Evaluation of the efficacy of a brief mindfulness-based intervention on state-rumination and stress response of medical students following an exam: A randomized controlled study

Evaluation of the efficacy of a brief mindfulness-based intervention on state-rumination and stress response of medical students following an exam: A randomized controlled study | 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 Evaluation of the efficacy of a brief mindfulness-based intervention on state-rumination and stress response of medical students following an exam: A randomized controlled study Théodore Guillaumée, Antoine Lutz, Antoine Duclos, Thomas Rimmelé, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4486967/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: To prevent the medical students from a deleterious psychophysiological activation, it is necessary to provide them a large variety of stress management techniques. The primary aim was to assess the efficacy of a short Mindfulness-Based Intervention (MBI) to reduce state-rumination following an exam (Objective Structured Clinical Examination: OSCE). The second aims were to assess the efficacy of the short MBI to reduce stress-response and to identify the determinants of state-rumination. Methods: Students were randomly allocated to two parallel groups: 6-minute MBI or 6-minute control video. Levels of state-rumination (Brief State-Rumination Inventory) and stress-response (psychological and physiological markers) were assessed. Feelings during the video were reported. OSCE performance, gender, sleep quality, and sport practice were assessed. Participants were blinded to the group assignment, but the administrators and outcome assessors were not. NCT05390879. Results: Four hundred eighty-two students participated (n = 239 in MBI and n = 243 in Control) . Rumination did not differ between the groups (∆BSRI MBI -5 ± 12, ∆BSRI Control -5 ± 13, ∆BSRI t-test − 0.38 95% CI [-2.61:1.86], p = 0.740). The same applies to psychological stress (all p < 0.05). However, MBI students presented a lower physiological stress and reported more positive feelings during the video (all p < 0.05). Poor exam performance, female gender, poor sleep quality, and no sport practice were positively associated with state-rumination (all p < 0.05). Conclusions: MBI following an OSCE led to positive feelings and reduced physiological stress but neither psychological stress nor state-rumination. Performance, gender, sleep quality, and sport practice are determinants of state-rumination. This study offers insights that can inform the future development of specific interventions to reduce rumination in medical students. Heart Rate Variability Medical Students Mindfulness-Based Intervention OSCE State-rumination Stress Figures Figure 1 Figure 2 Background The Objective Structured Clinical Examination (OSCE) is a valid method to evaluate the medical performance and has been implemented worldwide. In France, OSCE is an important part of the national ranking exam for undergraduate medical students (Cortet et al., 2022 ) and could thus be considered as an event inducing a high anxiety (Marra, 2018 ). During their curriculum, medical students face numerous stressful situations (Linn & Zeppa, 1984 ; Mosley et al., 1994 ; Notman et al., 1984 ; Pacheco et al., 1999 ), which might lead to intense cognitive, emotional, and physiological changes (Everly & Lating, 2013 ; Matthews et al., 2013 ). These changes, that can be described as psychophysiological activation or stress response, are associated with increased activity of the cardiovascular, endocrinological, immunological, and neurovisceral systems, which promotes the development of numerous physiological and psychological diseases (Brosschot et al., 2006 ; Contrada & Baum, 2010 ; Flores-Kanter et al., 2021 ). In France, an alarming incidence of depressive symptoms, burn-out and suicidal thoughts was found among medical students (ANEMF et al., 2021) and similar results were reported worldwide (Dyrbye et al., 2006 ; Mosley et al., 1994 ; Pacheco et al., 1999 ; Rosal et al., 1997 ). In addition to the detrimental health impacts, elevated stress levels among medical students might also impede their performances (LeBlanc, 2009). Following the confrontation with a stressful situation, a common response is perseverative cognition, as manifested by rumination, which is likely to prolong the psychophysiological activation (Brosschot et al., 2006 ). Rumination can be defined as a tendency to focus on negative self-relative thoughts, and the possible causes and consequences of a negative mood (Nolen-Hoeksema, 1991 ). Rumination has two components: the trait-rumination, which represents the stable tendency to ruminate, and the state-rumination, which is triggered by a specific situation (Martin & Tesser, 1996 ). The occurrence of state-rumination after a stressor is associated with an altered emotional recovery (LeMoult et al., 2013 ), and a higher emotional reactivity (Hilt et al., 2015 ). While the stress response was extensively described in the literature, state-rumination remains less explored, and no study was performed on medical students. To prevent the medical students from the psychophysiological changes, it is necessary to provide them a large variety of stress management techniques (Lilot, 2019 ; Schlatter et al., 2022 ; Stillwell et al., 2017 ). Among these techniques, the practice of mindfulness meditation appears particularly promising and has been proposed in a variety of mindfulness-based interventions (MBI). MBIs were promoted as a coping strategy, especially in case of stressful situations (Crane et al., 2017 ) and consist of cultivating intentionally the awareness of one’s body, emotions, and thoughts, in order to detect and decenter oneself from any harmful thought schemes or negative cognitions (Pascoe et al., 2017 ; Segal & Walsh, 2016 ). Medium-term MBIs (up to several weeks) allow to decrease the level of rumination, stress, anxiety, depressive symptoms, and the risk of burnout (Daya & Hearn, 2018 ; Goyal et al., 2014 ; Jain et al., 2007 ; Lavadera et al., 2020 ), which could lead to an improvement of the well-being and the self-confidence of the students. In educational settings, mindfulness, by enhancing attention and emotional self-regulation, offers benefits to students and teachers alike, fostering a positive and caring learning environment (Emerson et al., 2017 ; Felver et al., 2016 ; Klingbeil & Renshaw, 2018 ; Lomas et al., 2017 ; Zenner et al., 2014 ; Zoogman et al., 2015 ). An MBI therefore appears to be a relevant emotional management tool to offer medical students in the aftermath of a stressful event. While MBIs described in the literature typically consist of multiple sessions lasting around forty minutes each, medical students already contend with a demanding schedule, which may deter them from engaging in such time-consuming practices. Therefore, it appears pertinent to evaluate a brief, single-session intervention immediately following an examination. The primary objective of this single-center, controlled, and randomized study was to assess the efficacy of an auto-guided MBI to reduce state-rumination following OSCE among medical students. The secondary objectives were to assess the effect of MBI on psychophysiological stress response and to identify the determinants of state-rumination in medical students. Material and Methods Study design and ethics This single-center, randomized, parallel-group, controlled study, with a 1:1 ratio is part of a bigger research project called ECOSTRESS. The study protocol was approved by the Institutional Review Board of Université Claude Bernard Lyon 1, Lyon, France (Approval Number: 2020-05-12-01). The study complied with the Declaration of Helsinki and was registered on clinicaltrials.gov (NCT05390879). The study was reported using the Consolidated Standards of Reporting Trials guidelines (Schulz, 2010 ). Participants All adults (> 18 years old) registered as medical students in the Université Claude Bernard Lyon 1 (Medical School of Lyon Est), who participated to the OSCE exam and gave an informed written consent before the study were included. No exclusion criterion was applied. This study was conducted during the OSCE that contributed to the final exam grades of 4th year medical students between May 17 and 19 2022. During the 50-minute OSCE circuit, each student had to complete five consecutive 7-minute clinical situations. The scenarios assessed the technical and non-technical clinical skills of the students ( e.g. collection of patient history, clinical examination, suturing, x-ray interpretation, delivering bad-news). The performance during each scenario was evaluated by an examiner (independent and blinded to the study protocol) using a specific pre-established standardized grid (ranging from 0 to 40 points). The overall performance of the students was obtained from the average of the five scores. Students were not aware of their score during the study, but the examiner provided a short feedback at the end of each clinical situation. Intervention At the end of the OSCE, students were directed to a room and guided to individual tables; they were given computers and headphones (Fig. 1 ). The students completed questionnaires to evaluate their levels of perceived stress and confidence as well as their arousal state using the PsyToolkit software (Stoet, 2010 , 2017 ). Subsequently, they were equipped with a pulse sensor, to collect the physiological data, and were asked to do nothing for a period of 90 seconds, to allow them to focus on their feelings and thoughts. At the end of this period, students were asked to complete a questionnaire to assess their level of state-rumination. They were then subjected to a 6-minute auto-guided MBI (MBI group), or control ( Control group) video. The auto-guided MBI video was set up as follows: students were first invited to sit comfortably and to close their eyes. Then, they were guided through a brief breath awareness, a focused attention meditation, followed by a brief open monitoring meditation on spontaneous sensations, emotions, and thoughts. They were then invited to do a brief appreciation and gratitude meditation for themselves and for others. The auto-guided MBI ended by an instruction to stay in open awareness for a moment (French video: https://www.youtube.com/watch?v=KKIiED7cL30 , the English content is available in Appendix A. 1.). The control was a non-emotional video introducing some scientific contents that were not related to the medical field (French video: https://www.youtube.com/watch?v=yXfoHS1kEs4 , the English content is available in Appendix A. 2.). To control a potential bias, the control video was presented as a strategy that intended to distract them from stressful thoughts, by learning something new. Following both videos, students were asked to complete the rumination and stress questionnaires again, to collect psychological data (levels of state-rumination, perceived stress and confidence, their feelings and arousal state). Then, their demographic data were collected (age, gender and body mass index) and they reported their physical activity practice, and their level of sleep troubles. Outcomes The primary outcome was the assessment of the evolution of the state-rumination. Students were asked to report their immediate level of state-rumination using the Brief State Rumination Inventory (BSRI). The BSRI is an 8-item questionnaire developed by Marchetti et al. ( 2018 ) to explore the “maladaptive aspects of ruminative thinking” of the state-rumination (Abstract-Analytical Mode) (Marchetti et al., 2018 ). All items are measured on a 100-mm visual analog scale (VAS-100-mm) ranging from “complete disagreement” (0) to “complete agreement” (100). The level of state-rumination is the mean of these eight items on a scale of 0 to 100. The version used herein was the French version adapted by Douilliez, Baeyens and Nalborczyk with the triple translate-retro-translate methodology (Nalborczyk et al., 2021 ) (Appendix B.1.). The secondary outcomes were the assessment of the psychophysiological stress response and the identification of the determinants of state-rumination. Regarding the psychological stress response, the levels of perceived stress and inner-confidence were assessed before and after the video using VAS 100-mm; for stress, a quantitative measure ranging from 0 (zero) to 100 (extreme), VAS-Stress, and a qualitative measure ranging from 0 (negative feeling) to 100 (positive feeling), VAS-valence (Barret et al., 2024 ; Schlatter, 2021 ). For inner-confidence a VAS ranging from 0 (no inner-confidence at all) to 100 (maximal inner-confidence), VAS-confidence (Barret et al., 2024 ; Schlatter, 2021 ) (Appendix C). The psychological response was also evaluated by assessing the arousal state. Before and after the video, the Activation-Deactivation Adjective Check List (AD-ACL, French version) was assessed. The