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Year : 2015  |  Volume : 16  |  Issue : 2  |  Page : 81-84

Effectiveness of bibliotherapy for stress reduction among nursing students: An experimental study

1 MSc Nursing Student (at the time of submission), Narayana Hrudayalaya College of Nursing, Bangalore, India
2 Principal, Narayana Hrudayalaya College of Nursing, Bangalore, India

Date of Web Publication23-May-2020

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Stress experienced by nursing students is well documented, and is a result of multi-factorial aspects involving the cognition, emotion, and volition. Stress can adversely affect their performance. Bibliotherapy is found effective in the management of stress. Hence an experimental approach was used to assess the effectiveness of bibliotherapy in the management of stress experienced by nursing students in a selected college of nursing in Bangalore. A sample of 120 students who were randomly selected and assigned to the experimental and control groups participated in the study. The stress was measured using a standardized tool called ‘Student Nurses Stress Index’ which had a reliability score of Cronbach alpha of .7 when used among students in UK. The findings revealed that the groups matched in terms of the pretest stress scores. The independent “t” test was used to assess the effectiveness of bibliotherapy and the t value was 2.70 which was significant at < .05 level of significance. Paired “t” test was also done to assess the effectiveness within the group and it was found to be 2.09 significant at < .05 level of significance. There was no significant association between stress and selected demographical variables. The study implies that nursing students should be encouraged to use bibliotherapy as a means of handling the stress experienced.

Keywords: effectiveness, bibliotherapy, stress reduction, nursing students

How to cite this article:
Zacharias C, Theodore DD. Effectiveness of bibliotherapy for stress reduction among nursing students: An experimental study. Indian J Cont Nsg Edn 2015;16:81-4

How to cite this URL:
Zacharias C, Theodore DD. Effectiveness of bibliotherapy for stress reduction among nursing students: An experimental study. Indian J Cont Nsg Edn [serial online] 2015 [cited 2023 Feb 2];16:81-4. Available from: https://www.ijcne.org/text.asp?2015/16/2/81/284866

  Introduction Top

Anything that poses a challenge or a threat to our well-being is a stress. Without any stress at all, our lives would be boring and pointless. However, when the stress undermines both our mental and physical health they are bad (Nordqvist, 2009). Today’s undergraduates are under lots of pressure, especially those in health profession which can lead to emotional and mental health problems in them (Pehrsson, & McMillen, 2006; Scott, 2011). A survey of the American colleges reveals that the average college student has the worst emotional health compared to student groups previously studied. Among the many stress relief measures, the use of literature to assist individuals to deal with life’s transitional and normal developmental issues and are found to be both economical and effective too (Scott, 2011).

Nursing students specially beginners face stressors which are social in terms of separation from parents and adapting to roommates, balancing friends with studies, and dealing with the dynamics of young adult relationships. Stressors may also be financial in nature. Stressors may also be academic in nature with the sources of stress including the theoretical and clinical aspects of learning. Studies pertaining to stress experienced by student nurses in countries such as the US, Albnia, Brunie, Malta, Wales, Ireland, Iran etc. have revealed stressors significantly more than the students of other courses (Burnad et al., 2008; Frassrand, 2005; Timmins & Kaliszer, 2002).


  • To assess the pre-interventional stress level among interventional group and control group of nursing students using the perceived stress scale and the student nurses stress index
  • To assess the effectiveness of bibliotherapy in the reduction of stress by comparing the post interventional stress level among interventional group and control group of nursing students
  • To identify the association between pre- interventional stress level with selected demographic variables


H1:- There will be a significant reduction in the post interventional mean stress score in interventional group in comparison with control group ofnursing students at .05 level of significance.

H2:- There will be a significant association between pre intervention stress experienced by nursing students and the selected demographic variables at .05 level of significance.

  Methods Top

A true experimental study with pre-test post-test control group design was adopted for the study. The college was selected by convenience sampling. All the nursing students (GNM, B. Sc, and PBBSc) between the age group of 17 and 26 years, willing to participate in the study, and those who were available during the study period were screened for the level of stress. Among the 263 students identified to have moderate or severe stress, 120 students were randomly allocated into the control and experimental groups. Chi- square was used to check the matching of the groups and the groups matched in all demographic aspects except number of hours of sleep/day.

