Effects of Expressive Writing on Stress-Related and Work-Related Outcomes Among Chinese Nursing Interns: a Randomized Controlled Trial
Phase: NA
Conditions: Stress, Psychological
Sponsor: Changzhi Medical College

Research Proposal
Research title：
Effects of Expressive Writing on Stress and Work-Related Outcomes among
Student Nurse Interns: a randomized controlled trial
NCT ID：
Not yet assigned
Date of the document:
October 17th, 2023

Research title：
Effects of Expressive Writing on Stress and Work-Related Outcomes among
Student Nurse Interns: a randomized controlled trial
Funding sources:
Supported by the Program for the Philosophy and Social Sciences Research
(PSSR) of Higher Learning Institutions of Shanxi, China (Project No.:
2023W103)
Research schedule:
Ethical Review：
The Ethics Committee of Changzhi Medical College approved the study
protocol on October 17, 2013, registration number RT2023047.
1. Introduction
Nursing internships are essential to nursing programs and a crucial stage
in the early careers of nursing students. Those seeking hands-on experience
in hospitals or medical facilities are known as student nurse interns. The
clinical learning experience is considered a significant source of stress. The

stress level of nursing students during clinical practicum ranges from moderate
to severe, affecting 47.82 to 100% of participants.
Stressors in the clinical setting included discrepancy between theory and
practice, feeling unprepared, fear of making a mistake, issues related to death
and dying, witnessing suffering, challenging interpersonal relationships with
clinical staff, being observed and evaluated, communication with physicians,
conflict between personal life and internship tasks, and unfamiliarity with the
hospital environment. The rapid evolution of healthcare brings new stressors
for nurses and nursing students. Health professionals often play down or deny
mental health problems, which exacerbates the problem.
Stress not only affects the well-being of student nurse interns but also
impacts job satisfaction and can lead to turnover in nursing. The stress of
student nurse interns can affect motivation, communication, learning, clinical
practice, and academic performance, which can be detrimental to patients.
The American College Health Association (ACHA) and the Chinese Ministry of
Education have taken steps to promote student mental health. Academic
institutions actively conduct mental health research to develop effective
strategies and programs.
Stress management interventions (SMI), non-pharmacological
approaches to managing psychological and physical stress, show promise in
reducing stress among nursing students. Although SMIs have demonstrated
efficacy, more studies on senior students and Chinese student nurse interns
are needed.
According to the transactional model of stress and coping proposed by
Lazarus and Folkman, the three targets of effective stress management are
stressors, coping strategies, and cognitive reappraisal. The stressor refers to
any event or internal or external environmental stimulus that can be perceived

by an individual and elicit a positive or negative stress response; the coping
strategy refers to the process by which an individual deals with internal or
external demands that are perceived as stressful or exceed the resources of
the individual; cognitive reappraisal is the method of changing an individual's
evaluation of the stressor and self-defeating perception of stress.
Expressive writing (EW) is a form of writing therapy (WT) introduced by
James Pennebaker in 1986. It enables individuals to express important
emotional events they have experienced, to write down their deepest feelings
and thoughts, and to find positive meaning in advert events. Following the
transactional model of stress and coping, EW encompasses all three targets of
stress reduction (using stressors as a writing topic, writing as a form of coping,
and cognitive reappraisal during the writing process). At the same time, its
simplicity, cost-effectiveness, brevity, and low expertise requirements make
EW an easily accessible intervention method.
As there are few studies on the effectiveness of EW with student nurse
interns, this study aims to investigate the efficacy of expressive writing in
managing stress and work-related outcomes in student nurse interns, which
may provide a valuable new approach.
2. Research Questions

Is there any difference between the four repeated (at immediate, 4-week,
8-week, and 12-week follow-up) clinical practice stress tests between the
intervention and control group in terms of the mean?

Is there any difference between the four repeated (at immediate, 4-week,
8-week, and 12-week follow-up) coping strategy tests between the
intervention and control group in terms of the mean of positive coping and
negative coping?


Is there any difference between the four repeated (at immediate, 4-week,
8-week, and 12-week follow-up) work engagement tests between the
intervention and control group in terms of the mean?

Is there any difference between the four repeated (at immediate, 4-week,
8-week, and 12-week follow-up) perceived professional benefit tests
between the intervention and control group in terms of the mean?
3. Research Objectives
General objective:
Evaluate the impact of expressive writing (EW) intervention on stress and
work-related outcomes among Chinese student nursing interns
Specific objectives:

To compare the effectiveness of EW (expressive writing) and NW (neutral
writing) in managing clinical practice stress among student nurse interns
between intervention and control groups at immediate and 4-week, 8-week,
and 12-week follow-up.