AD-ACL is a multidimensional test composed of four subscales: energy, tiredness, internal tension, internal relaxation, ranging from 5 to 20 points for each dimension (Thayer, 1967 ). Considering the purpose of the study and thanks to a good reliability of subscales, internal relaxation and internal tension were assessed separately (Thayer, 1990 ). To evaluate the physiological stress response, students were equipped with an ear pulse sensor placed on one earlobe before the beginning of the video, which allowed the continuous record of the heart rate variability (HRV, EmWave Pro® software, HeartMath Technologies, Add Heart®, Boulder Creek, CA, USA). HRV analysis is a method to assess sympathetic and vagal activity (Malik et al., 1996 ). HRV was analyzed using Kubios (Kubios® HRV Standard 3.5.0 software, Kuopio, Finland). To obtain a reliable signal, three steps were followed: 1) the first ten seconds of each recording were systematically deleted; 2) to overcome missed heartbeats, an automatic low threshold was applied on raw interbeat interval; 3) the record was divided in 2 segments (T1: 00:00:10–00:02:10, T2: 00:02:11–00:07:10). T1 is the period of time of state-rumination emergence in which students stayed calm with no instruction for 90 seconds and answered to the BSRI, T2 is the period of time in which the students are watching the MBI or Control video. As such, only T2 was analyzed in this study. Recordings inferior to 7 minutes were considered as non-analyzable. Several HRV markers were computed. For the time-domain method, the standard deviation of normal-to-normal intervals (SDNN, ms, parasympathetically mediated), the root mean square of successive differences (RMSSD, ms, estimates the vagally-mediated changes), the proportion of NN50 divided by total number of NN (pNN50, percentage, estimates the vagally mediated changes) were extracted. All time-domain markers are highly correlated. For a subsequent multiple analysis RMSSD was selected, as it is the most cited (Shaffer & Ginsberg, 2017 ). For the frequency-domain method, the Low Frequency/High Frequency ratio (LF/HF ratio) was used. The LF/HF ratio is used for the sympathovagal balance (sympathetic/parasympathetic) (Shaffer & Ginsberg, 2017 ). The factors that may have influenced the markers including sports practice, age, gender, BMI, and sleep quality, were considered as needed. In addition, the feelings of the students during the video regarding pleasure, interest, fun, boredom, frustration, and discouragement were collected after the video, using Likert scales ranging from 1 (strong disagreement) to 5 (strong agreement). To identify the determinants of state-rumination, students reported their practice of physical activity using a Yes/No question and their level of sleep troubles using the French version of the Pittsburgh Sleep Quality Index (PSQI) (Buysse et al., 1989 ). The PSQI ranges from 0 to 21 points; scores greater or equal to six indicate sleep troubles during the last month(Buysse et al., 1989 ). As an exploratory outcome, this study tried to evaluate whether some secondary outcomes may have affected the evolution of state-rumination; the most experienced feelings during the videos as well as the RMSSD and LF/HF ratio stress markers were assessed. Sample size To align with fairness, ethics, and the pedagogical goals, participation was offered to all fourth year-students scheduled for the exam (n = 493), no other sample size was calculated. Randomization The students were randomly given a number before the OSCE. According to that number, they were guided to an individual table and allocated to the MBI group or to the Control group. Blinding Students were unaware of the different groups and whether they were in the intervention group. As mentioned above, the OSCE examiner was blinded to the study protocol. Statistical methods Statistical analyses were performed using the Rstudio software (Team 2022, Integrated Development Environment for R, Rstudio, PBC, Boston, MA, USA http://www.rstudio.com/ ). Visual inspection was used to confirm the normality of the data distribution with histograms and quantile-quantile plots. Variables were expressed as mean and standard deviation (SD) or as median and interquartile range (IQR). Results were compared using Student’s t-test or Wilcoxon signed rank test. All statistical analyses were two-tailed and a p-value < 0.05 was considered significant. To determine the influence of the video on the evolution of the state-rumination and of the other psychological responses, ∆scores were calculated for each psychological outcome assessed before and after the video (∆score = post-video score minus pre-video score). For instance, a negative ∆BSRI reflects a decrease of the level of state-rumination during the video. Multivariate analyses were conducted using multiple linear regressions. Results of multiple linear regressions are presented as estimate with 95% confidence interval (95% CI), the adjusted R 2 was also provided. Non-normally distributed variables were normalized using a logarithmic transformation. The effect size ( e.g. Cohen’s d or magnitude) can be classified as small (0.01), medium (0.06) or large (> 0.14) (Cohen, 2013). Cronbach’s alpha scores for internal consistency of BSRI and AD-ACL are provided. Results 1. Characteristics of the population A total of 482 students were included in the study (1 student declined to participate, Appendix D). At baseline, before the video, both groups were similar regarding demographical, psychological and physiological characteristics (Table 1 ). Table 1 Population's characteristics Variables MBI (n= 239) Control (n= 243) Demographic Age (years) 22 ± 2 [20;35] 22 ± 2 [18;38] Gender, n (%) Male 83 (35%) 83 (34%) Female 155 (65%) 159 (65%) Not answered 1 (< 0.1%) 1 ( 5, n (%) 125 (52%) 126 (52%) Psychological state pre-video BSRI (from 0 to 100) 43 ± 23 [0;100] 44 ± 23 [0;100] VAS-stress (from 0 to 100mm) 21 ± 26 [0;100] 23 ± 27 [0;100] VAS-valence (from 0 to 100mm) 53 ± 27 [0;100] 53 ± 27 [0;100] VAS-confidence (from 0 to 100mm) 46 ± 25 [0;100] 44 ± 26 [0;100] Internal relaxation (from 5 to 20) 11 ± 4 [5;18] 10 ± 4 [5;20] Internal tension (from 5 to 20) 7 ± 4 [5;20] 9 ± 4 [5;20] Values are expressed as mean ± standard deviation [min;max] or count and percentage. N = 482. Missing values: PSQI = 5. 251 (52%) students reported sleep troubles (PSQI > 5), 363 (75%) students declared practicing a regular sport practice. BSRI: Brief State Rumination Inventory. MBI: Mindfulness-Based Intervention. PSQI: Pittsburgh Sleep Quality Index. VAS: Visual Analog Scale. 2. Internal consistency of the scores All Cronbach’s alpha scores ranged from good to excellent internal consistency. The Cronbach’s alpha scores of pre- and post-video BSRI were 0.87 (95%CI [0.86;0.89]) and 0.92 95%CI [0.90;0.93], respectively. The Cronbach’s alpha scores of pre- and post-video AD-ACL internal tension were 0.85 (95%CI [0.824;0.88]) and 0.84 (95%CI [0.81;0.86]), respectively. The Cronbach’s alpha scores of pre- and post-video AD-ACL internal relaxation were 0.82 95%CI [0.80;0.84] and 0.83 95%CI [0.81;0.85], respectively. 3. Primary outcome BSRI MBI was 43 ± 23 before and 38 ± 24 after the video (∆BSRI MBI -5 ± 12). BSRI Control was 44 ± 23 before and 39 ± 25 after the video (∆BSRI Control -5 ± 13). The evolution of state-rumination did not differ between MBI and Control groups (∆BSRI t-test, -0.38 95%CI [-2.61:1.86], p = 0.740). 4. Secondary outcomes a. Psychological stress response The evolution of perceived stress (∆stress), inner confidence (∆confidence), internal relaxation (∆internal relaxation), and internal tension (∆internal tension) was not significantly different between the MBI group and the Control group (Table 2 ). Pre-video stress valence was slightly positive for both groups; the stress valence (VAS-valence) stayed positive in the Control group whereas it became neutral in MBI (∆valence, Table 2 ). Table 2 Effects of MBI on stress, stress valence, inner-confidence, internal relaxation, and internal tension compared to CONTROL. MBI (n = 239) Control (n =243) Estimate Difference [95%CI] p-value Effect size ∆stress -1 [-10;3] 0 [-11;5] -1 [-3;1] 0.348 NA ∆valence 0 [-9;10] -1 [-12;3] 3 [1;6] 0.008 0.121 (Small) ∆confidence 1 [-6;10] 0 [-7;8] 1 [-1;3] 0.328 NA ∆internal relaxation 1 [0;3] 1 [0;3] 0 [-0;1] 0.897 NA ∆internal tension 0 [-2;0] 0 [-1;0] -0 [-0;0] 0.445 NA Groups differences were assessed using Wilcoxon tests on deltas of variables. Delta (∆): post-video minus pre-video, presented with interquartile range. A negative delta represents a decrease, while a positive delta an increase of the score during the video. Results are repesented as estimate differences of the medians with 95% confidence intervals. MBI: Mindfulness-Based Intervention. CI: Confidence Interval. b. Physiological stress response The HRV markers were available for 465 students (97%), the percentage of analyzable segments did not differ between both groups ( Control 96.3% and MBI 96.6%, p = 1.000). Time-domain markers RMSSD and pNN50 showed no difference between groups (Table 3 ). SDNN was significantly higher in the MBI group compared to CONTROL (p < 0.001, Fig. 2 A, Table 3 ). It was not affected by factors such as sports practice, age, gender, BMI, and sleep quality (Table 4 ). Additionally, in the frequency-domain marker, students in the MBI group had a higher LF/HF ratio than those in the CONTROL group (p < 0.001, Fig. 2 B, Table 3 ). Table 3 HRV markers during the 6-minute video. MBI (n = 234) Control (n = 231) Estimate Difference p-value Effect size SDNN (ms) 49 [40;64] 43 [35;55] 6 [3; 9] < 0.001 0.176 (Small) RMSSD (ms) 46 [37;58] 43 [33;57] 3 [-0; 5] 0.058 NA pNN50 (%) 20 [14;29] 18 [11;30] 2 [-0; 4] 0.165 NA LF/HF ratio 1.9 [1.3;3.3] 1.6 [1;2.5] 0.36 [0.16; 0.57] < 0.001 0.159 (Small) n = 465. Group differences were assessed using Wilcoxon tests. HRV markers are presented as medians and interquartile ranges. Results of the tests are presented as estimate differences with 95% confidence intervals. HRV: Heart Rate Variability. LF/HF ratio: Low Frequency/High Frequency ratio. MBI: Mindfulness-Based Intervention. pNN50: Proportion of pairs of successive NNs that differ by more than 50ms. RMSSD: Root Mean Square of Successive Differences. SDNN: Standard Deviation of Normal-to-Normal. Table 4 SDNN according to the groups considering physiological factors SDNN Estimates [95% CI] p-value MBI 6.36 [2.734;9.99] 0.001 BMI 0.08 [-0.58;0.75] 0.804 Age -0.85 [-1.83;0.12] 0.087 Gender [Male] 4.06 [0.05;8.07] 0.047 Sport [Practice] 4.24 [-0.06;8.54] 0.053 Sleep [Troubles] -0.496 [-4.15;3.16] 0.790 The multiple linear regression was performed on 465 students due to missing data (on sleep quality and gender, n = 5 and 2 respectively). 95% CI: 95% Confidence Interval. BMI: Body Mass Index. MBI: Mindfulness Based Intervention. SDNN: Standard Deviation of Normal-to-Normal (higher SDNN means lower physiological stress). R 2 /R 2 adjusted: 0.05/0.04. c. Feelings during the video The students in the MBI group felt more pleasure, interest, enthusiasm, fun, and less boredom during the video compared with the students in the Control group. Both groups experienced similar levels of discouragement and frustration. The most represented positive feeling was interest, and the most represented negative feeling was boredom (Table 5 ). Table 5 Feelings reported by the students during the 6-minute video. Feeling MBI (n= 239) Control (n= 243) p value Effect size Positive feelings Fun 1[1;2] 1[1;1] 0.001 0.152 (large) Enthusiasm 2[1;3] 1[1;1] < 0.001 0.442 (large) Interest 3[2;3] 1[1;2] < 0.001 0.481 (large) Pleasure 2 [1;3] 1[1;1] < 0.001 0.449 (large) Negative feelings Discouragement 1[1;2] 1[1;2] 0.482 NA Boredom 2[1;3] 4[3;5] < 0.001 0.490 (large) Frustration 1[1;2] 1[1;3] 0.106 NA n = 482. Feelings’ intensities range from 0 (lowest intensity) to 5 (highest intensity). Values are expressed as medians and interquartile range. Groups differences were assessed using Wilcoxon tests. MBI: Mindfulness-Based Intervention. d. Determinants of pre-video state-rumination The multiple linear regression found that the pre-video level of state-rumination (pre video BRSI) was negatively associated with both the performance to the exam and a sport practice (Table 6 ). Conversely, it was positively associated with female gender and sleep troubles (Table 6 ). Table 6 Multiple linear regression of determinants of state-rumination state post-exam. BSRI pre-video Determinants Estimates [95% CI] p-value Overall Performance -0.88 [-1.37;-0.39] < 0.001 Gender [Female] 11.63 [7.50;15.75] < 0.001 Sport [Practice] -5.47 [-10.00;-0.95] 0.018 Sleep [Troubles] 9.48 [5.58;13.37] < 0.001 The multiple linear regression was performed on 475 students due to missing data (on sleep quality and gender, n = 5 and 2 respectively). 