The Distinct Effects of Mind-Body Modalities on Health Outcomes in Nursing Students
Phase: NA
Conditions: Stress Reaction, Stress, Psychological, Stress, Physiological
Sponsor: Jordan University of Science and Technology

 
 
 
The Distinct Effects of Mind-Body Modalities on Health Outcomes in Nursing Students 
Study Protocol 
Date: July 1, 2019 
NCT Number: Not issued yet  
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Introduction 
Stress has been recognized worldwide as a prevalent health issue in nursing education 
[1]. Nursing students generally reported moderate to high levels of stress, sometimes higher 
than students from other disciplines [1,2]. The reason is that undergraduate nursing students 
are not only influenced by academic and social stressors, but also clinical stressors during 
their long clinical training that require emotional and personal maturity [1,3]  
Although acute stress works to maintain bodily hemostasis, repeated exposures to 
stress over time can affect students’ physical, emotional, and cognitive health, academic 
performance, attrition, and ability to care for patients and themselves [4,5]. However, 
previous literature has showed that the negative effects of stress on health and wellbeing may 
be mediated by the activation of the hypothalamic-pituitary—adrenal (HPA) system (e.g. 
cortisol), and the sympathetic-adrenal-medullary (SAM) system (e.g. norepinephrine, 
epinephrine, and dopamine [6,7,8].  
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 affects mainly metabolic processes. Cortisol increases the concentration 
of blood glucose through gluconeogenesis, reduces glucose uptake in cells, suppresses 
immune system and inflammatory functions, increases amino acids, lipids, and fatty acids in 
the bloodstream, stimulates and increases gastric-acid secretion, and decreases formation of 
bone [6,7,8]. Increased cortisol resulting from stress usually impairs executive function 
abilities, which refers to the higher cognitive processes that enable planning, forethought, and 
goal-directed action [9].  
 

There are numerous potentially beneficial stress-reduction strategies that have been 
found to help college students effectively deal with stress and its negative health 
consequences worldwide [10]. Benson's (1975) relaxation response hypothesis states that all 
stress-reduction techniques have the same impact on health outcomes through evoking 
similar relaxation responses. Based on the relaxation response hypothesis, relaxation trainers 
are often contented to apply one general approach to relaxation to all clients.  However, the 
specificity theories of relaxation claim that each approach of relaxation is associated with 
different health benefits [11,12]. For example, PMR, classified as somatic technique, works 
better to improve physical health. Guided imagery is more effective in improving emotional 
health. Mindfulness meditation is categorized as a cognitive technique, which should work 
better for improving cognitive health. These benefits of all relaxation techniques are mediated 
by increased parasympathetic activity [11]. However, research offers conflicting support for 
this notion. This study will investigate and compare the empirically defined effects of three 
common mind-body modalities, including progressive muscle relaxation (PMR), guided 
imagery, (GI) and mindfulness meditation (MM), on cognitive, emotional and physical health 
in nursing students. In other words, this study is an attempt to rigorously map the emotional, 
physical, and cognitive effects of these mind-body modalities among Jordanian nursing 
students.  
Significance of Study 
Despite the potential benefits of using PMR, GI, and MM, their effects have not been 
studied among Jordanian nursing students. Specifically, the current study intends to offer 
information about the effect of PMR, GI, and MM on health outcomes in the target 
population. Practically, results from the study may inform the decision-making of faculty and 
administrators about adopting PMR, GI, and MM in nursing colleges. The expected results 
will hopefully give clinicians and relaxation trainers tools for intelligently tailoring 