To compare the impact of EW and NW on improving coping strategies
among student nurse interns between intervention and control groups at
immediate and 4-week, 8-week, and 12-week follow-up.

To evaluate the effectiveness of EW and NW in promoting work
engagement between intervention and control groups at immediate and
4-week, 8-week,12-week follow-up.

To compare the impact of EW and NW on promoting perceived
professional benefit among student nurse interns between intervention and
control groups among student nurse interns at immediate and 4-week,
8-week, and 12-week follow-up.

4. Study Design
A randomized controlled trial with parallel design.
5. Inclusion and Exclusion Criteria of Participants
Inclusion criteria:

Undergraduate student nurse interns in their first clinical internship (had no
prior clinical practice experience)

Have access and proficiency in utilizing social media

Be able to read and write via the internet

Be willing to fill in questionnaires and write according to the assigned
writing prompts

Never participated in an expressive writing or stress management
intervention programs
Exclusion criteria:

Intern at a self-contacted hospital

Severe current psychological conditions

Undergoing any form of psychotherapy

With a habit of keeping diaries
Withdrawal criteria:

Termination of internship for whatever reason

Not submitting writing materials twice
6. Sample Size
Using the sample size formula for comparing the means of two
independent samples of continuous variables to calculate the sample size.

ǒǍ = 2(
Ǆ1−ح/2 + Ǆ1−خ
퐸ƽ
)2
퐸ƽ = |μ1 −μ2|
σ
To detect between-group differences with an effect size of 0.69 in clinical
practice stress by Stress Rating Scale for Nursing Students in Practice after 10
weeks of intervention (primary outcome), with an α level of 0.05, we require
33 participants per group to attain a power of 80%. Accounting for an expected
10% loss to follow-up, we should include 74 participants.
7. Sampling and Grouping
All eligible student nurse interns in the four target hospitals constituted the
sampling frame. Two of the four target hospitals will be selected by lottery and
the intervention and control groups will be determined by a coin toss.
Participants will be sampled for both the intervention and control groups
using the following method: all potential participants were entered
alphabetically into Column A of the Excel sheet from A to Z. Then,
random
numbers will be generated in column B of the Excel sheet using the Rand( )
function. The 37 participants with small random numbers will be included as
study participants in both groups.
A research assistant who will not be involved in other parts of the study
completed all the above processes.
8. Blinding
This is a single-blinded randomized controlled study.
The intervention trainer will not be blinded, given that a single researcher
conducts the study. To minimize experimenter bias, outcome assessments will
be conducted through an online questionnaire survey platform (Wenjuanxing),
with the trainer distributing the same link to all participants. During data

collection, only acronyms of the questionnaires will be used to avoid
self-fulfilling expectations.
Participants will be informed during the recruitment phase only that the
study aimed to explore the effect of writing on internship experience and
feelings. Assignment to the intervention or control group will remain
undisclosed to participants until the end of the 3-month follow-up.
Participants could unblind themselves by exiting the study and requesting
debrief information.
9. Intervention Description
Intervention group：
According to the writing prompts, online expressive writing focuses on
stressful events and will be conducted twice a week (every Monday and
Thursday) for 15 minutes each time, lasting for ten weeks.
Writing prompts are developed based on Emotional Processing Theory
(EPT) and Cognitive Adaptation Theory (CAT).

1st writing/Monday:
Describe the distressing/stressful event (like workload, lack of
break/leisure time, knowledge proficiency, patient care, interpersonal
communication, role adaptation...) with causal links between the event's
segments; describe your thoughts and feelings at the time of the event;
describe what you did to keep the event under control.
In your writing, I'd like you to 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, or your future;
or to who you have been, who you would like to be or who you are now. Don't
worry about spelling, grammar, or sentence structure. The only rule is that
once you begin writing, you continue until the time is up.


2nd writing/Thursday:
Reflect on how the event you wrote about in your first writing of this week
affected your life (any gains or growth); how you currently think and feel about
the event; whether or not you are grateful it did not get worse; where do you
feel you did well in this coping; future coping with a similar event.
In your writing, I'd like you to 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, or your future;
or to who you have been, who you would like to be or who you are now. Don't
worry about spelling, grammar, or sentence structure. The only rule is that
once you begin writing, you continue until the time is up.
Control group：

According to the writing prompts, online neutral writing focuses on
immediate surroundings and will be conducted twice a week (every Monday
and Thursday) for 15 minutes each time, lasting for ten weeks. Writing prompts
are as follows：

1st writing/Monday:
Describe the specified object (from week one to week ten, specify the
specified object as "the door you see now", "your hairstyle", "the pants you are
wearing", "the room you are in", "your hands", "the shoes you are wearing",
"the view from the window", "the clothes you are wearing", "your water bottle"
and “your phone/computer” ).
In your writing, concentrate on the facts and details of the activity and thing
you chose. We are not interested in your emotions or opinions, rather we want
you to try to be completely objective. Feel free to be as detailed as possible.