95% CI: 95% Confidence Interval. BSRI: Brief State-Rumination Inventory, mean of the eight items on a scale of 0 to 100. R 2 /R 2 adjusted: 0.152/0.145. Discussion The first aim of this study was to assess the effect of a short MBI on rumination following an exam in medical students. The second aims were to assess the effect on psychophysiological stress response and to deepen our understanding of state-rumination. As main results, we determined that rumination and psychological stress did not differ between the groups. However, MBI students presented a lower physiological stress and reported more positive feelings. Poor exam performance, female gender, poor sleep quality, and no sport practice were positively associated with state-rumination. This study offers insights that can inform the future development of specific interventions to reduce rumination in medical students, such as improving sleep practices and increasing physical activity. MBI and state-rumination The results did not report an influence of a short MBI on the evolution of state-rumination after a stressful exam (OSCE). Conversely, in previous studies, medium-term MBI showed encouraging results concerning the reduction of rumination (Daya & Hearn, 2018 ; Goyal et al., 2014 ; Lavadera et al., 2020 ). Jain et al. reported a reduction of state-rumination in MBI-trained medical students (Jain et al., 2007 ). Nevertheless, the MBI developed by Jain et al. consisted of four 90-minute sessions prior to examinations. A similar pattern is observed in the studies included in the Daya & Hearn review. Consequently, the duration, frequency, and temporality of the intervention were distinct from those of our study. Those differences may account for the disparate outcomes, and it can be hypothesized that longer and/or more frequent interventions might be needed to see a decrease in rumination. MBI and psychological stress response Similar to the results for rumination, the evolutions of perceived stress, inner-confidence, internal relaxation, and in the internal tension were not influenced by the MBI. A significant, yet negligible, effect to “neutralize” the qualitative aspect of the stress was found among MBI students. However, this has not been the subject of previous research, and future studies are needed to clarify this point. MBI and physiological stress response The present study found that physiological stress response was lower in students of the MBI group compared with those of the Control group ( e.g. higher SDNN and LF/HF ratio in MBI, and a trend toward higher RMSSD). A low SDNN was widely used in studies as a marker of physiological stress response or of cardiac medical risk (Shaffer et al., 2014 ), hence, an increased SDNN might underline a reduction of this risk. While some authors found an increased LF/HF ratio following other stress remediation interventions (Schlatter et al., 2021 ), the interpretation of the LF/HF ratio remains controversial (Shaffer & Ginsberg, 2017 ). In a recent meta-analysis, Brown et al. ( 2021 ) assessed the link between MBI, RMSSD and SDNN, and concluded that MBI training did not significantly influence these markers compared to the control condition (Brown et al., 2021 ). However, in a recent randomized control trial, Kirk et al. found that a 20-minute MBI produced a significant change of RMSSD (Kirk & Axelsen, 2020 ). This finding, consistent with the results reported herein, supports the idea that a brief MBI still has a significant impact on the physiological stress response. The present study is the first to report that an even shorter intervention, that lasts only 6 minutes, can induce significant physiological changes. Feelings during the intervention Students who experienced MBI reported more pleasure, interest, enthusiasm, fun, and less boredom during the video; the two videos were not perceived in the same way by students. This underlines that the MBI may have benefited the students in dimensions other than rumination or stress. The positive feelings at the end of an exam could have medium- or long-term benefits, reducing apprehension about upcoming exams, for example. Future studies will require an extended observation period to determine the long-term influences of increased positive feelings. Determinants of state-rumination The present findings reported that a reduced exam performance was associated with higher state-rumination in medical students, which suggests that students may have had an implicit knowledge of their performance during the exam, potentially biased by the short feedback of the examiner at the end of each clinical scenario. No previous study assessed the potential links between performance at an exam and state-rumination in a real-life context. Being a female was also associated with higher state-rumination level. This gender difference is well known and results from a combination of multiple sociocultural and personal factors (Nolen-Hoeksema et al., 1999 , 2007 ). Nolen-Hoeksema et al. hypothesized that this difference might be one of the reasons of the difference regarding depression between males and females (Nolen-Hoeksema et al., 1999 ). Thus, female students appear to be particularly at risk for rumination, and possibly related long-term health issues, and may need closer support if they feel the need. The present results also found that poor sleep quality was associated with higher state-rumination. As a result, future studies should explore the effect of other interventions that would aim at improving sleep quality or quantity ( e.g. , medium-term mindfulness program, reduction of screen-time) to reduce rumination in medical students (Li et al., 2020 ; Ramjan et al., 2021 ; Spanhel et al., 2022 ). A sport practice was associated with lower state-rumination; hence, encouraging a sport practice during medical studies may be a key to reduce state-rumination triggered by exams. Limits and Strengths The present study has some limitations. Ten students did not come to their exam, and thus were not included. However, due to the large sample size, it is unlikely that the inclusion of those ten students would have changed the main result. Another limitation is that the post-exam recovery period might be not usual to students. They usually go out quickly after the exam and do not stay quietly in a room for half an hour. This situation could have interfered with the natural course of rumination. The results of this study may have limited generalizability due to its single-center design. However, as other studies reported similar stressful conditions among medical students worldwide, the present results could be extended to most of the medical students. The study also has notable strengths. Almost all the targeted students were included, leading to a large and homogenous sample size of more than 480 participants. The high level of participation may indicate that students are concerned about their mental health and saw a potential benefit to participate to the study. Still, it is of note that we focused on a particular population. Participants were young, mostly female, prone to stress, and presented sleep troubles, which aligns with the medical student’s population’s characteristics previously documented in the literature. (Khaksarian et al., 2020 ; Pacheco et al., 1999 ; Sun et al., 2022 ; Unwin et al., 2013 ). Also, the approach of the present findings is multimodal, which allows to distinct the effects on psychological and physiological aspects. Of note, a significant amount of physiological data was extracted and analyzed. The OSCE might be perceived as an uncontrollable, novel, unpredictable, and ego-threatening situation it may be considered as the perfect stressor. Since these characteristics were linked to higher level of stress and rumination in the literature (Zoccola et al., 2012), our results may be comparable to other types of stressors. Conclusion The short “single shot” MBI performed immediately after an exam did not provide a decrease of state-rumination state or psychological stress response as compared with control. However, it reduced the physiological stress response. Besides, this study highlighted that a poor exam performance, female gender, sleep troubles and a lack of sport practice were associated with an elevated state-rumination. These results suggest the need to evaluate the potential benefits of such single or repeated intervention over the longer term. This study also offers insights that can inform the future development of specific interventions to reduce rumination in medical students, such as improving sleep practices and increasing physical activity. Abbreviations AD-ACL Activation-Deactivation Adjective Check List BSRI Brief State-Rumination Inventory HRV Heart Rate Variability LF/HF ratio Low Frequency/High Frequency ratio MBI Mindfulness-Based Intervention OSCE Objective Structured Clinical Examination pNN50 Proportion of pairs of successive NNs that differ by more than 50ms PSQI Pittsburgh Sleep Quality Index RMSSD Root Mean Square of Successive Differences SDNN Standard Deviation of Normal-to-Normal VAS Visual Analog Scale Declarations Author Contribution TG: Conceptualization; Data curation; Formal analysis; Investigation; Methodology; Roles/Writing - original draft; Writing - review & editingAL: Conceptualization; Methodology; Writing - review & editingAD: Conceptualization; Methodology; Writing - review & editingTR: Conceptualization; Funding acquisition; Methodology; Project administration; Resources; Supervision; Writing - review & editingNB: Data curation; Formal analysis; Investigation; Methodology; Writing - review & editingAB: Data curation; Formal analysis; Investigation; MethodologyGR: Conceptualization; Funding acquisition; Project administration; Resources; Supervision; Writing - review & editingML: Conceptualization; Funding acquisition; Investigation; Methodology; Project administration; Resources; Supervision; Roles/Writing – original draft, Writing- review & editingSS: Conceptualization; Data curation; Formal analysis; Investigation; Methodology; Resources; Supervision; Roles/Writing - original draft; Writing - review & editing Acknowledgement The authors would like to thank: - The Service de Santé Universitaire of the Université Claude Bernard Lyon 1- Marion Cortet, Cecile Chenavas and Karima Chiter of Faculté de Médecine Lyon Est, Université Claude Bernard Lyon 1- Denis Favre and David Romeuf of the University Lyon 1 Information Technology department - Lucas Denoyel and Sebastien Sygiel of the University Lyon 1 simulation center (CLESS), SIMULYON.- The scientific review committee of the Hospices Civils de Lyon - All investigators, teachers and students involved in the ECOSTRESS project: Aissaou Ouissal, Badina Evane, Ben Messaoud Alexandre, Binay Marion, Bretaire Kenza, Chaoui Clara, Chour Ali, Cuisinier Valentine, Degot Matthieu, Delacour Isia, Elmoujahid Azzeddine, Haouchache Nour, Le Noach Marie, Le Saux Olivia, Lecante Ludivine, Lecoq Valériane, Mairet Sacha, Maresca Sonia, Marolleau Julie, Melchior Dan, Moulin Owein, Nanette Pierre, Neidecker Marie, Plasse Benjamin, Ravaux Camille, Schmidt Laura, Tapastau Alisa, Tran Gaston.- Ursula Debarnot and Aymeric Guillot of Inter-University Laboratory of Human Movement Biology-EA 7424, Université de Lyon, for their help for the writing of the script of the control video. 