techniques to students based on stress symptoms or health problems they experience [13]. 
Theoretically, the current study also extends the body of nursing knowledge and fill the 
theoretical gap in the literature regarding the effects of PMR, GI, and MM on health in 
nursing students and potentially support specificity theories of relaxation. 
Methods 
Design 
This study uses a blocked randomized controlled design. The study subjects will be 
selected using a convenience sampling method. When selected, the subjects will be randomly 
assigned to either one of the 4 study groups using a stratified random strategy (stratifying 
variable= academic year of study). The study groups (PMR, MM, GI, Control group) will 
received 5 30-minute weekly sessions of their assigned intervention over 5 weeks. However, 
there will be a 4-hours workshop explaining the purposes and techniques of the study 
interventions before introducing the actual session.  The subjects will be asked and 
encouraged to practice their assigned intervention for 30 minutes daily at home. The 
dependent variables will be measured three times for the 4 groups: at baseline, at the middle 
(after the second session), and at the end of intervention.  
Participants 
Participants are undergraduate nursing students who will be selected using a stratified 
random sampling method from Jordan University of Science and Technology. Jordanian 
undergraduate nursing students will be asked to participate in the current study if they are at 
least 18 years old and taking a clinical course. Exclusion criteria include students who are 1) 
practicing of any type of relaxation techniques, such as yoga, guided imagery, meditation, 
cognitive behavioral therapy, or 2) taking hypnotics, sedatives, anxiolytic, anti-depressant, 
anti-inflammatory drugs.  

Determination of Sample Size 
Using G* Power software 3.1, mixed-design (within groups-between groups) repeated 
measures ANOVA, an alpha of .05, a power of 0.8, the number of measurements of 3, the 
number of groups of 4, and a moderate effect size of 0.25, the sample size of 180 was 
generated. A 15 % attrition rate was reported in a previous study with variables similar to the 
present study [14]. Considering an expected attrition rate of 15 %, the required final total 
sample size 210.  
Intervention  
In the current study, the ABC standardized versions of PMR, MM, and GI will be 
used, including 5 30-minute weekly sessions of each version [11]. Each group will be 
encouraged to practice once at home daily. An additional educational 4-hour workshop about 
each intervention will be provided before the actual training session to enhance the subjects’ 
understanding of their assigned intervention. Especially such interventions are rarely 
practiced and little known about them in Jordan. In the initial educational session, the PI will 
separately provide a power point presentation to participants in each experimental group 
about the rationale and procedures of their assigned intervention and a demonstration of the 
entire intervention protocol. Participants will be asked briefly to practice their assigned 
intervention and then evaluated by the PI to make sure the interventions have been done 
correctly. The PI will give the participants the opportunity to ask questions during the 
educational session 
During the actual training sessions, the interventions will be introduced to subjects in 
the experimental groups using an audio CD designed and produced by the PI based on the 
Smith’s (2005) guidelines and protocols [11]. All groups will be given identical instructions; 
only the specific instructions regarding the intervention will be different. The participants in 

all groups will be asked to close their eyes. All of the groups will be meet in an academic 
classroom, where the interventions will be provided. Participants will sit in hard chairs 
behind a desk. Floors will be hard tile. Lights will be dimmed during relaxation phases, and 
turned on when measures will be filled out. The study groups will be given a CD about their 
assigned intervention and encouraged to practice their assigned intervention daily over the 
study. They will be asked to document their practices of the assigned intervention at home. 
The PI will randomly select sessions to evaluate the delivery of intervention using checklists 
produced according to the Smith’s protocols. PI is an experienced practitioner who received a 
stress management training at the Psychology Department, Kent State University 7 years ago. 
Since then, PI has been practicing the stress management techniques daily, especially used in 
the current study. 
Progressive Muscle Relaxation. PMR (Smith Version) involves a tense-let go 
exercise of 11 muscle groups including hand, arm, arm and sides, back, shoulder, face, front 
of neck, stomach, chest, leg, and foot. This tense-let go exercise is performed twice for each 
muscle group. The tensing up phase for each muscle group should last for 5 to 10 seconds 
and the letting go phase for 20-30 seconds. Simultaneously, the subjects will be asked to pay 
attention to the sensations of muscle tension and relaxation. After the tense-let go exercise, 
subjects are asked to systematically scan the muscle groups to notice and let go any 
remaining muscle tension. The entire exercise should take around 30 minutes, not counting 
instructions and times of measurement [11]. 
Guided Imagery. Guided imagery (Smith Version) involves creating in one's mind or 
imagining a passive relaxing places or activities. In sense imagery, one simply imagines 
sensations associated with a relaxing setting or activity. The relaxation approach involves the 
sense of sight, sound, touch, and smell. The categories of stimuli consist of: (1) Travel such 
as boats, plains, trains, balloons, horses, (2) outdoor nature settings such as mountains, 