The conceptual frame work adopted for the study is based on Betty Neuman’s system model, which focuses on stress and stress reduction.

The instruments used were a demographic profile, perceived stress scale, and student nurses stress index. The Perceived stress scale (Ice & Yogo, 2005) is a standardized tool used to assess the stress with 10 statements. Responses were rated on a 5-point Likert scale from 0 - never to 4 - very often. Total score was 40 and the stress was classified as low stress (0-13), moderate stress (14-26), and high stress (2740). The Student nurses stress index (SNSI) is a 22-item self- report instrument designed to measure the sources and levels of stress in student nurses. SNSI covers four areas validated as affecting nursing student self-reported stress levels: 1) Academic load; 2) Clinical concerns; 3) Personal problems; 4) Interface worries, such as interpersonal relations among students and between college staff and other professionals (Jones & Johnston, 1999). Responses were rated on a 5-point Likert scale from 1-Not stressful to 5-Extremely stressful. The scores on different items which come under the four factors were summed together to give a subscale total ranging from 7-35 for all the factors except personal problems which ranged from 4-20.

All the tools used for the study were found to have a good reliability (Cronbach alpha of SNSI is .7 and PSS is .82) and these tools were also given to experts in the field, consisting of psychiatrist, statistician, and psychiatric social worker, clinical psychologist, and psychiatric nurses. The content validity index (CVI) was found to be .86 for PSS and .83 for SNSI. A pilot study was conducted on a sample size of 12 students and the study was found to be feasible.

After approval from the ethical committee, a written permission was obtained by the head of the institution and a written consent was obtained from the participants after a detailed explanation of the nature of the study, role of the participants, and the time involved. Participants were also assured confidentiality of the data provided and their identity. Students identified with moderate or severe stress using PSS were randomly assigned to interventional and control group of 60 students each. Selected participants were asked to complete the demographic profile and SNSI. Bibliotherapy was given to interventional group for 20 days (30 min/day) in a separately arranged room of student’s hostel and they were given the freedom to choose books of various domains like short stories, comics, religious, self-help, and novels. One week after the intervention both the groups were assessed again with PSS and data were analyzed by using descriptive and inferential statistics.

  Results and discussion Top

In order to check the matching of the control and experimental group, Chi-square test was used and the groups were found to match as there was no significant difference between the groups except in the demographic areas of daily hours of sleep and the regional state they came from.

On analysis majority of the participants (both control and experimental group) were belonging to the age group of 17-20yrs in both the group. Majority of them studied for less than 2 hrs/day, in addition to the regular class work. Seventy four percent of students in interventional group and 80% in control group slept for 4-6 hrs daily and 72% in the interventional group and 67% in the control group had scored 70-80% in their secondary school. Majority of the subjects selected nursing because of job opportunity (57% in interventional group and 62% in control group).

Among the interventional group 90% had moderate and 10% had severe stress before intervention, however, 100% reported moderate stress level following intervention. While in control group the stress rate remained same on pre and post tests with 91% had moderate and 9% had severe stress. Area wise analysis of stress of nursing students reveals that academic load with mean percentage of 55.66 and 62.77 among interventional and control group respectively, was found to be the greatest stress factor followed by interface worries (49.51 and 52.29 respectively).

The pre-interventional stress score of the experimental group was 22.23 and that of the control group was 21.57. Participants in the interventional group showed a decrease in mean stress level from 22.23 to 21.13 following intervention as revealed by the pre and post tests and the calculated paired ‘t’ value was found to be greater than table value at 0.05 level of significance (t=2.08) (see [Table 1]). This finding is similar to the findings reported by Daise (2011) in a study conducted to assess the effectiveness of bibliotherapy in stress reduction among senior citizens in Bangalore which revealed that the post test mean stress score (43.7) was significantly lower than the pre test mean score (59.23) with reduction of 12.94%. Another study to assess the effectiveness of bibliotherapy in stress reduction among Hansen’s disease patients in Mangalore also demonstrated a highly significant reduction in the stress level of Hansen’s disease patients in the experimental group after the introduction of bibliotherapy (t=13.26, p<0.01) (Sreejesh & Kirubakaran, 2005). Both studies support the findings of the present study.
Table 1: Comparison of Pre-test Stress Scores with Post-test Stress Scores of the Experimental Group (n=60)