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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-4486967","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":310995703,"identity":"25f98822-1877-473c-b68b-3ec93b721345","order_by":0,"name":"Théodore Guillaumée","email":"data:image/png;base64,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","orcid":"","institution":"Université Claude Bernard Lyon 1, Faculté de Médecine Lyon Est","correspondingAuthor":true,"prefix":"","firstName":"Théodore","middleName":"","lastName":"Guillaumée","suffix":""},{"id":310995704,"identity":"c18de6b0-145c-43cb-8d00-80bfdcdf48da","order_by":1,"name":"Antoine Lutz","email":"","orcid":"","institution":"Université Claude Bernard Lyon 1, Faculté de Médecine Lyon Est","correspondingAuthor":false,"prefix":"","firstName":"Antoine","middleName":"","lastName":"Lutz","suffix":""},{"id":310995705,"identity":"ce09b4b3-780a-4117-a4f1-1a31cd2b8e0d","order_by":2,"name":"Antoine Duclos","email":"","orcid":"","institution":"INSERM U1290, Université Claude Bernard Lyon 1","correspondingAuthor":false,"prefix":"","firstName":"Antoine","middleName":"","lastName":"Duclos","suffix":""},{"id":310995706,"identity":"640f7570-1b44-45f8-8d95-2a8466158fd6","order_by":3,"name":"Thomas Rimmelé","email":"","orcid":"","institution":"Université Claude Bernard Lyon 1, Faculté de Médecine Lyon Est","correspondingAuthor":false,"prefix":"","firstName":"Thomas","middleName":"","lastName":"Rimmelé","suffix":""},{"id":310995707,"identity":"8256a54e-0cdb-4787-be3d-d04469b0f489","order_by":4,"name":"Noémie Barret","email":"","orcid":"","institution":"Université Claude Bernard Lyon 1, Faculté de Médecine Lyon Est","correspondingAuthor":false,"prefix":"","firstName":"Noémie","middleName":"","lastName":"Barret","suffix":""},{"id":310995708,"identity":"00823172-f429-43ce-888e-c6aece52d6ab","order_by":5,"name":"Alexandre Berland","email":"","orcid":"","institution":"Université Claude Bernard Lyon 1, Faculté de Médecine Lyon Est","correspondingAuthor":false,"prefix":"","firstName":"Alexandre","middleName":"","lastName":"Berland","suffix":""},{"id":310995709,"identity":"71a6f8cc-484f-474a-826e-02421f5b9233","order_by":6,"name":"Gilles Rode","email":"","orcid":"","institution":"Université Claude Bernard Lyon 1, Faculté de Médecine Lyon Est","correspondingAuthor":false,"prefix":"","firstName":"Gilles","middleName":"","lastName":"Rode","suffix":""},{"id":310995713,"identity":"28155097-61b2-48db-8289-0fc5e858d82b","order_by":7,"name":"Marc Lilot","email":"","orcid":"","institution":"Université Claude Bernard Lyon 1, Faculté de Médecine Lyon Est","correspondingAuthor":false,"prefix":"","firstName":"Marc","middleName":"","lastName":"Lilot","suffix":""},{"id":310995716,"identity":"0c650335-78ee-47b2-97e5-55096e336aa1","order_by":8,"name":"Sophie Schlatter","email":"","orcid":"","institution":"INSERM U1290, Université Claude Bernard Lyon 1","correspondingAuthor":false,"prefix":"","firstName":"Sophie","middleName":"","lastName":"Schlatter","suffix":""}],"badges":[],"createdAt":"2024-05-27 20:44:14","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4486967/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4486967/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":58229039,"identity":"aa231c7e-c913-4858-8cd1-1ee4396b3d27","added_by":"auto","created_at":"2024-06-12 19:13:49","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":597430,"visible":true,"origin":"","legend":"\u003cp\u003eStudy design\u003c/p\u003e\n\u003cp\u003eOSCE: Objective Structured Clinical Examination. BSRI: Brief State Rumination Inventory. VAS: Visual Analog Scale. AD-ACL: Activation-Deactivation Adjective Check List. HRV: Heart Rate Variability. MBI: Mindfulness-Based Intervention.\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4486967/v1/235809798fccdb42b37162de.jpg"},{"id":58229037,"identity":"5c9f85b8-700c-4eda-bb4b-ed6eb965255c","added_by":"auto","created_at":"2024-06-12 19:13:49","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":237667,"visible":true,"origin":"","legend":"\u003cp\u003eSDNN and LF/HF ratio during the video according to the group\u003c/p\u003e\n\u003cp\u003en=465. Boxplots represent medians, first and third quartiles, colored violin plots show the probability density. A. SDNN: Standard deviation of NN intervals, expressed in ms. B. LF/HF ratio: Low Frequency on High Frequency ratio. Higher SDNN scores showed higher activation of parasympathetic nervous system. Higher LF/HF scores showed a modification of the sympathetic/parasympathetic balance. MBI: Mindfulness-Based Intervention. White boxplots indicate the controlgroup. Grey violin plots indicate the controlgroup. Orange violin plots indicate the MBI group.\u003c/p\u003e","description":"","filename":"Figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4486967/v1/d57238ec475d67beb9ae23a0.jpg"},{"id":58289441,"identity":"38bf94ad-7b17-4314-b87a-1b9e3972175d","added_by":"auto","created_at":"2024-06-13 13:15:17","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1480220,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4486967/v1/86926c79-1d36-4678-9599-d8271008cf45.pdf"},{"id":58230766,"identity":"fd479ad6-e913-40f9-9d83-43420f5da655","added_by":"auto","created_at":"2024-06-12 19:21:49","extension":"doc","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":308736,"visible":true,"origin":"","legend":"","description":"","filename":"Appendices.doc","url":"https://assets-eu.researchsquare.com/files/rs-4486967/v1/ba9e3cdd32d5ee5963b076cb.doc"}],"financialInterests":"No competing interests reported.","formattedTitle":"Evaluation of the efficacy of a brief mindfulness-based intervention on state-rumination and stress response of medical students following an exam: A randomized controlled study","fulltext":[{"header":"Background","content":"\u003cp\u003eThe Objective Structured Clinical Examination (OSCE) is a valid method to evaluate the medical performance and has been implemented worldwide. In France, OSCE is an important part of the national ranking exam for undergraduate medical students (Cortet et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) and could thus be considered as an event inducing a high anxiety (Marra, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). During their curriculum, medical students face numerous stressful situations (Linn \u0026amp; Zeppa, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e1984\u003c/span\u003e; Mosley et al., \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e1994\u003c/span\u003e; Notman et al., \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e1984\u003c/span\u003e; Pacheco et al., \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e1999\u003c/span\u003e), which might lead to intense cognitive, emotional, and physiological changes (Everly \u0026amp; Lating, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2013\u003c/span\u003e; Matthews et al., \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2013\u003c/span\u003e). These changes, that can be described as psychophysiological activation or stress response, are associated with increased activity of the cardiovascular, endocrinological, immunological, and neurovisceral systems, which promotes the development of numerous physiological and psychological diseases (Brosschot et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2006\u003c/span\u003e; Contrada \u0026amp; Baum, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2010\u003c/span\u003e; Flores-Kanter et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). In France, an alarming incidence of depressive symptoms, burn-out and suicidal thoughts was found among medical students (ANEMF et al., 2021) and similar results were reported worldwide (Dyrbye et al., \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2006\u003c/span\u003e; Mosley et al., \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e1994\u003c/span\u003e; Pacheco et al., \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e1999\u003c/span\u003e; Rosal et al., \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e1997\u003c/span\u003e). In addition to the detrimental health impacts, elevated stress levels among medical students might also impede their performances (LeBlanc, 2009).\u003c/p\u003e \u003cp\u003eFollowing the confrontation with a stressful situation, a common response is perseverative cognition, as manifested by rumination, which is likely to prolong the psychophysiological activation (Brosschot et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2006\u003c/span\u003e). Rumination can be defined as a tendency to focus on negative self-relative thoughts, and the possible causes and consequences of a negative mood (Nolen-Hoeksema, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e1991\u003c/span\u003e). Rumination has two components: the trait-rumination, which represents the stable tendency to ruminate, and the state-rumination, which is triggered by a specific situation (Martin \u0026amp; Tesser, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e1996\u003c/span\u003e). The occurrence of state-rumination after a stressor is associated with an altered emotional recovery (LeMoult et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2013\u003c/span\u003e), and a higher emotional reactivity (Hilt et al., \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). While the stress response was extensively described in the literature, state-rumination remains less explored, and no study was performed on medical students.\u003c/p\u003e \u003cp\u003eTo prevent the medical students from the psychophysiological changes, it is necessary to provide them a large variety of stress management techniques (Lilot, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Schlatter et al., \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Stillwell et al., \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). Among these techniques, the practice of mindfulness meditation appears particularly promising and has been proposed in a variety of mindfulness-based interventions (MBI). MBIs were promoted as a coping strategy, especially in case of stressful situations (Crane et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2017\u003c/span\u003e) and consist of cultivating intentionally the awareness of one\u0026rsquo;s body, emotions, and thoughts, in order to detect and decenter oneself from any harmful thought schemes or negative cognitions (Pascoe et al., \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Segal \u0026amp; Walsh, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). Medium-term MBIs (up to several weeks) allow to decrease the level of rumination, stress, anxiety, depressive symptoms, and the risk of burnout (Daya \u0026amp; Hearn, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Goyal et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; Jain et al., \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2007\u003c/span\u003e; Lavadera et al., \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2020\u003c/span\u003e), which could lead to an improvement of the well-being and the self-confidence of the students. In educational settings, mindfulness, by enhancing attention and emotional self-regulation, offers benefits to students and teachers alike, fostering a positive and caring learning environment (Emerson et al., \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Felver et al., \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; Klingbeil \u0026amp; Renshaw, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Lomas et al., \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Zenner et al., \u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; Zoogman et al., \u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). An MBI therefore appears to be a relevant emotional management tool to offer medical students in the aftermath of a stressful event. While MBIs described in the literature typically consist of multiple sessions lasting around forty minutes each, medical students already contend with a demanding schedule, which may deter them from engaging in such time-consuming practices. Therefore, it appears pertinent to evaluate a brief, single-session intervention immediately following an examination.\u003c/p\u003e \u003cp\u003e The primary objective of this single-center, controlled, and randomized study was to assess the efficacy of an auto-guided MBI to reduce state-rumination following OSCE among medical students. The secondary objectives were to assess the effect of MBI on psychophysiological stress response and to identify the determinants of state-rumination in medical students.\u003c/p\u003e"},{"header":"Material and Methods","content":"\u003cp\u003eStudy design and ethics\u003c/p\u003e\n\u003cp\u003eThis single-center, randomized, parallel-group, controlled study, with a 1:1 ratio is part of a bigger research project called ECOSTRESS. The study protocol was approved by the Institutional Review Board of Universit\u0026eacute; Claude Bernard Lyon 1, Lyon, France (Approval Number: 2020-05-12-01). The study complied with the Declaration of Helsinki and was registered on clinicaltrials.gov (NCT05390879). The study was reported using the Consolidated Standards of Reporting Trials guidelines (Schulz, \u003cspan class=\"CitationRef\"\u003e2010\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eParticipants\u003c/p\u003e\n\u003cp\u003eAll adults (\u0026gt;\u0026thinsp;18 years old) registered as medical students in the Universit\u0026eacute; Claude Bernard Lyon 1 (Medical School of Lyon Est), who participated to the OSCE exam and gave an informed written consent before the study were included. No exclusion criterion was applied. This study was conducted during the OSCE that contributed to the final exam grades of 4th year medical students between May 17 and 19 2022. During the 50-minute OSCE circuit, each student had to complete five consecutive 7-minute clinical situations. The scenarios assessed the technical and non-technical clinical skills of the students (\u003cem\u003ee.g.\u003c/em\u003e collection of patient history, clinical examination, suturing, x-ray interpretation, delivering bad-news). The performance during each scenario was evaluated by an examiner (independent and blinded to the study protocol) using a specific pre-established standardized grid (ranging from 0 to 40 points). The overall performance of the students was obtained from the average of the five scores. Students were not aware of their score during the study, but the examiner provided a short feedback at the end of each clinical situation.