gardens, and forest, (3) water such as rivers, lakes, ocean, beach, rain, and (4) indoor settings 
such as childhood home, castle, religious institution, and cabin [11].  
Mindfulness Meditation. Smith version of the mindfulness meditation will be used 
in the current study. The mindful mediators are neutral observers who view the world as it is, 
without reactions, judgments, and evaluations. They quietly attend to, note, and let go of 
every internal external stimulus such as thought, feeing, sensation, sound, idea that enters 
awareness. They do not try to think about, push away, and do anything with these stimuli 
experienced and do not have to figure out the connections between each stimulus. They 
simply let each stimulus come and go and wait for the next stimulus. They do not have to be 
concerned about distractions. Each time they are distracted, they note it as yet another passing 
stimulus (Ah, a distraction… how interesting") [11].  
Control Group. Participants in the control condition will be instructed to sit with 
their eyes closed during the intervention periods. Participants in the control group will follow 
an identical time period as the experimental groups. For instance, when the experimental 
groups will practice for 30 minutes, the participants in the control group will be asked to sit 
with eyes closed and relax for 30 minutes.  
Procedure 
First, approvals from the JUST institutional review boards will be obtained. After 
that, a translation from English to Arabic and pilot testing of the English versions of the 
scales used in the current study will be performed. The scales used in the study will be 
introduced for 30 Jordanian undergraduate nursing students, and then the construct validity, 
reliability (internal consistency), readability of these scales will be examined.   
After taking the permission of the dean of nursing college and class’s instructors, the 
PI will visit students in their classrooms. As the lecture finishes, The PI will announce the 

title and objectives of the study and ask the students who would like to participate to contact 
him using a business card including the PI’s contact information (his name, phone number, 
and email) given for each one. The contact information will be used only for the purpose of 
the study. The PI will arrange an initial meeting to meet with students who would like to 
participate on another day in a private room at the university. At this meeting, the PI will 
inform the students the study’s objectives, risks, benefits, and confidentiality and answer 
questions that they have about the study. Also, they will be assured that they have the full 
right to refuse or discontinue the participation at any time and that such refusal or 
discontinuation will not affect their academic achievements in any way. If agree to participate 
and eligibility criteria are met, informed consent will be obtained at the meeting. After that, 
the participants will be randomly assigned equally to the study groups using a stratified 
random assignment method (stratifying variable= academic year of study).  Finally, dates and 
times for sessions will be set up and sent to the participants using their e-mails.  
In the 4-hour education session, the baseline measurements of the study variables will 
first be obtained. Then the PI will separately provide a power point presentation to 
participants in each experimental group as explained previously. At the end of the workshop, 
to avoid experiment contamination, the participants in each experimental group will be asked 
not to share any information related to the intervention with subjects in other groups.  
  
The actual training will be introduced to subjects in the experimental groups, using an 
audio CD designed and produced by the PI based on the Smith’s (2005) guidelines and 
protocols.  Based on the ABC Relaxation Theory (Smith, 2005), at least two, and preferably 
five sessions of actual mind-body training should be provided to evoke relaxation and 
optimize health [15]. In the proposed study, the dependent variables will be measured at the 
middle and at the end of intervention to see whether further health benefits occur between 
these two measurements. The sessions will be provided to the study groups in a private, quiet, 

