Study to assess the effectiveness of Expressive Emotional Writing on perceived stress and general well being of Nursing students.

https://doi.org/10.33698/NRF0209 Nitasha Sharma, Karobi Das, Ramandeep Kaur, Reena Sharma, Reetika Bhardwaj

Abstract : Stress is an inevitable part of life. Nursing students more likely to experience it during their education and training. Various stress management interventions are currently being used by the educationist to reduce the stress among students and ‘Expressive Emotional Writing’ is one of them. The current study was planned with the objective to assess the effectiveness of Expressive Emotional Writing on perceived stress and general well being of nursing students. Perceived stress reactivity scale and general well being scale were used to assess the stress and general well being of the students. Four sessions of expressive emotional writing in experimental group and neutral writing in control group were conducted for a duration of 20 minutes, each once in a week for one month. The subjects in experimental group showed a statistically significant increase (p=0.013) in perceived stress reactivity after intervention. However, on the domain of general well being, there was statistically significant improvement in general well being of experimental group (p=0.010). Results showed that expressive emotional writing is effective in improving general well being of the subjects.

Keywords

Stress, Expressive writing.

Correspondence at

 Dr Nitasha Sharma

Assistant Professor, Psychiatric Nursing, Department of Psychiatry

GMCH-32, Chandigarh

Introduction

Stress is an inevitable part of human existence. The levels of stress may vary during various developmental phases of life. The development phase of formal years of college has substantial stressors to deal with. The various factors contributing to stress among students include the academic challenges, financial concerns, interpersonal difficulties, new environment, family related issues and poor coping skills.1-4 At times the individual factors like cultural difference, linguistic barriers, social isolation and discrimination can add to the stressors. These stressors are common to students of all disciplines. However, the students of medical & paramedical courses are additionally burdened with the stress of working with sick and dying patients. There is always a need to develop, administer and evaluate some novice interventions to minimize stress among students and maximise their well being. Expressive Emotional Writing seems to be one of such promising non pharmacological and cost effective therapeutic intervention. This therapy was first scientifically tested by Literature mentions that nursing students Pennebaker & Beall  in 1986.6 They have an additional vulnerability to stress when compared with general college conducted a scientific investigation in which college students wrote for 15 minutes on 4 students.5 Pulido- Martos et al reported consecutive days about ‘the most traumatic clinical sources of stress like fear of unknown situations, mistakes with patients or handling of technical equipment.5 Similarly, Admi et. al. reported inadequate knowledge and training, adverse and embarrassing sights, instructor’s close supervision, insufficient hospital resources, causing pain and suffering, and education reality conflict as common sources of stress or upsetting experiences’ of their entire lives, while controls wrote about superficial topics (such as their room or their shoes). Participants who wrote about their deepest thoughts and feelings reported significant benefits in both objectively assessed and self-reported physical health 4 months later, with less frequent visits to the health centre and a trend towards fewer days out of role in nursing students.3 Zuipira et al owing to illness. Over the years such conceptualised some of sources of stress in nursing students originating from interpersonal sources like lack of competence, uncertainty and impotence, being harmed by the relationship with patients, emotional involvement, lack of control in relationships with patients, contact with suffering, relationships with tutors, workmates and classmates and patients seeking a close relationship.4 These increased stress loads come with some dire consequences. Suicide rates amongst college-aged students are three times higher than they were in 1950. India has one of the world’s highest rate of suicides among people aged between 15 years and 29 years.5 Acknowledging such facts and figures, it is the moral duty of educations and administrators today to induce such mechanisms in curriculum that develop a resilient youth who has a healthy profile of experiments were replicated and it was demonstrated that when individuals are given the opportunity to disclose deeply personal aspects of their lives, they readily do so. Even though a large number of participants report crying or being deeply upset by the experience, the overwhelming majority report that the writing experience was valuable and meaningful in their lives. 7- 12 The Expressive Emotional writing popularised so much in consecutive years that by 1996, approximately 20 studies had been published. By 2009, over 200 have been published in English  language journals.6

The researchers did not limit such studies to immediate psychological health benefits of expressive writing rather further scientific investigations explored the objective impact of the therapy on various physical health related outcomes. Various investigations revealed that Expressive Emotional writing has various health related long term outcomes like improved immune system functioning, reduced blood pressure, improved lung function, improved liver function and fewer days in reactivity to failure and reactivity to social evaluation. Each item considers an individual’s exposure to stress and a typical response to a stressor. Respondents are required to pick one of three possible answers. Each item was scored from 0, 1 & hospital.13