\u003c/p\u003e\n\u003cp\u003eIntervention\u003c/p\u003e\n\u003cp\u003eAt the end of the OSCE, students were directed to a room and guided to individual tables; they were given computers and headphones (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e). The students completed questionnaires to evaluate their levels of perceived stress and confidence as well as their arousal state using the PsyToolkit software (Stoet, \u003cspan class=\"CitationRef\"\u003e2010\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e2017\u003c/span\u003e). Subsequently, they were equipped with a pulse sensor, to collect the physiological data, and were asked to do nothing for a period of 90 seconds, to allow them to focus on their feelings and thoughts. At the end of this period, students were asked to complete a questionnaire to assess their level of state-rumination. They were then subjected to a 6-minute auto-guided MBI \u003cspan class=\"SmallCaps\"\u003e(MBI\u003c/span\u003e group), or control (\u003cspan class=\"SmallCaps\"\u003eControl\u003c/span\u003e group) video.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe auto-guided MBI video was set up as follows: students were first invited to sit comfortably and to close their eyes. Then, they were guided through a brief breath awareness, a focused attention meditation, followed by a brief open monitoring meditation on spontaneous sensations, emotions, and thoughts. They were then invited to do a brief appreciation and gratitude meditation for themselves and for others. The auto-guided MBI ended by an instruction to stay in open awareness for a moment (French video: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.youtube.com/watch?v=KKIiED7cL30\u003c/span\u003e\u003c/span\u003e, the English content is available in Appendix A. 1.).\u003c/p\u003e\n\u003cp\u003eThe control was a non-emotional video introducing some scientific contents that were not related to the medical field (French video: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.youtube.com/watch?v=yXfoHS1kEs4\u003c/span\u003e\u003c/span\u003e, the English content is available in Appendix A. 2.). To control a potential bias, the control video was presented as a strategy that intended to distract them from stressful thoughts, by learning something new.\u003c/p\u003e\n\u003cp\u003eFollowing both videos, students were asked to complete the rumination and stress questionnaires again, to collect psychological data (levels of state-rumination, perceived stress and confidence, their feelings and arousal state). Then, their demographic data were collected (age, gender and body mass index) and they reported their physical activity practice, and their level of sleep troubles.\u003c/p\u003e\n\u003cp\u003eOutcomes\u003c/p\u003e\n\u003cp\u003eThe primary outcome was the assessment of the evolution of the state-rumination. Students were asked to report their immediate level of state-rumination using the Brief State Rumination Inventory (BSRI). The BSRI is an 8-item questionnaire developed by Marchetti et al. (\u003cspan class=\"CitationRef\"\u003e2018\u003c/span\u003e) to explore the \u0026ldquo;maladaptive aspects of ruminative thinking\u0026rdquo; of the state-rumination (Abstract-Analytical Mode) (Marchetti et al., \u003cspan class=\"CitationRef\"\u003e2018\u003c/span\u003e). All items are measured on a 100-mm visual analog scale (VAS-100-mm) ranging from \u0026ldquo;complete disagreement\u0026rdquo; (0) to \u0026ldquo;complete agreement\u0026rdquo; (100). The level of state-rumination is the mean of these eight items on a scale of 0 to 100. The version used herein was the French version adapted by Douilliez, Baeyens and Nalborczyk with the triple translate-retro-translate methodology (Nalborczyk et al., \u003cspan class=\"CitationRef\"\u003e2021\u003c/span\u003e) (Appendix B.1.).\u003c/p\u003e\n\u003cp\u003eThe secondary outcomes were the assessment of the psychophysiological stress response and the identification of the determinants of state-rumination. Regarding the psychological stress response, the levels of perceived stress and inner-confidence were assessed before and after the video using VAS 100-mm; for stress, a quantitative measure ranging from 0 (zero) to 100 (extreme), VAS-Stress, and a qualitative measure ranging from 0 (negative feeling) to 100 (positive feeling), VAS-valence (Barret et al., \u003cspan class=\"CitationRef\"\u003e2024\u003c/span\u003e; Schlatter, \u003cspan class=\"CitationRef\"\u003e2021\u003c/span\u003e). For inner-confidence a VAS ranging from 0 (no inner-confidence at all) to 100 (maximal inner-confidence), VAS-confidence (Barret et al., \u003cspan class=\"CitationRef\"\u003e2024\u003c/span\u003e; Schlatter, \u003cspan class=\"CitationRef\"\u003e2021\u003c/span\u003e) (Appendix C). The psychological response was also evaluated by assessing the arousal state. Before and after the video, the Activation-Deactivation Adjective Check List (AD-ACL, French version) was assessed. The AD-ACL is a multidimensional test composed of four subscales: energy, tiredness, internal tension, internal relaxation, ranging from 5 to 20 points for each dimension (Thayer, \u003cspan class=\"CitationRef\"\u003e1967\u003c/span\u003e). Considering the purpose of the study and thanks to a good reliability of subscales, internal relaxation and internal tension were assessed separately (Thayer, \u003cspan class=\"CitationRef\"\u003e1990\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eTo evaluate the physiological stress response, students were equipped with an ear pulse sensor placed on one earlobe before the beginning of the video, which allowed the continuous record of the heart rate variability (HRV, EmWave Pro\u0026reg; software, HeartMath Technologies, Add Heart\u0026reg;, Boulder Creek, CA, USA). HRV analysis is a method to assess sympathetic and vagal activity (Malik et al., \u003cspan class=\"CitationRef\"\u003e1996\u003c/span\u003e). HRV was analyzed using Kubios (Kubios\u0026reg; HRV Standard 3.5.0 software, Kuopio, Finland). To obtain a reliable signal, three steps were followed: 1) the first ten seconds of each recording were systematically deleted; 2) to overcome missed heartbeats, an automatic low threshold was applied on raw interbeat interval; 3) the record was divided in 2 segments (T1: 00:00:10\u0026ndash;00:02:10, T2: 00:02:11\u0026ndash;00:07:10). T1 is the period of time of state-rumination emergence in which students stayed calm with no instruction for 90 seconds and answered to the BSRI, T2 is the period of time in which the students are watching the MBI or \u003cspan class=\"SmallCaps\"\u003eControl\u003c/span\u003e video. As such, only T2 was analyzed in this study. Recordings inferior to 7 minutes were considered as non-analyzable. Several HRV markers were computed. For the time-domain method, the standard deviation of normal-to-normal intervals (SDNN, ms, parasympathetically mediated), the root mean square of successive differences (RMSSD, ms, estimates the vagally-mediated changes), the proportion of NN50 divided by total number of NN (pNN50, percentage, estimates the vagally mediated changes) were extracted. All time-domain markers are highly correlated. For a subsequent multiple analysis RMSSD was selected, as it is the most cited (Shaffer \u0026amp; Ginsberg, \u003cspan class=\"CitationRef\"\u003e2017\u003c/span\u003e). For the frequency-domain method, the Low Frequency/High Frequency ratio (LF/HF ratio) was used. The LF/HF ratio is used for the sympathovagal balance (sympathetic/parasympathetic) (Shaffer \u0026amp; Ginsberg, \u003cspan class=\"CitationRef\"\u003e2017\u003c/span\u003e). The factors that may have influenced the markers including sports practice, age, gender, BMI, and sleep quality, were considered as needed.\u003c/p\u003e\n\u003cp\u003eIn addition, the feelings of the students during the video regarding pleasure, interest, fun, boredom, frustration, and discouragement were collected after the video, using Likert scales ranging from 1 (strong disagreement) to 5 (strong agreement).\u003c/p\u003e\n\u003cp\u003eTo identify the determinants of state-rumination, students reported their practice of physical activity using a Yes/No question and their level of sleep troubles using the French version of the Pittsburgh Sleep Quality Index (PSQI) (Buysse et al., \u003cspan class=\"CitationRef\"\u003e1989\u003c/span\u003e). The PSQI ranges from 0 to 21 points; scores greater or equal to six indicate sleep troubles during the last month(Buysse et al., \u003cspan class=\"CitationRef\"\u003e1989\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eAs an exploratory outcome, this study tried to evaluate whether some secondary outcomes may have affected the evolution of state-rumination; the most experienced feelings during the videos as well as the RMSSD and LF/HF ratio stress markers were assessed.\u003c/p\u003e\n\u003cp\u003eSample size\u003c/p\u003e\n\u003cp\u003eTo align with fairness, ethics, and the pedagogical goals, participation was offered to all fourth year-students scheduled for the exam (n\u0026thinsp;=\u0026thinsp;493), no other sample size was calculated.\u003c/p\u003e\n\u003cp\u003eRandomization\u003c/p\u003e\n\u003cp\u003eThe students were randomly given a number before the OSCE. According to that number, they were guided to an individual table and allocated to the MBI group or to the \u003cspan class=\"SmallCaps\"\u003eControl\u003c/span\u003e group.\u003c/p\u003e\n\u003cp\u003eBlinding\u003c/p\u003e\n\u003cp\u003eStudents were unaware of the different groups and whether they were in the intervention group. As mentioned above, the OSCE examiner was blinded to the study protocol.\u003c/p\u003e\n\u003cp\u003eStatistical methods\u003c/p\u003e\n\u003cp\u003eStatistical analyses were performed using the Rstudio software (Team 2022, Integrated Development Environment for R, Rstudio, PBC, Boston, MA, USA \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://www.rstudio.com/\u003c/span\u003e\u003c/span\u003e). Visual inspection was used to confirm the normality of the data distribution with histograms and quantile-quantile plots. Variables were expressed as mean and standard deviation (SD) or as median and interquartile range (IQR). Results were compared using Student\u0026rsquo;s t-test or Wilcoxon signed rank test. All statistical analyses were two-tailed and a p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered significant.\u003c/p\u003e\n\u003cp\u003eTo determine the influence of the video on the evolution of the state-rumination and of the other psychological responses, ∆scores were calculated for each psychological outcome assessed before and after the video (∆score\u0026thinsp;=\u0026thinsp;post-video score \u003cem\u003eminus\u003c/em\u003e pre-video score). For instance, a negative ∆BSRI reflects a decrease of the level of state-rumination during the video.\u003c/p\u003e\n\u003cp\u003eMultivariate analyses were conducted using multiple linear regressions. Results of multiple linear regressions are presented as estimate with 95% confidence interval (95% CI), the adjusted R\u003csup\u003e2\u003c/sup\u003e was also provided. Non-normally distributed variables were normalized using a logarithmic transformation.\u003c/p\u003e\n\u003cp\u003eThe effect size (\u003cem\u003ee.g.\u003c/em\u003e Cohen\u0026rsquo;s d or magnitude) can be classified as small (0.01), medium (0.06) or large (\u0026gt;\u0026thinsp;0.14) (Cohen, 2013). Cronbach\u0026rsquo;s alpha scores for internal consistency of BSRI and AD-ACL are provided.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e1. Characteristics of the population\u003c/p\u003e\n\u003cp\u003eA total of 482 students were included in the study (1 student declined to participate, Appendix D). At baseline, before the video, both groups were similar regarding demographical, psychological and physiological characteristics (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003ctable id=\"Tab1\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003ePopulation's characteristics\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eVariables\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e\u003cspan class=\"SmallCaps\"\u003eMBI\u003c/span\u003e (n=\u0026nbsp;239)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e\u003cspan class=\"SmallCaps\"\u003eControl\u003c/span\u003e (n=\u0026nbsp;243)\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eDemographic\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAge (years)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e22\u0026thinsp;\u0026plusmn;\u0026thinsp;2 [20;35]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e22\u0026thinsp;\u0026plusmn;\u0026thinsp;2 [18;38]\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eGender, n (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMale\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e83 (35%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e83 (34%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eFemale\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e155 (65%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e159 (65%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNot answered\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1 (\u0026lt;\u0026thinsp;0.