comfortable, and spacious room at the university. The dependent variables will be measured 
three times for the groups: at baseline, after 2nd actual training session, and at the end of 
intervention (after 5th session), as mentioned previously.  
Various strategies will be followed to decrease measurement errors potentially 
affected by variations of data collection procedure. For example, filling out the questionnaire 
may be stressful for some subjects and, in turn, influences objective measures. Therefore, the 
self-reports measures will be completed after taking the objective measures such as biological 
markers. Also, all study measurements in the intervention and control groups will be 
undertaken in the same conditions (i.e., same room temperature and environment) by well-
trained nurses as much as possible. The ELISA protocol, including blood sampling will 
strictly be followed. The neurotransmitters/hormones will be measured between 8:30 am and 
9:30 am for all subjects at sitting position. Drinking coffee, tea, and having should be avoided 
6 hours before the measurement of neurotransmitters/hormones. To decrease venipuncture-
related pain during blood sampling, EMLA cream will be used, which has been found 
effective in decreasing venipuncture-related pain in different populations [17]. In addition, 
quiet environments, free from distraction, will be maintained with a “Do Not Disturb” sign on 
the door of the rooms during the intervention and data collection.  
Instruments  
The study data will be collected using self-reported and physical measures. For the 
self-reported variables, the study will use a self-reporting questionnaire in 6 main parts. The 
first part includes questions about smoking behaviors and demographic characteristics  
including: age, religion, gender, marital status, academic year of study, nationality, history of 
medical or psychiatric illnesses, and smoking behaviors. The second part includes scales used 
to measure cognitive responses such as executive function, mindfulness, and perceived stress. 

The third part involves scales used to measure emotional health such as anxiety and 
depression. The fourth part includes a scale used to measure physical symptoms. The fifth 
part includes scale used to measure coping behaviors. The sixth part includes a scale used to 
measure fear-related injection.  The seventh part includes open-ended questions focusing on 
the students' experiences of practicing their assigned intervention. The last three parts will be 
measured to examine the confounding effects of coping behaviors and fear associated with 
blood sampling on the study outcomes.  
For the physical variables. The Enzyme-linked Immunosorbent Assay (ELISA) 
procedure will be used to measure serum biomarkers such as cortisol, melatonin, C-reactive 
protein, interleukin 1, and Leptin.  
Cognitive Responses  
Executive Functioning. Executive functioning is a set of inter-related higher-order 
cognitive abilities involved in self-regulatory functions that organize, direct, and manage 
cognitive activities, emotional responses, and overt behaviors (Barkley, 2011). The Barkley 
Deficits in Executive Functioning Scale- Short form (BDEFS-SF) (Adult version) will be 
used to measure executive functions including self-organization, self-restraint, self-
motivation, self-regulation of emotion, and self-management to time. It is a self-reported 
scale consisting of 20 items measured using a 4-point Likert-type scale, ranging from Never 
or rarely (1) to Sometimes (2), Often (3), and Very often (4).  The BDEFS-SF internal 
consistency was reported at an alpha of .92 in adult population. A confirmatory factor 
analysis supported the 5-factor structure of BDEFS in college students (19). 
Mindfulness. Mindfulness is defined as open or receptive awareness of and attention 
to what is taking place in the present (20).  Mindful Attention Awareness Scale (MAAS) will 
be used to measure dispositional mindfulness. It is one-dimensional scale including 15 items 

measured on a six-point Likert type scale, ranging from 1 (almost always) to 6 (almost 
never).  The score range is between 15 and 90, with higher score indicting higher levels of 
mindfulness. The scale has shown strong psychometric properties when validated in college 
students. It showed acceptable levels of reliability and validity in university students (20). 
Perceived Stress. The Perceived Stress Scale (PSS) is used to measure the degree to 
which situations in one’s life are appraised as stressful (unpredictable, uncontrollable, and 
overloaded). It includes 10 items measured on a 5-point Likert scale (0=never, 4= very often), 
which are relatively free of content specific to any subpopulation group. The scores range 
from 0 to 40 with higher score indicating higher levels of perceived stress (21). PSS has been 
validated for use with college students (21). 
Emotional Responses  
Depression. Depression will be measured by the General Health Questionnaire-9 
(PHQ-9) (22). It is reliable self-administered tool to evaluate the frequency of depressive 
symptoms in nursing students (23). It includes 9 items measured on a 4 likert scale (0= not at 
all, 3= nearly every day). The scores range from 0 to 27, with the higher scores indicated 
higher levels of depression (22).  
 Anxiety. Anxiety will be measured using the General Health Questionnaire-7 (PHQ-
7) (24). It is a valid and reliable self-report questionnaire for assessing the frequency of 
symptoms of anxiety in nursing students (23). It includes 7 items measured on 4-point Likert 
scale that ranges from 0 (not at all) to 3 (nearly every day0. The scores range from 0 to 21, 
with higher the total score indicates higher levels of anxiety (24).  
Negative Emotions: The negative emotions will be measured by the valid and 
reliable Depression, Anxiety and Stress Scale - 21 (DASS-21). It includes 3 self-administered 
subscales developed to assess the negative emotional states of depression, anxiety, and stress 

