Coronavirus Disease 2019 (COVID-19), first reported in Wuhan China, has been described as
the first pandemic contributed to a coronavirus that has drawn intense attention
worldwide. Up to April 11th, 2020, at least 381 diagnosed cases and 7 deaths have been
reported in Jordan (Jordanian Health Ministry, 2020). Facing this critical situation,
nurses are struggling on the front line to manage patients with COVID-19, placing them at
risk of contracting the infectious disease (World Health Organization (WHO), 2020).

Like other countries, health care providers in Jordan account for a significant share of
their Covid-19 cases (Jordanian Health Ministry, 2020). Although Jordanian government has
undertaken much efforts to provide healthcare providers with personal protective
equipment and immunization to avoid contracting the disease, their psychological
well-being, like in other countries, have been disregarded (Duan, & Zhu, 2020; Huffington
& Williams, 2020). A combination of long shifts, understaffing, overwhelming workload,
and lack of sleep may all contribute to stress and mental burden of these healthcare
providers, compromising immune systems and make them more vulnerable to the infectious
disease (Chen, et al., 2020; WHO, 2020). The psychological effect experienced by nurses
during the COVID-19 pandemic was evident in the literature. Anxiety, stress, and
depression were commonly reported by nurses during the COVID-19 pandemics (Pratiwi, et
al., 2023) Nurses' health in hospital settings is the most important consideration for
providing excellent patient care. To achieve the optimal outcomes for the patients and
their families, it is required that nurses to be kept at the highest level of
psychological health. Therefore, officials and those in charge of health institutions
must find appropriate solutions to help nurses to cope with mental health problems. A
possible solution to nurses' mental health problems may rest in promoting medical
interventions such as mind- body interventions (Goyal, et al., 2014).

Mindfulness-based intervention (MBI) is one of the most popular mind-body therapy methods
used recently in psychotherapy, which is strongly associated with promotion physical and
psychological well-being, it is an effective method for reducing stress and improving
health (Bartlett, et al., 2021). Pascoe et al. (2017) imagined it as a combination of
five main components: act with awareness, internal observation and external experiences,
being non-judgmental, description and labeling and not reacting to thoughts and feelings.
Theoretically, practicing MBI develops mindfulness trait, and then relaxes the body and
mind and helps reduce the response or reactivity to stressful situation, traumatic events
and challenging experiences (Hofmann & Gómez, 2017). Many researchers have pointed to the
effectiveness of in-person mindfulness training programs in reducing nurses' stress,
anxiety, and depression in general health settings (Ghawadra, et al. 2020; Green &
Kinchen, 2021; Lomas, et al. 2019; Ramachandran, et al. 2022; Sulosaari, et al. 2022).

Mindfulness-based intervention (MBI) as a Mind-body therapy, recently increasing its
popularity in Jordan, are easily accessible, easy to learn and inexpensive (Yanyu, et
al., 2020). For easily accessible and nonphysical contact training mode, they can be
delivered quite efficiently by easy-to-carry electronic devices to healthcare providers
(Kubo, et al., 2019; Wiseman, et al., 2018). M-Health-based intervention is an innovative
approach of treatment delivery using mobile technologies such as cell phones (Kubo, et
al., 2019). Mobile phones are widely used in Jordan, with the most Jordanians (95%)
having a smart phone (Gazal, 2020). The widespread use of smart phones highlights their
potential to deliver cost-effective mind-body therapies that can be easily integrated
into the lives of busy healthcare providers who are unable to attend regular in-person
training sessions (Kubo, et al., 2019; Wiseman, et al., 2018). It also provides a
feasible and effective therapeutic way to optimize physical distancing during pandemics,
which contributes to decrease the transmission of infection (Tukur et al., 2023) Although
a wide array of research has been conducted examining the relationship between MBI and
psychological health problems in different populations (McGee, et al., 2023), this study
came as first study-to the best of research knowledge- to examine the effectiveness of
m-health-based MBI on stress, anxiety, and depression among nurses taking care patients
with COVID-19. Investigating the effects of MBI on psychological health in such nurses
may contribute to the development of evidence-based methods and guidelines for enhancing
the mental well-being of them during this unprecedented epidemic and may also enhance
humanity's ability to respond to other emerging pandemics.

Design This was an experimental study using pretest post-test randomized controlled
design.

3.2 Sample Nurses taking care patients with COVID-19 in the King Abdullah University
hospital (KAUH) who were aged at least 21 years old, had smart phones, and were able to
read and write in English, were included. KAUH designated by the Jordanian Ministry of
Health as the main COVID-19 testing and isolation center in the country's north.
Participants who had psychological therapies or medications were excluded.

Using G* Power software 3.1 (Faul et al., 2007), independent t-test, an alpha of 0.05, a
power of 0.8, and a moderate effect size of 0.5, a sample size of 102 was generated.

The sample was distributed randomly into the experimental group (n=61) and the control
group (n= 61).