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1 (\u0026lt;\u0026thinsp;0.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eBody Mass Index (score)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e22\u0026thinsp;\u0026plusmn;\u0026thinsp;3 [16;38]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e22\u0026thinsp;\u0026plusmn;\u0026thinsp;3 [16;38]\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSport practice \u0026laquo;\u0026nbsp;yes\u0026nbsp;\u0026raquo;, n (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e175 (73%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e188 (77%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePSQI\u0026thinsp;\u0026gt;\u0026thinsp;5, n (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e125 (52%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e126 (52%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003ePsychological state pre-video\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eBSRI (from 0 to 100)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e43\u0026thinsp;\u0026plusmn;\u0026thinsp;23 [0;100]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e44\u0026thinsp;\u0026plusmn;\u0026thinsp;23 [0;100]\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eVAS-stress (from 0 to 100mm)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e21\u0026thinsp;\u0026plusmn;\u0026thinsp;26 [0;100]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e23\u0026thinsp;\u0026plusmn;\u0026thinsp;27 [0;100]\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eVAS-valence (from 0 to 100mm)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e53\u0026thinsp;\u0026plusmn;\u0026thinsp;27 [0;100]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e53\u0026thinsp;\u0026plusmn;\u0026thinsp;27 [0;100]\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eVAS-confidence (from 0 to 100mm)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e46\u0026thinsp;\u0026plusmn;\u0026thinsp;25 [0;100]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e44\u0026thinsp;\u0026plusmn;\u0026thinsp;26 [0;100]\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eInternal relaxation (from\u0026nbsp;5 to 20)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e11\u0026thinsp;\u0026plusmn;\u0026thinsp;4 [5;18]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e10\u0026thinsp;\u0026plusmn;\u0026thinsp;4 [5;20]\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eInternal tension (from\u0026nbsp;5 to 20)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e7\u0026thinsp;\u0026plusmn;\u0026thinsp;4 [5;20]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e9\u0026thinsp;\u0026plusmn;\u0026thinsp;4 [5;20]\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cem\u003eValues are expressed as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation [min;max] or count and percentage. N\u0026thinsp;=\u0026thinsp;482. Missing values: PSQI\u0026thinsp;=\u0026thinsp;5. 251 (52%) students reported sleep troubles (PSQI\u0026thinsp;\u0026gt;\u0026thinsp;5), 363 (75%) students declared practicing a regular sport practice. BSRI: Brief State Rumination Inventory. MBI: Mindfulness-Based Intervention. PSQI: Pittsburgh Sleep Quality Index. VAS: Visual Analog Scale.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e2. Internal consistency of the scores\u003c/p\u003e\n\u003cp\u003eAll Cronbach\u0026rsquo;s alpha scores ranged from good to excellent internal consistency. The Cronbach\u0026rsquo;s alpha scores of pre- and post-video BSRI were 0.87 (95%CI [0.86;0.89]) and 0.92 95%CI [0.90;0.93], respectively. The Cronbach\u0026rsquo;s alpha scores of pre- and post-video AD-ACL internal tension were 0.85 (95%CI [0.824;0.88]) and 0.84 (95%CI [0.81;0.86]), respectively. The Cronbach\u0026rsquo;s alpha scores of pre- and post-video AD-ACL internal relaxation were 0.82 95%CI [0.80;0.84] and 0.83 95%CI [0.81;0.85], respectively.\u003c/p\u003e\n\u003cp\u003e3. Primary outcome\u003c/p\u003e\n\u003cp\u003eBSRI\u003csub\u003eMBI\u003c/sub\u003e was 43\u0026thinsp;\u0026plusmn;\u0026thinsp;23 before and 38\u0026thinsp;\u0026plusmn;\u0026thinsp;24 after the video (∆BSRI\u003csub\u003eMBI\u003c/sub\u003e -5\u0026thinsp;\u0026plusmn;\u0026thinsp;12). BSRI\u003csub\u003e\u003cspan class=\"SmallCaps\"\u003eControl\u003c/span\u003e\u003c/sub\u003e was 44\u0026thinsp;\u0026plusmn;\u0026thinsp;23 before and 39\u0026thinsp;\u0026plusmn;\u0026thinsp;25 after the video (∆BSRI\u003csub\u003e\u003cspan class=\"SmallCaps\"\u003eControl\u003c/span\u003e\u003c/sub\u003e -5\u0026thinsp;\u0026plusmn;\u0026thinsp;13). The evolution of state-rumination did not differ between MBI and \u003cspan class=\"SmallCaps\"\u003eControl\u003c/span\u003e groups (∆BSRI t-test, -0.38 95%CI [-2.61:1.86], p\u0026thinsp;=\u0026thinsp;0.740).\u003c/p\u003e\n\u003cp\u003e4. Secondary outcomes\u003c/p\u003e\n\u003cp\u003ea. Psychological stress response\u003c/p\u003e\n\u003cp\u003eThe evolution of perceived stress (∆stress), inner confidence (∆confidence), internal relaxation (∆internal relaxation), and internal tension (∆internal tension) was not significantly different between the \u003cspan class=\"SmallCaps\"\u003eMBI\u003c/span\u003e group and the \u003cspan class=\"SmallCaps\"\u003eControl\u003c/span\u003e group (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e). Pre-video stress valence was slightly positive for both groups; the stress valence (VAS-valence) stayed positive in the \u003cspan class=\"SmallCaps\"\u003eControl\u003c/span\u003e group whereas it became neutral in \u003cspan class=\"SmallCaps\"\u003eMBI\u003c/span\u003e (∆valence, Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e).\u0026nbsp;\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab2\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eEffects of MBI on stress, stress valence, inner-confidence, internal relaxation, and internal tension compared to CONTROL.\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eMBI (n\u0026thinsp;=\u0026thinsp;239)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e\u003cspan class=\"SmallCaps\"\u003eControl\u003c/span\u003e (n\u0026nbsp;=243)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eEstimate Difference [95%CI]\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003ep-value\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eEffect size\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e∆stress\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-1 [-10;3]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0 [-11;5]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-1 [-3;1]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.348\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNA\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e∆valence\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0 [-9;10]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-1 [-12;3]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3 [1;6]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.008\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.121 (Small)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e∆confidence\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1 [-6;10]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0 [-7;8]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1 [-1;3]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.328\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNA\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e∆internal relaxation\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1 [0;3]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1 [0;3]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0 [-0;1]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.897\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNA\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e∆internal tension\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0 [-2;0]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0 [-1;0]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-0 [-0;0]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.445\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNA\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cem\u003eGroups differences were assessed using Wilcoxon tests on deltas of variables. Delta (∆): post-video minus pre-video, presented with interquartile range. A negative delta represents a decrease, while a positive delta an increase of the score during the video. Results are repesented as estimate differences of the medians with 95% confidence intervals. MBI: Mindfulness-Based Intervention. CI: Confidence Interval.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eb. Physiological stress response\u003c/p\u003e\n\u003cp\u003eThe HRV markers were available for 465 students (97%), the percentage of analyzable segments did not differ between both groups (\u003cspan class=\"SmallCaps\"\u003eControl\u003c/span\u003e 96.3% and \u003cspan class=\"SmallCaps\"\u003eMBI\u003c/span\u003e 96.6%, p\u0026thinsp;=\u0026thinsp;1.000). Time-domain markers RMSSD and pNN50 showed no difference between groups (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e). SDNN was significantly higher in the MBI group compared to CONTROL (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003eA, Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e). It was not affected by factors such as sports practice, age, gender, BMI, and sleep quality (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e). Additionally, in the frequency-domain marker, students in the MBI group had a higher LF/HF ratio than those in the CONTROL group (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003eB, Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003ctable id=\"Tab3\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eHRV markers during the 6-minute video.\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eMBI (n\u0026thinsp;=\u0026thinsp;234)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e\u003cspan class=\"SmallCaps\"\u003eControl\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;231)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eEstimate Difference\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003ep-value\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eEffect size\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSDNN (ms)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e49 [40;64]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e43 [35;55]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e6 [3; 9]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.176 (Small)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eRMSSD (ms)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e46 [37;58]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e43 [33;57]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3 [-0; 5]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.058\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNA\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003epNN50 (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e20 [14;29]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e18 [11;30]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2 [-0; 4]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.165\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNA\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eLF/HF ratio\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.9 [1.3;3.3]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.6 [1;2.5]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.36 [0.16; 0.57]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.159 (Small)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cem\u003en\u0026thinsp;=\u0026thinsp;465. Group differences were assessed using Wilcoxon tests. HRV markers are presented as medians and interquartile ranges. Results of the tests are presented as estimate differences with 95% confidence intervals. HRV: Heart Rate Variability. LF/HF ratio: Low Frequency/High Frequency ratio. MBI: Mindfulness-Based Intervention. pNN50: Proportion of pairs of successive NNs that differ by more than 50ms. RMSSD: Root Mean Square of Successive Differences. SDNN: Standard Deviation of Normal-to-Normal.