2nd writing/Thursday:
Describe the specified object in the picture (from week one to week ten,
provide pictures of the door, hairstyle, pants, room, hands, shoes, view from a
window, clothes, water bottle, and computer).
In your writing, concentrate on the facts and details of the activity and thing
you chose. We are not interested in your emotions or opinions, rather we want
you to try to be completely objective. Feel free to be as detailed as possible.
To ensure the effectiveness of online writing, we developed a webpage
suitable for the program. Participants can write from their computers or mobile
devices. When a participant goes to the web page, the first page will be the
instructions. This page shown before the writing tasks described the main
objective of each task, emphasizing the importance of carefully reading the
instructions. After reading the instructions, participants fill in their unique
number and click on the “start writing” button. Then it will turn to the second

page for writing. There will be a countdown clock on this page, with the
remaining time for the task. The clock flashed when one minute remained.
When the time expires, the writing page will automatically close and display
the final text. At this point, no editing was possible, but participants could read
their texts.
10. Outcome Measures
All measures will be taken one day before the start of the intervention, one
day after the end of the intervention, and followed up at 4 weeks, 8 weeks, and
12 weeks after the end of the intervention.
Primary outcome: Clinical Practice Stress
Stress Rating Scale for Nursing Students in Practice
The scale consists of 6 dimensions and 37 entries, including the nature of
work, workload, preparation for an internship, interpersonal relationships, work
support, and learning and work impulse. The scale rates on a 4-point Likert
scale, with no stress, mild stress, moderate stress, and severe stress,
assigned a score of 0, 1, 2, and 3, respectively, and the higher the score, the
greater the stress.
Secondary outcome: Coping Strategy, Work Engagement, Perceived
Professional Benefit
Brief Coping Style Scale
The scale consists of two dimensions, positive and negative coping, with
20 entries. A 4-point Likert scale is used, with 1-4 indicating "not used" to
"often used". Positive coping has 12 entries, and negative coping has 8 entries,
with higher scores indicating more frequent use of coping strategies.
Utrecht Work Engagement Scale

The scale consists of 3 dimensions: vitality, dedication, and concentration,
comprising 15 entries. A 7-point Likert scale is used, with scores ranging from
0-6 for "never," "almost never," "rarely," "sometimes," "often," "frequently," and
"always." The total score is the sum of the scores of each entry. An average
entry score of 4 or more is defined as a high level of work engagement, 2-4 as
a moderate level, and less than 2 as a low level of work engagement.
Perceived Professional Benefits Scale
The scale consists of 7 items of positive career sense, 6 items of good
nurse-patient relationship, 6 items of sense of belonging to the team, 8 items of
self-growth, and 6 items of identification with friends and relatives, 33 items in
5 dimensions in total, and each item is scored 1 to 5 on a 5-point Likert scale
ranging from "strongly disagree" to "strongly agree. The higher the score, the
stronger the perceived professional benefit.
11. Data Analysis
Data will be analyzed with Stata version 14. All endpoints will be analyzed
with generalized estimating equations and will use robust standard errors. The
working correlation structure will be specified as exchangeable.
Data from all available time points will be used. The independent variables
included in the model will be the treatment group (categorical) and the baseline
value of the dependent variable (continuous). A model that additionally
adjusted for age and sex for the primary endpoint will run.
The primary endpoint and secondary endpoints will all be analyzed with an
intention-to-treat approach.
References
Ahmad, T. B., & Meltem Meriç, R. (2021). The effect of an online
psychoeducational stress management program on international students'