3.4 Intervention The experimental group received five individuals 30-minute sessions of
MBI for five weeks in a private and quiet room at the hospital, according to Smith's
(2005) recommendation. The study intervention was an audio based MBI sent to them by the
WhatsApp application. It is a free, self-paced program developed by an experienced,
certified mindfulness practitioner based on the Smith's (2005) protocol to guarantee
greater adherence and consistent delivery of MBI. The audio recording of the MBI was
evaluated and validated for the clarity of voice and the MBI content by two psychologists
who are experts in MBI.

However, an instructional session, other than the five weekly sessions mentioned above,
was first conducted by the certified mindfulness practitioner to explain the rationale
and procedures of MBI including a demonstration of the entire MBI protocol for the
participants in the experimental group. This practitioner was also present during the
delivery of the five MBI sessions in the hospital to confirm and facilitate the
administration of the MBI sessions and answer any participants' questions. In addition,
the experimental groups' participants were encouraged to practice the intervention daily
at home, but home-based practice was not mandatory. Through the WhatsApp group, daily
reminders were sent to the participants in the experimental group to encourage them to
practice at home. Diaries was used by the experimental group's participants to document
the daily home-based practices. The participants in the experimental groups were
encouraged not to share any information regarding the MBI with anyone during the study.

The theory-based program includes the ABC standardized versions of MBI (Smith, 2005),
described as follows:

- The mindful mediators are asked to act as 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 19 stimuli. 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") (Smith, 2005).

- Participants in the control group were not asked to do anything during the study,
except their traditional practices. However, the MBI was provided to them after the
study.

3.5 Measurements The study data were collected using a self-report questionnaire at
baseline and at the end of intervention. The participants were asked to complete the
study self-report questionnaire, including three parts, as follows: 1) demographic
characteristics, and 2) The Depression, Anxiety, and Stress Scale (DASS-21), and 3)
Mindful attention Awareness Scale 3.5.1 Demographic and Health Characteristics The
demographic and health characteristics included sex, marital status, religion,
department, educational level, nursing experience (years), having chronic diseases, age,
weight, monthly income, general health status, nutritional status, sleeping status.

3.5.2 The Depression, Anxiety, and Stress Scale (DASS-21) The Arabic DASS was used to
measure depression, anxiety and stress in the current study (Lovibond & Lovibond, 1995).
The DASS-21 is a set of three self-report scales designed to measure the negative
emotional states of depression, anxiety and stress. Each of the three DASS subscales
contains 7 items. Subjects were asked to use 4-point severity/frequency scales to rate
the extent to which they had experienced each state. Scores for Depression, Anxiety and
Stress were calculated by summing the scores for the relevant items, and then multiplying
the summed scores by 2. The score range of each subscale is between 0.0 to 42. Higher
scores of the three subscales indicate higher levels of those emotional states. The DASS
has shown acceptable levels of validity and reliability in clinical and healthy
populations (Lovibond & Lovibond, 1995). The reliability and validity of Arabic version
of DASS demonstrated acceptable reliability and validity of this tool (Alharbi et al.
2023). In Jordanian nursing students, the Cronbach's alphas for the stress, anxiety, and
depression subscales were .73, .82, and .80 respectively (Alhawatmeh et al., 2022).

3.5.3. the Mindful Attention Awareness Scale (MAAS) was used to measure trait
mindfulness. The MAAS is one-dimensional and comprises 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 scores indicating higher levels of trait mindfulness. The
Arabic MAAS has been shown to have excellent internal consistency and convergent validity
among an Arab population.

3.6 Data collection and Ethical consideration After getting the IRB approval, the
hospital administrators were contacted by the study researchers to obtain approval for
conducting the study. After approval, the nurses were contacted in person by one of the
study researchers to explain the study purpose and procedure. If they agreed to
participate, the nurses were asked to sign the consent form. After that, a study
researcher who was not involved in the recruitment process and patient assessment
randomly assigned the participants to the intervention group or the control group, using
a simple 1:1 computer-generated sequence. Then, the schedule of practicing the MBI as the
protocol described above was given for the participants in the experimental group, which
was built based on their work schedule.

The study measurements were taken at the hospital by one of the study researchers
(nurses) at baseline and at the end of the intervention. Also, all study measurements in
the intervention and control groups were undertaken in the same conditions (i.e., same
room temperature and environment) by a well-trained nurse who has a master's degree in
nursing science.

3.7 Statistical Analysis Data were analyzed using the Statistical Package for Social
Science (SPSS), Version 26. Descriptive statistics were used to describe the study
participants as appropriate. For instance, frequency and percentage were used to describe
the categorical variables, while mean and standard deviation (SD) were used to describe
the continuous variables. Also, the baseline statistical equivalence between the study
groups on the dependent and sociodemographic variables was evaluated using independent
t-tests. Dependent t-tests were used to examine if there were statistically significant
changes between the pretest and posttest in each study group. Finally, independent
t-tests were used to examine if there was a statistically significant difference between
the experimental and control group at the end of the intervention.