\u003c/em\u003e\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003ctable id=\"Tab4\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eSDNN according to the groups considering physiological factors\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eSDNN\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eEstimates [95% CI]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ep-value\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMBI\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e6.36 [2.734;9.99]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eBMI\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.08 [-0.58;0.75]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.804\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAge\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-0.85 [-1.83;0.12]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.087\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eGender [Male]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4.06 [0.05;8.07]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.047\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSport [Practice]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4.24 [-0.06;8.54]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.053\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSleep [Troubles]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-0.496 [-4.15;3.16]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.790\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cem\u003eThe multiple linear regression was performed on 465 students due to missing data (on sleep quality and gender, n\u0026thinsp;=\u0026thinsp;5 and 2 respectively). 95% CI: 95% Confidence Interval. BMI: Body Mass Index. MBI: Mindfulness Based Intervention. SDNN: Standard Deviation of Normal-to-Normal (higher SDNN means lower physiological stress). R\u003c/em\u003e \u003csup\u003e \u003cem\u003e2\u003c/em\u003e \u003c/sup\u003e \u003cem\u003e/R\u003c/em\u003e \u003csup\u003e \u003cem\u003e2\u003c/em\u003e \u003c/sup\u003e \u003cem\u003eadjusted: 0.05/0.04.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003ec. Feelings during the video\u003c/p\u003e\n\u003cp\u003eThe students in the \u003cspan class=\"SmallCaps\"\u003eMBI\u003c/span\u003e group felt more pleasure, interest, enthusiasm, fun, and less boredom during the video compared with the students in the \u003cspan class=\"SmallCaps\"\u003eControl\u003c/span\u003e group. Both groups experienced similar levels of discouragement and frustration. The most represented positive feeling was interest, and the most represented negative feeling was boredom (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003cdiv class=\"colspec\" align=\"char\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003ctable id=\"Tab5\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eFeelings reported by the students during the 6-minute video.\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eFeeling\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e\u003cspan class=\"SmallCaps\"\u003eMBI\u003c/span\u003e (n=\u0026nbsp;239)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e\u003cspan class=\"SmallCaps\"\u003eControl\u003c/span\u003e (n=\u0026nbsp;243)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003ep value\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eEffect size\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003ePositive feelings\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eFun\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1[1;2]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1[1;1]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.152 (large)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eEnthusiasm\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2[1;3]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1[1;1]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.442 (large)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eInterest\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3[2;3]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1[1;2]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.481 (large)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePleasure\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2 [1;3]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1[1;1]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.449 (large)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eNegative feelings\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDiscouragement\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1[1;2]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1[1;2]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.482\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNA\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eBoredom\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2[1;3]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4[3;5]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.490 (large)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eFrustration\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1[1;2]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1[1;3]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.106\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNA\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cem\u003en\u0026thinsp;=\u0026thinsp;482. Feelings\u0026rsquo; intensities range from 0 (lowest intensity) to 5 (highest intensity). Values are expressed as medians and interquartile range. Groups differences were assessed using Wilcoxon tests. MBI: Mindfulness-Based Intervention.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003ed. Determinants of pre-video state-rumination\u003c/p\u003e\n\u003cp\u003eThe multiple linear regression found that the pre-video level of state-rumination (pre video BRSI) was negatively associated with both the performance to the exam and a sport practice (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e6\u003c/span\u003e). Conversely, it was positively associated with female gender and sleep troubles (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003ctable id=\"Tab6\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eMultiple linear regression of determinants of state-rumination state post-exam.\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003cth colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eBSRI pre-video\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDeterminants\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eEstimates [95% CI]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ep-value\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eOverall Performance\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-0.88 [-1.37;-0.39]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eGender [Female]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e11.63 [7.50;15.75]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSport [Practice]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-5.47 [-10.00;-0.95]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.018\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSleep [Troubles]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e9.48 [5.58;13.37]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cem\u003eThe multiple linear regression was performed on 475 students due to missing data (on sleep quality and gender, n\u0026thinsp;=\u0026thinsp;5 and 2 respectively). 95% CI: 95% Confidence Interval. BSRI: Brief State-Rumination Inventory, mean of the eight items on a scale of 0 to 100. R\u003c/em\u003e \u003csup\u003e \u003cem\u003e2\u003c/em\u003e \u003c/sup\u003e \u003cem\u003e/R\u003c/em\u003e \u003csup\u003e \u003cem\u003e2\u003c/em\u003e \u003c/sup\u003e \u003cem\u003eadjusted: 0.152/0.145.\u003c/em\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe first aim of this study was to assess the effect of a short MBI on rumination following an exam in medical students. The second aims were to assess the effect on psychophysiological stress response and to deepen our understanding of state-rumination. As main results, we determined that rumination and psychological stress did not differ between the groups. However, MBI students presented a lower physiological stress and reported more positive feelings. Poor exam performance, female gender, poor sleep quality, and no sport practice were positively associated with state-rumination. This study offers insights that can inform the future development of specific interventions to reduce rumination in medical students, such as improving sleep practices and increasing physical activity.\u003c/p\u003e \u003cp\u003eMBI and state-rumination\u003c/p\u003e \u003cp\u003eThe results did not report an influence of a short MBI on the evolution of state-rumination after a stressful exam (OSCE). Conversely, in previous studies, medium-term MBI showed encouraging results concerning the reduction of rumination (Daya \u0026amp; Hearn, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Goyal et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; Lavadera et al., \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Jain et al. reported a reduction of state-rumination in MBI-trained medical students (Jain et al., \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2007\u003c/span\u003e). Nevertheless, the MBI developed by Jain et al. consisted of four 90-minute sessions prior to examinations. A similar pattern is observed in the studies included in the Daya \u0026amp; Hearn review. Consequently, the duration, frequency, and temporality of the intervention were distinct from those of our study. Those differences may account for the disparate outcomes, and it can be hypothesized that longer and/or more frequent interventions might be needed to see a decrease in rumination.\u003c/p\u003e \u003cp\u003eMBI and psychological stress response\u003c/p\u003e \u003cp\u003eSimilar to the results for rumination, the evolutions of perceived stress, inner-confidence, internal relaxation, and in the internal tension were not influenced by the MBI. A significant, yet negligible, effect to \u0026ldquo;neutralize\u0026rdquo; the qualitative aspect of the stress was found among \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eMBI\u003c/span\u003e students. However, this has not been the subject of previous research, and future studies are needed to clarify this point.\u003c/p\u003e \u003cp\u003eMBI and physiological stress response\u003c/p\u003e \u003cp\u003eThe present study found that physiological stress response was lower in students of the \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eMBI\u003c/span\u003e group compared with those of the \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eControl\u003c/span\u003e group (\u003cem\u003ee.g.\u003c/em\u003e higher SDNN and LF/HF ratio in MBI, and a trend toward higher RMSSD). A low SDNN was widely used in studies as a marker of physiological stress response or of cardiac medical risk (Shaffer et al., \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e2014\u003c/span\u003e), hence, an increased SDNN might underline a reduction of this risk. While some authors found an increased LF/HF ratio following other stress remediation interventions (Schlatter et al., \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e2021\u003c/span\u003e), the interpretation of the LF/HF ratio remains controversial (Shaffer \u0026amp; Ginsberg, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). In a recent meta-analysis, Brown et al. (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2021\u003c/span\u003e) assessed the link between MBI, RMSSD and SDNN, and concluded that MBI training did not significantly influence these markers compared to the control condition (Brown et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). However, in a recent randomized control trial, Kirk et al. found that a 20-minute MBI produced a significant change of RMSSD (Kirk \u0026amp; Axelsen, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). This finding, consistent with the results reported herein, supports the idea that a brief MBI still has a significant impact on the physiological stress response. The present study is the first to report that an even shorter intervention, that lasts only 6 minutes, can induce significant physiological changes.\u003c/p\u003e \u003cp\u003eFeelings during the intervention\u003c/p\u003e \u003cp\u003eStudents who experienced MBI reported more pleasure, interest, enthusiasm, fun, and less boredom during the video; the two videos were not perceived in the same way by students. This underlines that the MBI may have benefited the students in dimensions other than rumination or stress. The positive feelings at the end of an exam could have medium- or long-term benefits, reducing apprehension about upcoming exams, for example. Future studies will require an extended observation period to determine the long-term influences of increased positive feelings.