1. INTRODUCTION:

The nurse-patient relationship is one of the essential parts of nursing practice. Nurses always try to act in the best interests of the patients by establishing therapeutic relationship with them. Its importance has been stressed by many nursing scholars since nursing emerged as science in 1950s. For example, Peplau proposed the theory of interpersonal relations in 1952, by describing the nurse-patient relationship as a significant therapeutic interpersonal process¹. However, it is not easy for nurses to establish therapeutic relationship with their patients. Unlike scientific knowledge and nursing skills, therapeutic relationships with patients cannot be acquired without reflective processes. One of the strategies nursing students can use for reflective process is bibliotherapy.

Bibliotherapy is a dynamic process, involving the process of identification, catharsis, and insight². The reader can actively interpret the material in light of his or her own circumstances through reading fictional materials³. By reading books, the reader gains an alternative position from which to view their own issues through identification with a character in the story. The reader can also empathize with the character through a catharsis that leads to release emotional tension. Consequently, the reader gains insights and can change his/her undesirable behavior^2,4,5,6.

Establishing therapeutic relationships with patients requires some capabilities such as being empathic, understanding, caring, and having ethical qualities⁷. Self-awareness, self-knowledge, self-worth, empathy, and awareness of boundaries and limits of professional role are also essential for building therapeutic relationship¹. Bibliotherapy can be one of the methods in cultivating some of these capabilities for nursing students. Most nurses, as first-line health care providers, frequently experience high levels of emotional distress that lead to burn-out⁸. Nurses need to relieve this distress and burden by enlarging the awareness of their behaviors¹. Nurses, with high level of ability to know and perceive themselves and others, can develop better therapeutic relationship with their patients⁹. On the other hand, when their self-awareness level is low, nurses tend to project their unacknowledged personal stress to their patients, resulting ineffective relationship with their patients¹⁰. Self-awareness will help evaluating themselves of their reactions to emotionally charged situation, people and places. It will offer an opportunity to recognize how their attitudes, perceptions, past and present experiences, and relationships frame or distort interactions with their patients¹¹. Bibliotherapy can help nursing students promote self-awareness through reflective thinking about their own values, beliefs, thoughts, emotions, and behaviors by investigating the human condition and understanding the essence of humankind as a whole.

Bibliotherapy could improve students' clinical reasoning skills and ethical components as well as reflective thinking, as stories encompass information, knowledge, context, and emotion¹². Through bibliotherapy, nursing students can understand not only themselves better, but what another person is experiencing from within the other’s frame of reference^12-15, resulting in more patient-centered perspectives¹². In addition, it may help promote emotional intelligence^16. and sensitivity to physical and psychological needs of patients¹⁷. Furthermore, utilizing stories might help gaining the balance between the aspect of science and aspect of humanity in nursing education.¹²

However, not enough studies on bibliotherapy have been conducted for nursing students in Korea. Moreover, most are studies with small samples of fewer than 20, or studies without control groups. Therefore, it is necessary to investigate the effects of bibliotherapy with a more powerful research design3. Therefore, the present study was conducted to investigate the effects of bibliotherapy on self-esteem, emotional awareness, and empathy in first-year nursing students in Korea.

2. METHODS:

2.1. Design:

This study used randomized controlled pretest-posttest design.

2.1.1. Samples:

Freshman nursing students in a 3-year nursing school in women’s college were invited to participate in the study. To calculate an appropriate sample size, Cohen’s sample size table¹⁸ (1988, p.54) was used with a power of .80, α of .05, effect size of .80¹⁹, and a one-tailed test, and it was determined that 40 participants were needed for analysis of t-test and 41students among 240 were recruited for this study.

2.1.2. Procedures:

Subsequent to obtaining approval from the Institutional Review Board of Seoul National University in Korea, needs assessment survey was done for the freshman nursing students in a nursing school. Table 1 shows the results of the needs assessment. The principal investigator recruited the participants by posting the purpose and procedure of the study on the website of the nursing school. After informed consent was obtained, participants were randomly assigned to either the bibliotherapy group (n = 21) or the control group (n = 20) using randomization table.

The experimental group was divided into two groups, each consisting of 10-11 students. Ninety-minute bibliotherapy was provided two times a week for 4 weeks to each experimental group at the nursing school in 2014. The control group received no intervention during the study, but same bibliotherapy as the experimental group received was provided to the control group after the study for ethical reason. Survey questionnaires were distributed to all participants before the first session and right after last session of bibliotherapy. The first and last session took 120 minutes, including data collection, and other sessions took 90 minutes.