(PFA, 2014). The total scores for each subscale ranges from 0 to 42, with higher scores 
indicating more depression, anxiety and stress (25).   
Physical Responses 
Physical symptoms. The PHQ-15 is a self-reported somatic symptoms subscale, 
derived from the full Patient-Health-Questionnaire. It is a 15-item instrument that assesses 15 
common somatic symptoms. Subjects are asked to rate the severity of symptoms as 0 (“not 
bothered at all”), 1 (“bothered a little”), or 2 (“bothered a lot”). The score ranges from 0 to 30 
and scores of ≥5, ≥10, ≥15 represent mild, moderate, and severe levels of somatization 
respectively. Evidence supports reliability and validity of the PHQ-15 as a measure of 
physical symptoms in the general population (26).  
Biomarkers. The procedure and protocol of ELISA will be followed to measure the 
concentrations of the neurotransmitters and hormones in plasma that include cortisol, c-
Reactive protein, Interleukines, Melatonine, and Liptin (27).  
Covariates  
Coping Behaviors. Nursing students’ self-directed coping behaviors included in the 
current study as a covariate were assessed by the Coping Behaviors Inventory (CBI) (28). 
The CBI is used to identify nursing students’ coping behaviors. It includes nineteen 5-point 
Likert-type items divided into four factors: avoidance behavior (efforts to avoid a stressful 
situation), 6 items; problem-solving behavior (efforts to manage or change the stress arising 
out of a stressful situation), 6 items; optimistic coping behavior (efforts to keep a positive 
attitude toward the stressful situation), 4 items; and transference behavior (efforts to transfer 
one’s attention from the stressful situation to other things), 3 items. Higher scores for each 
factor indicate more frequent use and greater effectiveness of a certain type of coping 
behavior. It showed acceptable levels of reliability and validity in nursing students (28)   

Experiences of practicing the study interventions 
Open-ended questions asking about the students experiences of practicing the PMR, 
GI, or MM?” will be added to the questionnaire packet at the end of study. The objective of 
these questions is to explore the narratives as provided by the subjects in the experimental 
groups. Findings from this question will help the principal investigators to understand any 
positive and/or negative reactions on the study interventions based on the subjects’ feedback, 
thus, benefiting a plan for future larger research. Examples of these questions includes (29): 
1. What did you think about the (assigned intervention)? 
2. What did not like most about (assigned intervention)? 
3. What did like most about (assigned intervention)? 
4. Do you think (assigned intervention) were effective and worked for you?  
a. If no, please could you explain why it did not work for you? 
b. If yes, please could you explain how it worked for you? 
5. Was the length okay? Would you have preferred longer, shorter, or the same? 
6. Were there any obstacles of practicing (the assigned intervention) at home? 
Statistical Analysis 
Statistical analysis will be conducted using SPSS software (version 23). Descriptive 
statistics will be used to describe the sample. The sample and variables will be described by 
measures of central tendency and dispersion appropriate to the level of measurement. Initial 
analyses will be conducted to ensure that the randomization across covariates was successful. 
The gender, marital status, employment, nationality, and smoking behavior variables will be 
all tested at baseline using Chi-square to demonstrate that they are not significantly different 