ability to cope and adapt. Perspectives in Psychiatric Care, 57(4),
1673-1684. doi:10.1111/ppc.12735
Aloufi, M. A., Jarden, R. J., Gerdtz, M. F., & Kapp, S. (2021). Reducing stress,
anxiety, and depression in undergraduate nursing students: Systematic
review. Nurse Education Today, 102, 104877.
doi:10.1016/j.nedt.2021.104877
Aslan, H., & Pekince, H. (2021). Nursing students' views on the COVID-19
pandemic and their perceived stress levels. Perspectives in Psychiatric
Care, 57(2), 695-701. doi:10.1111/ppc.12597
Auerbach, R. P., Mortier, P., Bruffaerts, R., Alonso, J., Benjet, C., Cuijpers, P.,
Demyttenaere, K., Ebert, D. D., Green, J. G., Hasking, P., Murray, E.,
Nock, M. K., Pinder-Amaker, S., Sampson, N. A., Stein, D. J., Vilagut, G.,
Zaslavsky, A. M., Kessler, R. C., & WHO WMH-ICS Collaborators. (2018).
WHO World Mental Health Surveys International College Student Project:
Prevalence and distribution of mental disorders. Journal of Abnormal
Psychology, 127(7), 623–638. doi: 10.1037/abn0000362
Benito, K. G., & Walther, M. (2015). Therapeutic process during exposure:
Habituation model. Journal of Obsessive-compulsive and Related
Disorders, 6, 147-157. doi:10.1016/j.jocrd.2015.01.006
Bhurtun, H. D., Azimirad, M., Saaranen, T., & Turunen, H. (2019). Stress and
coping among nursing students during clinical training: An integrative
review. Journal of Nursing Education, 58(5), 266-272.
doi:10.3928/01484834-20190422-04
Budu, H. I., Abalo, E. M., Bam, V., Budu, F. A., & Peprah, P. (2019). A survey
of the genesis of stress and its effect on the academic performance of
midwifery students in a college in Ghana. Midwifery, 73, 69-77.
doi:10.1016/j.midw.2019.02.013
Butcher, N. J., Monsour, A., Mew, E. J., Chan, A. W., Moher, D., Mayo-Wilson,
E., ... & Offringa, M. (2022). Guidelines for reporting outcomes in trial

reports: the CONSORT-Outcomes 2022 extension. Jama, 328(22),
2252-2264.doi:10.1001/jama.2022.21022
Cankaya, P., & Duman, Z. C. (2010). Evaluation of nursing students' attitudes
towards seeking psychological help and factors affecting their attitudes.
Nurse Education Today, 30(8), 784-788. doi:10.1016/j.nedt.2010.02.005
Doucet, M. H., Guzzo, M. F., & Groleau, D. (2018). Brief report: A qualitative
evidence synthesis of the psychological processes of school-based
expressive writing interventions with adolescents. Journal of Adolescence,
69, 113-117. doi:10.1016/j.adolescence.2018.09.010
Eva, E. O., Islam, M. Z., Mosaddek, A. S. M., Rahman, M. F., Rozario, R. J.,
Iftekhar, A. F., Haque, M. (2015). Prevalence of stress among medical
students: a comparative study between public and private medical schools
in Bangladesh. BMC Research Notes, 8, 327.
doi:10.1186/s13104-015-1295-5
Gurková, E., & Zeleníková, R. (2018). Nursing students' perceived stress,
coping strategies, health and supervisory approaches in clinical practice:
A Slovak and Czech perspective. Nurse Education Today, 65, 4-10.
doi:10.1016/j.nedt.2018.02.023
Hu J., & Liu X.H. (2013). Establishment of a questionnaire of nurses' perceived
professional benefits: reliability and validity assessment. Nursing Journal
of Chinese People’s Liberation Army, 30(22), 1-5.
doi:10.3969/j.issn.1008-9998.2013.22.001
Lim, S. J., & Kim, C. (2014). Effects of autogenic training on stress response
and heart rate variability in nursing students. Asian Nursing Research,
8(4), 286-292. doi:10.1016/j.anr.2014.06.003
Pennebaker, J. W. (2010). Expressive writing in a clinical setting. The
Independent Practitioner, 30, 23-25. Retrieve from:
https://scholar.google.com/scholar?hl=en&as_sdt=0%2C5&q=%5B16%5
DExpressive+writing+in+a+clinical+setting.+The+Independent+Practition
er%2C+30%2C+23-25.&btnG=

Schafer, T., Wood, S., & Williams, R. (2011). A survey into student nurses'
attitudes towards mental illness: Implications for nurse training. Nurse
Education Today, 31(4), 328-332. doi:10.1016/j.nedt.2010.06.010
Xiao J.Y., Liu P.X., Zhao Y., Xia B.D., & Hong F.F. (2018). Progress in
Research on Stress Measurement Tools for Student Nurse Interns.
Journal of Nursing, 25(8), 24-26.
doi:10.16460/j.issn1008-9969.2018.08.024
Xie Y.N. (1998). A preliminary study of the reliability and validity of the Brief
Coping Styles Scale. Chinese Journal of Clinical Psychology, 6(2),
114-115.doi:CNKI:SUN:ZLCY.0.1998-02-017
Zhang Y.W., & Gan Y.Q. (2005). Reliability testing of the Chinese version of
the Utrecht Work Engagement Scale (UWES). Chinese Journal of Clinical
Psychology, 13(3), 268-270.doi:1005-3611(2005)03-0268-03
Zhu X.B., Zhang L.M., & Zhu J.J. (2010). Progress in Expressive Writing
Research. Journal of Ningbo University: Education Science Edition, 32(4),
41-46. doi:10.3969/j.issn.1008-0627.2010.04.010