participants in each subgroup, 
as previously explained. At the end of the workshop, to avoid experimental contamination, 
the participants in each experimental group were asked not to share any information related to 
the intervention with the participants in the control group.  

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 The actual training sessions were introduced to the participants in the experimental 
groups by the PI based on Smith’s (2005) guidelines and protocols. Based on the ABC 
Relaxation Theory (Smith, 1999, 2002, 2005), at least two, and preferably five, weekly 
sessions of actual mind-body training should be provided to evoke relaxation and optimize 
health (36, 37). The sessions were held in a private, quiet, comfortable, and spacious room at 
the university. As previously mentioned, the dependent variables were measured twice, at 
baseline and at the end of the intervention (i.e., In the next morning after the 5th session).  
Various strategies were followed to decrease measurement errors that could 
potentially be affected by variations in the data collection procedure. For example, filling out 
the questionnaire may be stressful for some subjects, hence influencing the objective 
measures. Therefore, the self-report measures were completed after the physical measures 
were taken. Also, all of the study measures in the intervention and control groups were taken 
in similar conditions, including similar room temperature and environment. In addition, quiet 
environments were maintained, with a “Do Not Disturb” sign placed on the doors of the 
rooms during the interventions and data collection. The data (questionnaire and blood 
samples) were collected by three research assistants with at least 10 years nursing 
experiences who were not involved in any other parts of the study. 
Statistical Analysis 
Statistical analysis was conducted using SPSS software (version 25). First, the data 
were examined for outlies, missing data, and violations of statistical tests assumptions and 
managed as appropriate.  Descriptive statistics were used to describe the sample. The sample 
and study variables were described by measures of central tendency and dispersion 
appropriate to the level of measurement. Initial independent t-tests and Chi-squared tests 
were conducted to ensure that the randomization across the covariates was successful, and 
one-way MANOVA was used to test the study hypotheses. Post hoc one-way ANOVAs were 

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run to examine if there were significant differences in each of the dependent variables 
between the study groups. Due to multiple testing, the p-value was adjusted by dividing the p 
value of .05 by 4 (i.e., the number of dependent variables), with a level of .0125 considered 
as the level of significance for the ANOVA tests.  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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