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In the control group the mean stress level increased from 21.57 to 22.42 in post-test and comparison of this post test score with that of interventional group using independent ‘t’ test showed significance at .05 level (t=2.70). Thus the hypothesis H1 was accepted (see [Table 2]).
Table 2: Comparison of Post-test Stress Scores between the Interventional and Control Group (n=60)

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Hence it was concluded that, there is a significant reduction in stress among interventional group and bibliotherapy is effective in stress management. In terms of association between demographic variables and the levels of stress no association was revealed.

  Conclusion Top

Students face many stressors in their journey to become a professional, more so in the field of nursing. Nursing students express stress in areas related to academic, clinical concerns, personal problems, and interface worries. In order to cope with the stress they experience, nurses and nursing students need to develop healthy coping mechanisms. Bibliotherapy is one such means to reduce stress among the nursing students. The nurses’ and nursing students’ hostels can consider keeping books for their use. Since this method is cost effective, nurses’ and nursing students can use this therapy as a means for stress reduction among patients and their caregivers too. Further study of its effectiveness in stress reduction among the patients and their care givers can be undertaken. Long term effects of bibliotherapy can also be studied using longitudinal designs.

Conflicts of Interest: The authors have declared no conflicts of interest

  References Top

Burnard, P., Edwards, D., Bennett, K., Tothova, V., Baldacchino, D., Bara, P., & Mytevelli, J. (2008). A comparative, longitudinal study of stress in student nurses in five countries: Albania, Brunei, the Czech Republic, Malta and Wales. Nurse Education Today, 28(2), 134-145.  Back to cited text no. 1
Daise, J. (2011). Effectiveness of bibliotherapy on level of stress among senior citizens in selected old age homes in Bangalore (Unpublished master’s thesis). Rajiv Gandhi University of Health Science, Bangalore.  Back to cited text no. 2
Frassrand, S. (2005). A comparative analysis of stress levels in undergraduate university students. Journal of Psychology, 12(3), 221-229.  Back to cited text no. 3
Ice, G. H., & Yogo, J. (2005). Measuring stress among Luo elders: development of the Luo Perceived Stress Scale. Field Methods, 17(4), 394-411.Jones, M. C., & Johnston, D. W. (1999). The derivation of a brief Student Nurse Stress Index. Work and Stress, 13(2), 162-181. http://doi.org/10.1080/026783799296129  Back to cited text no. 4
Nordqvist, C. (2009). What is stress? How to deal with stress. Retrieved from http://www.medicalnewstoday.com/ articles/145855.ph.  Back to cited text no. 5
Pehrsson, D. E, & McMillen, P. (2006). Preparing counselors who use literature to be culturally responsive. Retrieved from: http ://www.wiziq.com/tutorial/3 40-Competent- Bibliotherapy  Back to cited text no. 6
Scott, E. M. S. (2011). Stress and health. Retrieved from http://stress.about.com/od/stresshealth7a/stresshealth.ht.  Back to cited text no. 7
Sreejesh, P. K. (2005). Effectiveness of bibliotheraphy on stress reduction among Hansen’s disease patients in selected settings in Mangalore (Unpublished master’s thesis). Rajiv Gandhi University of Health Science, Bangalore. Retrieved from www.rguhs.ac.in/cdc/ onlinecdc/uploads/05_N036_1147.doc  Back to cited text no. 8
Timmins, F., & Kaliszer, M. (2002). Aspects of nurse education programmes that frequently cause stress to nursing studentsfact-finding sample survey. Nurse Education Today, 22(3), 203-211.  Back to cited text no. 9
Table 1  Back to cited text no. 10
Comparison of Pre-test Stress Scores with Post-test Stress Scores of the Experimental Group (n=60)  Back to cited text no. 11
Table 2  Back to cited text no. 12
Comparison of Post-test Stress Scores between the Interventional and Control Group (n=60)  Back to cited text no. 13


  [Table 1], [Table 2]


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