between groups. Independent t-tests will be run at baseline measurements of dependent 
variables to make sure the study groups will be not significantly different on these variables 
before introducing the study intervention. One-way- ANOVA will be used to test the study 
hypotheses. Post hoc t-tests will be run to examine if the study groups will be significantly 
different on the dependent variables at end of the intervention. In case of having confounding 
effects of some variables, ANCOVA will be used. 
Ethical consideration  
Physical or psychological harm or risks that might be associated with the 
measurement activities or intervention employed in the current study will be minimal. One 
risk that might have resulted from the study was making demands on the subject’s time and 
venipuncture-related pain. Thus, the subjects were provided with compensations (10 
Jordanian Dinars) for their times spent in the study and ELMA cream will be used before 
blood sampling to decrease venipuncture-related pain. Moreover, trained nurses will draw 
blood from participants, following the Blood Sampling Guideline of the European Federation 
of Clinical Chemistry and Laboratory Medicine, 2017.  
Potential benefits of the measurement activities and intervention to study subjects 
included increased knowledge and awareness about their health and mind-body modalities. 
For society, potential benefits included a greater understanding of the effects of mind-body 
modalities on stress reduction and the potential improvement of the study population’s health. 
In this study, potential benefits are believed to exceed risks. 
To protect the ethical principle of respect for subjects, all subjects will be informed 
about the purpose and nature of the study, and informed consent will be obtained from all. 
Students will be assured that they have the full right to refuse to participate in the study, and 
that such refusal will not affect their academic achievements in any way. They will also be 

assured that their information would not be made available to others without prior consent, 
the study data will be locked in a secured storage area in a locked locker and that their names 
will be replaced by numbers to avoid their identification. Also, the meetings with students 
will be conducted in a private room at JUST and at convenient times for subjects. Moreover, 
to meet the ethical principle of justice, no student will be excluded from the study because of 
gender, ethnicity, or nationality. 
 
 
 
 
 
 
 
 
 
 
 
 
References 

1. Pulido‐Martos M, Augusto‐Landa JM, Lopez‐Zafra E. Sources of stress in nursing 
students: a systematic review of quantitative studies. International Nursing Review. 2012 
Mar;59(1):15-25. 
2.Shaban, I., Khater, W., & Akhu-Zaheya, L. (2012). Undergraduate nursing students’ stress 
sources and coping behaviors during their initial period of clinical training: A Jordanian 
perspective. Nurse Education in Practice, 12, 204-209. 
3.Wolf, L., Stidham, W., & Ross, R. (2014). Predictors of stress and coping strategies of US 
accelerated vs. generic BSN students: An embedded mixed methods study. Nursing 
Education Today, 35(1), 201-205. 
4.Chan, C., So, W., & Fong, D. (2009). Hong Kong baccalaureate nursing students’ stress 
and their coping strategies in clinical practice. Journal of Professional Nursing 25(5), 307-
313. 
5.Evans, W., & Kelly, B. (2004). Pre-registration diploma student nurse stress and coping 
measures. Nurse Education Today, 24(6), 473-483. 
6.Kinlein, S. A; Karatsoreos, I. N. The hypothalamic-pituitary-adrenal axis as a substrate for 
stress resilience: Interactions with the circadian clock. Front Neuroendocrinol 2020, 56, 
100819. https://doi.org/10.1016/j.yfrne.2019.100819 
7.Knight, E. L; Jiang, Y; Rodriguez-Stanley, J; Almeida, D. M; Engeland, C. G; Zilioli, S. 
Perceived stress is linked to heightened biomarkers of inflammation via diurnal cortisol in a 
national sample of adults. Brain Behav Immun 2021, 93, 206-13. 
https://doi.org/10.1016/j.bbi.2021.01.015 
8.Markozannes, G; Koutsioumpa, C; Cividini, S; Monori, G; Tsilidis, K.K; Kretsavos, N; 
Theodoratou, E; Gill, D; Ioannidis, J.P; Tzoulaki, I. Global assessment of C-reactive protein 