The social psychologists have Higher scale indicative more stress. The tried to reiterate the role of Expressive writing in various Social and behavioural outcomes like reduced absenteeism from PSRS has well established validity and reliability. Scale has good stability of PSRS scores over a 4-week period, and validation work,14 loss,15 quicker re-employment after job improved working memory,16  analysis has showed expected associations with related constructs such as self-efficacy, improved sporting performance and higher students’ grade point average. With such background the present study was undertaken to assess the effectiveness of Expressive Emotional Writing (EEW) on perceived stress and well being of nursing students.

Materials &Methods

The present study aimed to investigate the effectiveness of “Expressive Emotional Writing” on perceived stress and general wellbeing of nursing students. Keeping in view the objectives of this study, pre testpost test control group design was employed for the study. The study was conducted at a National level Institute of Nursing in north India. Through lottery method two out of four batches of B.Sc. Nursing degree were selected & labelled as experimental and control group. Further 45 subjects in each group were selected by random selection with replacement from two selected classes. Both the groups were administered the perceived stress reactivity scale (PSRS)18 and the general well being scale19. PSRS is a 23 item standardized scale which yields a total score on perceived stress along with scores on 5 subscales viz. Prolonged Reactivity , reactivity to work overload , reactivity to social conflicts, neuroticism, chronic stress, and perceived stress. The General Well Being Scale is a standardized scale that contains 14 items and these items are developed to assess the general well being of the participants. Each item contains 6 options for answer (0-5), option 0 means severe well being and option 5 means positive well being and maximum score is 110. The score between 0-25 stands for severe well being, 26-40 means serious well being, 41-55 means the subject is distressed, 56-70 indicates that the subject is having stress problems, 71-75 indicates subject is having marginal well being, 76- 80 stands for low positive well being and 81- 110 means subject is having positive well being.

Typical writing instructions given to the experimental and control group before the writing sessions:

Experimental group: For the four days, 20 minutes each day, I would like you to write your very deepest thoughts and feelings about the most traumatic experience of your entire life or an extremely important emotional issue that has affected you and your life. In your writing, I’d like you to really let go and explore your deepest emotions and thoughts. You might tie your topic to your relationships with others including parents, lovers, friends or relatives; to your past, your present and your future. You may write about the same general issues or  experiences on all days of writing or about different topics each day. All of your writing will be completely confidential. Don’t worry about the spelling, grammar or sentence structure. The only rule is that once you begin writing, you continue until the time is up.

Control group: For the four days, 20 minutes each day, I would like you to write as objectively and factually as possible about neutral topics (e.g. your favorite actor, city etc.), without revealing your emotions or opinions. Each day we’ll give you the topics on which you have to write. All of your writing will be completely confidential. Don’t worry about the spelling, grammar or sentence structure. The only rule is that once you begin writing, you continue until the time is up.

The ethical clearance was taken from the Institute’s Ethical Committee for data collection. The written consent was taken from all the subjects as well as the subjects were given full autonomy to participate in research and withdrawal from research at any time. Anonymity and confidentiality of the subjects was maintained. The subjects were explained about objectives, activities and duration of their involvement. The psychological intervention was non invasive and was not likely to cause any potential, psychological or physical harm to the study participants. The data was analyzed by using Statistical package for social sciences (SPSS).

Results

The age of subjects ranged from18-23 years with mean ages of 19 years in experimental and 21 years in control groups. More than half of subjects (57.8%) in experimental group and (42.2%) were from Sikh religion. Most of the subjects in both the groups were belonging to nuclear families.More than half of subjects from both groups were fron urban background. The average income of experiment group was Rs 5920±3512 and Rs. 7860.00±5548 in control group. The experimental & control groups were comparable with respect to their religion, type of family, income & background.

Table 2 depicts that overall stress score in the subjects of experimental group increased significantly from 21.22 to 23.73 (p=0.013 as per paired t test) after the intervention and in control group there was marginal decrease in stress score after intervention from 24.42 to 23.16 though the difference was not statistically significant. This shows that emotional writing immediately increases perceived stress as the post test was taken immediately after the intervention.