Table 2. Structure and contents of 8-Session bibliotherapy

Phase	Session	Goal	Books	Activity
Relation- ship building phase	1	Building trusting relationship	Christmas cactus (picture book)	Informed consent & survey Self-introduction Signing on the group pledge
Exploration phase	2	Exploring emotion	The red tree (picture book)	Picking 3-5 emotion cards Writing a reflective journal about emotion
	3	Exploring identity	The bear who wanted to be a bear (picture book)	Praising a friend next to me Imitative writing
	4	Exploring relationship	The wall(picture book) Two persons (picture book)	Creating the ending part of ‘the wall’ Writing a letter to a person in a difficult relationship
Insight phase	5	Knowing my value	You are special (picture book) Self-esteem which makes me love myself (psychology book)	Writing down my strengths and bragging them in a group
	6	Understanding other's perspective	I’m Tyranosaurus (picture book)	Writing a letter to a character in the story
	7	Understanding true relationship	Little prince (Novel)	Writing a letter to an important person
Ending phase	8	Planning the future	I am going to lay golden eggs (picture book) Jisun, I love you (illness narrative)	Writing a letter to myself Writing rolling paper Survey

2.1.3. Ethical Consideration:

Approval for this study was granted by the Institutional Review Board of Seoul National University in Korea. Participants were informed about the purpose and procedures of the study, emphasizing that the information they provided would be used only for research and they could stop participating in the study any time and doing so would not cause any harm. After all the explanation, participants were asked to sign the consent form if they agreed to participate and then survey questionnaires were distributed. All participants received 20,000 KRW (equivalent to about 17 USD) for participation.

2.1.4. Measures:

Rosenberg Self-esteem Scale: The Korean version²¹ of the Rosenberg Self-esteem scale²² was used to measure self-esteem. It comprises 10 items and a four-point Likert-type scale, with a higher score indicating higher self-esteem. The Cronbach’s α coefficient was .85²¹and .85 in this study.

Trait Meta-mood Scale: Emotional awareness was measured using the Trait Meta-mood Scale (TMMS) developed by Salovey et al.²³and validated in Korean by Lee and Lee ²⁴. In this study, clarity of the awareness of one’s mind and attention to one’s mood were operationally defined as emotional awareness, therefore, 16 questions among 21 items were used. The TMMS is a five-point Likert-type scale, with a higher score indicating higher level of emotional awareness. The Cronbach’s α coefficient for the 16 items of emotional awareness was .85 ²⁵ and .81 in the present study.

Interpersonal Reactivity Index: Empathy was measured using the Interpersonal Reactivity Index (IRI) developed by Davis²⁶ and translated into Korean by Park ²⁷. The IRI has 4 subscales; perspective taking, fantasy, empathic concern, and personal distress. Perspective taking and fantasy belongs to cognitive empathy and empathic concern and personal distress is called emotional empathy. Cognitive empathy is the ability to take others' perspectives and positions. Emotional empathy is vicarious experiencing of emotion such as feelings of warmth or compassion ²⁶. IRI comprises 28 items and a five-point Likert-type scale, with a higher score indicating higher degree of empathy. Cronbach’s α coefficient was .75²⁸ and .76 in the present study.

2.1.5. Statistical analysis:

The data were analyzed using IBM SPSS Statistics Version 21.0²⁹. Descriptive statistics were used to analyze the general characteristics of the participants. T-test, χ² test, and Fisher’s exact test, and Fisher-Freeman-Halton test were used to ensure homogeneity of the two groups. Finally, t-test and ANCOVA was used to analyze the effects of bibliotherapy. A p value of < 0.05 was considered to be statistically significant.

3. RESULTS:

Table 4 shows the general characteristics of the participants. The mean (SD) age of the participants was 19.63 (3.48). Twenty three of them (56.1%) were highly satisfied with nursing as a major and 19 students (46.3%) reported the reason for choosing nursing was to fit for their aptitude. Thirty two students (78.1%) reported that they read books for less than an hour per week and 29 students (70.7%) reported they enjoy reading fiction. As shown in Table 4, significant differences in demographic characteristics were not identified between the two groups. But homogeneity test of dependent variables showed that empathic concern, which is subcategory of empathy, was significantly different in two groups.