and health-related outcomes: an umbrella review of evidence from observational studies and 
Mendelian randomization studies. Eur J Epidemiol 2021, 36(1),11-36. 
https://doi.org/10.1007/s10654-020-00681-w 
9.Shields, G. S., Sazma, M. A., & Yonelinas, A. P. (2016). The effects of acute stress on core 
executive functions: a meta-analysis and comparison with cortisol. Neuroscience & 
Biobehavioral Reviews, 68, 651-668. 
10.Higginbotham, H. (2013). A psychoeducational approach to improving college student 
mental health. (Electronic Thesis or Dissertation). Retrieved from https://etd.ohiolink.edu/ 
11. Smith JC. Relaxation, meditation, & mindfulness: A mental health practitioner's guide to 
new and traditional approaches. Springer Publishing Company; 2005 Mar 4. 
12.Davidson, RJ, Schwartz GE. Psychobiology of relaxation and related states: A 
multiprocess theory. In D. I. Mostofsky (Ed.), Behavior control and the modification of 
physiological activity (pp. 399-442). Engle wood Cliffs, NJ: Prentice-Hall, 1976. 
13. Gillani NB, Smith JC. Zen meditation and ABC relaxation theory: An exploration of 
relaxation states, beliefs, dispositions, and motivations. Journal of Clinical Psychology. 2001 
Jun;57(6):839-46.  
14. Prato CA, Yucha CB. Biofeedback-assisted relaxation training to decrease test anxiety in 
nursing students. Nursing education perspectives. 2013 Mar 1;34(2):76-81. 
15. Matsumoto M, Smith JC. Progressive muscle relaxation, breathing exercises, and ABC 
relaxation theory. Journal of clinical psychology. 2001 Dec;57(12):1551-7. 
16. Jang FL, Lin CC. Synchronous measurements of finger surface temperature from three 
different kinds of temperature sensors. Transactions of the Canadian Society for Mechanical 
Engineering. 2013;37(3):1035-41.  

17. Fetzer, S. J. Reducing venipuncture and intravenous insertion pain with eutectic mixture 
of local anesthetic: a meta-analysis. Nurs Res 2002, 51(2), 119-24.  
18. Barkley RA. Barkley deficits in executive functioning scale (BDEFS). Guilford Press; 
2011 Feb 1. 
19. Coffman TP. The psychometric properties of the Barkley Deficits in Executive 
Functioning Scale (BDEFS) in a college student population (Doctoral dissertation). The 
Florida State University, 2014.  
 20. Brown KW, Ryan RM. The benefits of being present: mindfulness and its role in 
psychological well-being. Journal of personality and social psychology. 2003 Apr;84(4):822. 
21 Cohen S, Kamarck T, Mermelstein R. A global measure of perceived stress. Journal of 
health and social behavior. 1983 Dec 1:385-96.  
22. Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity 
measure. J Gen Intern Med. 2001;16(9):606–13. https://doi.org/10.1046/j.1525-
1497.2001.016009606.x. 
23. Ren L, Wang Y, Wu L, Wei Z, Cui LB, Wei X, Hu X, Peng J, Jin Y, Li F, Yang Q. 
Network structure of depression and anxiety symptoms in Chinese female nursing students. 
BMC psychiatry. 2021 Dec;21(1):1-2. 
24. Spitzer RL, Kroenke K, Williams JBW, Lowe B. A brief measure for assessing 
generalized anxiety disorder: the GAD-7. Arch Intern Med. 2006;166(10):1092–7. 
25. Rathnayake S, Ekanayaka J. Depression, anxiety, and stress among undergraduate nursing 
students in a public university in Sri Lanka. International Journal of Caring Sciences. 2016 
Sep 1;9(3):1020-32. 

26. Kocalevent RD, Hinz A, Brähler E. Standardization of a screening instrument (PHQ-15) 
for somatization syndromes in the general population. BMC psychiatry. 2013 Dec;13(1):1-8. 
27. Westermann J, Hubl W, Kaiser N, Salewski L. Simple, rapid and sensitive determination 
of epinephrine and norepinephrine in urine and plasma by non-competitive enzyme 
immunoassay, compared with HPLC method. Clinical laboratory. 2002 Jan 1;48(1-2):61-72. 
28. Sheu S, Lin HS, Hwang SL. Perceived stress and physio-psycho-social status of nursing 
students during their initial period of clinical practice: the effect of coping behaviors. Int J 
Nurs Stud. 2002 Feb;39(2):165-75. doi: 10.1016/s0020-7489(01)00016-5. PMID: 11755447. 
29. Kwekkeboom KL, Wanta B, Bumpus M. Individual difference variables and the effects 
of progressive muscle relaxation and analgesic imagery interventions on cancer pain. J Pain 
Symptom Manage. 2008 Dec;36(6):604-15. doi: 10.1016/j.jpainsymman.2007.12.011.