\u003c/p\u003e \u003cp\u003eDeterminants of state-rumination\u003c/p\u003e \u003cp\u003eThe present findings reported that a reduced exam performance was associated with higher state-rumination in medical students, which suggests that students may have had an implicit knowledge of their performance during the exam, potentially biased by the short feedback of the examiner at the end of each clinical scenario. No previous study assessed the potential links between performance at an exam and state-rumination in a real-life context. Being a female was also associated with higher state-rumination level. This gender difference is well known and results from a combination of multiple sociocultural and personal factors (Nolen-Hoeksema et al., \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e1999\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2007\u003c/span\u003e). Nolen-Hoeksema et al. hypothesized that this difference might be one of the reasons of the difference regarding depression between males and females (Nolen-Hoeksema et al., \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e1999\u003c/span\u003e). Thus, female students appear to be particularly at risk for rumination, and possibly related long-term health issues, and may need closer support if they feel the need.\u003c/p\u003e \u003cp\u003eThe present results also found that poor sleep quality was associated with higher state-rumination. As a result, future studies should explore the effect of other interventions that would aim at improving sleep quality or quantity (\u003cem\u003ee.g.\u003c/em\u003e, medium-term mindfulness program, reduction of screen-time) to reduce rumination in medical students (Li et al., \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Ramjan et al., \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Spanhel et al., \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). A sport practice was associated with lower state-rumination; hence, encouraging a sport practice during medical studies may be a key to reduce state-rumination triggered by exams.\u003c/p\u003e \u003cp\u003eLimits and Strengths\u003c/p\u003e \u003cp\u003eThe present study has some limitations. Ten students did not come to their exam, and thus were not included. However, due to the large sample size, it is unlikely that the inclusion of those ten students would have changed the main result. Another limitation is that the post-exam recovery period might be not usual to students. They usually go out quickly after the exam and do not stay quietly in a room for half an hour. This situation could have interfered with the natural course of rumination. The results of this study may have limited generalizability due to its single-center design. However, as other studies reported similar stressful conditions among medical students worldwide, the present results could be extended to most of the medical students.\u003c/p\u003e \u003cp\u003eThe study also has notable strengths. Almost all the targeted students were included, leading to a large and homogenous sample size of more than 480 participants. The high level of participation may indicate that students are concerned about their mental health and saw a potential benefit to participate to the study. Still, it is of note that we focused on a particular population. Participants were young, mostly female, prone to stress, and presented sleep troubles, which aligns with the medical student\u0026rsquo;s population\u0026rsquo;s characteristics previously documented in the literature. (Khaksarian et al., \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Pacheco et al., \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e1999\u003c/span\u003e; Sun et al., \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Unwin et al., \u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e2013\u003c/span\u003e). Also, the approach of the present findings is multimodal, which allows to distinct the effects on psychological and physiological aspects. Of note, a significant amount of physiological data was extracted and analyzed. The OSCE might be perceived as an uncontrollable, novel, unpredictable, and ego-threatening situation it may be considered as the perfect stressor. Since these characteristics were linked to higher level of stress and rumination in the literature (Zoccola et al., 2012), our results may be comparable to other types of stressors.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe short \u0026ldquo;single shot\u0026rdquo; MBI performed immediately after an exam did not provide a decrease of state-rumination state or psychological stress response as compared with control. However, it reduced the physiological stress response. Besides, this study highlighted that a poor exam performance, female gender, sleep troubles and a lack of sport practice were associated with an elevated state-rumination. These results suggest the need to evaluate the potential benefits of such single or repeated intervention over the longer term. This study also offers insights that can inform the future development of specific interventions to reduce rumination in medical students, such as improving sleep practices and increasing physical activity.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eAD-ACL\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eActivation-Deactivation Adjective Check List\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eBSRI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eBrief State-Rumination Inventory\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHRV\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHeart Rate Variability\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eLF/HF ratio\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eLow Frequency/High Frequency ratio\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMBI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMindfulness-Based Intervention\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eOSCE\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eObjective Structured Clinical Examination\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003epNN50\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eProportion of pairs of successive NNs that differ by more than 50ms\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePSQI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePittsburgh Sleep Quality Index\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eRMSSD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eRoot Mean Square of Successive Differences\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSDNN\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eStandard Deviation of Normal-to-Normal\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eVAS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eVisual Analog Scale\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eTG: Conceptualization; Data curation; Formal analysis; Investigation; Methodology; Roles/Writing - original draft; Writing - review \u0026amp; editingAL: Conceptualization; Methodology; Writing - review \u0026amp; editingAD: Conceptualization; Methodology; Writing - review \u0026amp; editingTR: Conceptualization; Funding acquisition; Methodology; Project administration; Resources; Supervision; Writing - review \u0026amp; editingNB: Data curation; Formal analysis; Investigation; Methodology; Writing - review \u0026amp; editingAB: Data curation; Formal analysis; Investigation; MethodologyGR: Conceptualization; Funding acquisition; Project administration; Resources; Supervision; Writing - review \u0026amp; editingML: Conceptualization; Funding acquisition; Investigation; Methodology; Project administration; Resources; Supervision; Roles/Writing \u0026ndash; original draft, Writing- review \u0026amp; editingSS: Conceptualization; Data curation; Formal analysis; Investigation; Methodology; Resources; Supervision; Roles/Writing - original draft; Writing - review \u0026amp; editing\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eThe authors would like to thank: - The Service de Sant\u0026eacute; Universitaire of the Universit\u0026eacute; Claude Bernard Lyon 1- Marion Cortet, Cecile Chenavas and Karima Chiter of Facult\u0026eacute; de M\u0026eacute;decine Lyon Est, Universit\u0026eacute; Claude Bernard Lyon 1- Denis Favre and David Romeuf of the University Lyon 1 Information Technology department - Lucas Denoyel and Sebastien Sygiel of the University Lyon 1 simulation center (CLESS), SIMULYON.- The scientific review committee of the Hospices Civils de Lyon - All investigators, teachers and students involved in the ECOSTRESS project: Aissaou Ouissal, Badina Evane, Ben Messaoud Alexandre, Binay Marion, Bretaire Kenza, Chaoui Clara, Chour Ali, Cuisinier Valentine, Degot Matthieu, Delacour Isia, Elmoujahid Azzeddine, Haouchache Nour, Le Noach Marie, Le Saux Olivia, Lecante Ludivine, Lecoq Val\u0026eacute;riane, Mairet Sacha, Maresca Sonia, Marolleau Julie, Melchior Dan, Moulin Owein, Nanette Pierre, Neidecker Marie, Plasse Benjamin, Ravaux Camille, Schmidt Laura, Tapastau Alisa, Tran Gaston.- Ursula Debarnot and Aymeric Guillot of Inter-University Laboratory of Human Movement Biology-EA 7424, Universit\u0026eacute; de Lyon, for their help for the writing of the script of the control video.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eANEMF, ISNI, \u0026amp; ISNAR-IMG. 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Mindfulness. 2015;6(2):290\u0026ndash;302. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s12671-013-0260-4\u003c/span\u003e\u003cspan address=\"10.1007/s12671-013-0260-4\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"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":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Heart Rate Variability, Medical Students, Mindfulness-Based Intervention, OSCE, State-rumination, Stress","lastPublishedDoi":"10.21203/rs.3.rs-4486967/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4486967/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground:\u003c/h2\u003e \u003cp\u003eTo prevent the medical students from a deleterious psychophysiological activation, it is necessary to provide them a large variety of stress management techniques. The primary aim was to assess the efficacy of a short Mindfulness-Based Intervention (MBI) to reduce state-rumination following an exam (Objective Structured Clinical Examination: OSCE). The second aims were to assess the efficacy of the short MBI to reduce stress-response and to identify the determinants of state-rumination.\u003c/p\u003e\u003ch2\u003eMethods:\u003c/h2\u003e \u003cp\u003eStudents were randomly allocated to two parallel groups: 6-minute MBI or 6-minute control video. Levels of state-rumination (Brief State-Rumination Inventory) and stress-response (psychological and physiological markers) were assessed. Feelings during the video were reported. OSCE performance, gender, sleep quality, and sport practice were assessed. Participants were blinded to the group assignment, but the administrators and outcome assessors were not. NCT05390879.\u003c/p\u003e\u003ch2\u003eResults:\u003c/h2\u003e \u003cp\u003eFour hundred eighty-two students participated (n\u0026thinsp;=\u0026thinsp;239 in MBI and n\u0026thinsp;=\u0026thinsp;243 in \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eControl)\u003c/span\u003e. Rumination did not differ between the groups (∆BSRI\u003csub\u003eMBI\u003c/sub\u003e -5\u0026thinsp;\u0026plusmn;\u0026thinsp;12, ∆BSRI\u003csub\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eControl\u003c/span\u003e\u003c/sub\u003e -5\u0026thinsp;\u0026plusmn;\u0026thinsp;13, ∆BSRI t-test \u0026minus;\u0026thinsp;0.38 95% CI [-2.61:1.86], p\u0026thinsp;=\u0026thinsp;0.740). The same applies to psychological stress (all p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). However, MBI students presented a lower physiological stress and reported more positive feelings during the video (all p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Poor exam performance, female gender, poor sleep quality, and no sport practice were positively associated with state-rumination (all p\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e\u003ch2\u003eConclusions:\u003c/h2\u003e \u003cp\u003eMBI following an OSCE led to positive feelings and reduced physiological stress but neither psychological stress nor state-rumination. Performance, gender, sleep quality, and sport practice are determinants of state-rumination. This study offers insights that can inform the future development of specific interventions to reduce rumination in medical students.\u003c/p\u003e","manuscriptTitle":"Evaluation of the efficacy of a brief mindfulness-based intervention on state-rumination and stress response of medical students following an exam: A randomized controlled study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-06-12 19:13:45","doi":"10.21203/rs.3.rs-4486967/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"6d55d3d4-3b8e-4a7d-bc16-5d7b3aa0cbdf","owner":[],"postedDate":"June 12th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-08-31T09:52:49+00:00","versionOfRecord":[],"versionCreatedAt":"2024-06-12 19:13:45","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4486967","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4486967","identity":"rs-4486967","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}