The general wellbeing score of subjects in experiment group increased significantly (p=0.01as per paired t test) and in control group also the general wellbeing score increased but the difference was not statistically significant. It indicates that the experimental group subjects felt significantly better after intervention as compared to control group.

This indicates that though the subjects of experimental group felt  stressed immediately after emotional writing still they felt better as general well being score increased significantly.

Table 1: Socio demographic profile of subjects 

Variables	Experimental group (n1=45) f(%)	Control group (n2=45) f(%)	Chi square (df) P value
Age
18-20	44(97.8)	19(42.2)
21-23	1(2.2)	26(57.8)
mean±SD	19.33±0.707	20.78±0.927
Religion
Hindu	18(40)	24(53.3)	2.946 (3)
Sikh	26(57.8)	19(42.2)	0.400
Muslim	0(0)	1(2.2)
Christian	1(2.2)	1(2.2)
Type of family
Nuclear	37(82.2)	41(91.1)	1.538(1)
Joint	8(17.8)	4(8.9)	0.215
Per capita income
<1000	0(0)	2(4.4)	6.757(4)
1000-5000	27(60)	18(40)	0.149
5000-10000	14(31.1)	17(37.8)
10000-15000	3(6.7)	3(6.7)
>20000	1(2.2)	5(11.1)
mean±SD	5920.00±3512	7860.00±5548
Background
Urban	24(53.3)	25(55.6)	0.045(1)
Rural	21(46.7)	20(44.4)	0.832

 

Table 2: Perceived stress score and general well being score of experimental and control group before and after the intervention:

N=90

Subscales of PSRS	Experimental group(n1=45) Perceived stress score			Control group(n2=45) Perceived stress score
	Pre test mean±SD	Post test mean±SD	t-test df P value	Pre test mean±SD	Post test mean±SD	t-test df P value
overall perceived stress reactivity	21.22±5.83	23.73±5.49	-2.601(44) 0.013*	24.42±5.78	23.16±5.30	1.585(44) 0.12
General well being score	35.56±11.4	38.64±10.3	-2.640(44) 0.011*	35.07±7.47	36.69±7.28	-1.643(44) 0.108

 

 Table 3 depicts the mean pre-test& post test scores on various subscales of perceived stress reactivity scale viz Prolonged reactivity, reactivity to work overload, reactivity to social conflict, reactivity to failure, reactivity to social evaluation for both groups. The paired t-test revealed statistically significant increase in mean perceived stress in relation to reactivity to failure in experimental group (p<0.001) and in control group also there is increase in mean stress score during post test but this increase was not statistically significant. There was significant decrease in mean perceived stress score related to reactivity to work overload in control group (p=0.025) and in experiment group also there was decrease in mean perceived stress score though the difference was statistically not significant.

Mean post-test perceived stress score of prolonged reactivity and reactivity to social conflict increased in experimental group and decreased in control group though the differences were statistically not significant. Mean post-test perceived stress score reactivity to social evaluation decreased in experimental group and increased in control group though these differences were not statistically significant.

Table 3: Perceived stress score and general wellbeing score of experimental and control group before and after the intervention

N=90

Subscales of PSRS	Experimental group(n1=45) Perceived stress score			Control group(n2=45) Perceived stress score
	Pre test mean±SD	Post test mean±SD	t-test df P value	Pre test mean±SD	Post test mean±SD	t-test df P value
Prolonged reactivity	3.51±1.890	4.20±1.575	-1.807(44) 0.078	4.04±1.522	3.67±1.537	1.494 (44) 0.142
Reactivity to work overload	4.71±2.252	4.69±1.607	0.083(44) 0.934	5.07±2.093	4.49±1.878	2.318(44) 0.025*
Reactivity to social conflict	5.24±2.356	5.89±1.837	-1.448(44) 0.155	6.16±2.153	5.62±1.600	1.814(44) 0.077
Reactivity to failure	3.13±1.687	4.80±1.646	-5.218(44) <0.001*	4.80±1.217	5.04±1.537	-1.336(44) 0.189
Reactivity to social evaluation	4.58±2.369	4.09±2.065	1.089(44) 0.282	4.36±1.979	4.82±2.146	-1.285(44) 0.206

 Table 4 depicts the frequency distribution of subjects based on pre and post intervention scores on PSRS in both experimentalas well as control group. The middle value of total possible score of 46 i.e 23 was taken as reference to divide groups into two with score less than 23 and score more than 23. The Fishers exact test revealed statistically significant differences onfrequencies pre and post intervention. There were 32 subjects with PSRS sore below 23 pre-intervention which reduced to 21 post intervention. Similarly, the number of subjects with PSRS above 23 was 13 before intervention which increased to 24 after intervention. Which shows the subjects with higher stress increased significantly after intervention. There were no significant differences in the frequencies pre and post intervention in control group. This indicates that emotional writing increased the perceived stress among the subjects

Table 4: PSPR and General Well Being Score of subjects in both groups before and after intervention

Scores	Experimental Group			Control Group
	Pre intervention n(%)	Post intervention n(%)	Fishers exact test p value	Pre intervention n(%)	Post intervention n(%)	Fishers exact test p value
PSRS score
<23	32	21	0.03	23	23	1.0
>23	13	24		22	22

 Table 4 depicts the frequency distribution of subjects based on pre and post intervention scores on General well being in both experimental as well as control group. The Fishers exact test revealed non- significant differences pre and post intervention in both groups.

Table 5 : Subject Distribution as per General Well Being scores in both groups before and after intervention

General well being score	Experimental Group			Control Group
	Pre intervention n(%)	Post intervention n(%)	Fishers exact test p value	Pre intervention n(%)	Post intervention n(%)	Fishers exact test p value
Severe well being (0-25)	10(22.2)	4(8.9)	0.11	4(8.9)	5(11.1)	0.73
Serious Well Being(26-40)	25(55.6)	23(51.1)		29(64.4)	25( 55.6)
Distressed (41-55)	6(13.3)	14(31.1)		12(26.7)	15(33.3)
Having stress problems (56-70)	4(8.9)	4(8.9)		0	0

 Discussion

There is ample literature on beneficiary effects of expressive writing. There are varied explanations and hypothesis as to how the therapy really work or what is it that makes to the Healthy coping through expression in the form of written words. Inhibition and confrontation was the explanation proposed by Pennebaker’s (1985).13,20 It was proposed that when a person actively inhibits or suppresses the thoughts and feelings associated with a stressful event, such inhibition itself serves as a cumulative stressor on the body and lead to longer-term disease like hypertension and coronary artery disease. At same stance confronting such trauma through talking or writing about it, and acknowledging the associated emotions is thought to reduce the physiological work of inhibition, gradually lowering the overall stress on the body. Such confrontation involves translating the event into words, enabling rational understanding of the life event and stressor, which further contribute to the reduction in physiological activity associated with inhibition. (Pennebaker, 1985).13,20 The second proposed theory is that of “Development of coherent narrative”. It is seen that participants whose health improved used more positive-emotion words, a moderate number of negative-emotion words and an increased number of ‘cognitive mechanism’ words (the latter include insight words such as understand, realise and causal words such as because, reason). Such observation suggested that expressive writing manifests its beneficial effect through the development of a coherent narrative over time, reflecting increasing cognitive processing of the experience. 21

In the present study it was hypothesized that Expressive Emotional writing sessions shall lead to significant decrease in the perceived reactivity and increase in well being. The findings of the study revealed increase in perceived reactivity scores with improvement in well being scores. The increase in overall stress reactivity and reactivity to failure can be explained owing to short duration of therapy. Moreover considering the Inhibition and confrontation theory explaining the effect of expressive writing, it can be said that the process of translating an event into words might develop over time. The therapy of only four sessions is not enough to complete the work. Secondly, in the present study the post test was done immediately after fourth session. After thinking and writing about a deeply inhibited and suppressed event one is expected to be in a state of heightened emotionality which might have coloured the increased scores on stress reactivity. While, the general well being scores have shown a significant improvement because first the well being is a more comprehensive measure and secondly, the items on well being scale are more general in terms of situations assessed involving all range of activities of day to day life unlike the stress reactivity score which is more event specific.

The current study was undertaken on a small sample size. The duration of intervention was limited to four sessions only. In conclusion, the expressive emotional writing is an effective therapy to combat stress when conducted for an adequate duration. However, to make this more robust, the study can be conducted on a larger sample, with longer duration and stringent sampling and design.

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