Table 4. Characteristics of the participants and Homogeneity test (N=41)

Variables	Categories	Exp (n=21)	Cont (n=20)	Total	t or χ²	p
Variables	Categories	n(%) or M(SD)	n(%) or M(SD)	n(%) or M(SD)	t or χ²	p
Age	Mean(SD)	19.14(1.32)	20.15(4.82)	19.63(3.48)	-.924	.361
Religion	Yes	11(52.4)	7(35.0)	18(43.9)	1.257	.262
Religion	No	10(47.6)	13(65.0)	23(56.1)	1.257	.262
Satisfaction to nursing	Low	6(14.6)	1(2.4)	7(17.1)	3.906	.089†
	Medium	5(12.2)	6(14.6)	11(26.8)
	High	10(24.4)	13(31.7)	23(56.1)
Reason for choosing nursing	Employment	9(22.0)	6(14.6)	15(36.6)	1.237	.645†
	Aptitude	8(19.5)	11(26.8)	19(46.3)
	Others	4(9.8)	3(7.3)	7(17.1)
Reading time (min/wk)	Less than 60	18(43.9)	14(34.1)	32(78.1)	1.476	.277*
Reading time (min/wk)	more than 60	3(7.4)	6(14.6)	9(22.0)	1.476	.277*
Kinds of books read	Fiction	13(31.7)	16(39.0)	29(70.7)	1.620	.306*
Kinds of books read	Non-fiction	8(19.5)	4(9.8)	12(29.3)	1.620	.306*
Reading preference		15.38(2.73)	16.65(2.68)	16.00(2.75)	-1.501	.141
Self-esteem		27.24(4.55)	28.55(4.78)	27.88(4.65)	-.900	.374
Emotional awareness		57.85(7.73)	55.45(7.06)	56.68(7.42)	1.039	.305
Attention		20.00(2.99)	20.35(2.96)	20.11(2.92)	-.360	.721
Clarity		37.50(6.73)	34.59(6.32)	36.18(6.53)	1.348	.184
Empathy		99.43(10.00)	102.35(6.90)	100.85(8.65)	-1.093	.282
Perspective taking		24.58(3.42)	25.35(2.63)	24.86(3.01)	-.639	.527
Fantasy		26.95(4.10)	27.00(3.74)	27.02(3.84)	-.040	.968
Empathic concern		24.68(3.70)	27.35(2.47)	26.03(3.40)	-2.513	.017
Personal distress		22.37(3.56)	23.00(2.03)	22.70(2.89)	-.643	.525

* Fisher exact test

†Fisher-Freeman-Halton Test

Exp=Experimental group, Cont=Control group

4. DISCUSSION:

This study was conducted to identify the effects of bibliotherapy in nursing students. In this study, eight sessions of 90-minute bibliotherapy effectively enhanced self-esteem in nursing students. This is consistent with previous studies conducted for university students^{30, 31}. This result is also in good agreement with meta-analysis, which showed that bibliotherapy using fiction was effective on self-expression, self-esteem, interpersonal relationship, and etc.¹⁹ A qualitative study on the experience of group bibliotherapy using grounded theory showed that voluntary participation to change, warm and supportive group atmosphere, dynamic group interaction, reading material, professional therapist's role were some of the therapeutic factors³². And these therapeutic factors led to changed perspectives on self and others and changed interpersonal relationships³². In this study, the nursing students who are interested in understanding self and understanding others participated voluntarily in the bibliotherapy. The warm, trustful, and supportive group atmosphere enabled students to express their feelings and thoughts in a group freely. By sharing stories together and giving support to each other, they released negative feelings and gained different perspectives on their individual situations. The selected reading material seemed to be appropriate for building self-esteem. The students reported that psychology book, entitled ‘self-esteem which makes me love myself’, was helpful in dealing with their inferiority as well as self-esteem. Self-esteem of nursing students is an important factor affecting the nurse-patient relationships³³. Valizadeh and colleagues argued that many pressure or protective factors influencing nursing students’ self-esteem were out of students’ control and it is the nurse instructor to attempt to promote protective factors ³⁴. Therefore, nurse educators not only should try to improve students' skills and knowledge, but should also enhance their self-esteem by providing nursing students with feeling of being important and applying participatory teaching strategy ³⁴.

The bibliotherapy also had a positive effect on emotional awareness in nursing students. This is consistent with other studies ^5,35. Edwards addressed that writing and reading personal stories related to nursing practice can deepen emotional awareness and contribute nurses’ learning and professional development³⁵. Jack found that the use of poetry enabled the pre-registration nursing students to consider not only their feelings, but those of others³⁶. Emotional awareness helps people better control their emotion³⁷and recover from negative feelings²³. As emotional awareness helps emotional expression, emotional regulation, interpersonal relationships³⁸, and adjustment to tertiary education³⁹, bibliotherapy can be more useful if it is provided to first-year students to adjust to a new life in college.

Empathy is a basic component in a therapeutic nurse-patient relationship. It involves an understanding of the experiences, needs, or concerns of patients. Empathic interactions lead to positive outcomes, including both patient and professional satisfaction⁴⁰. However, a significant effect of bibliotherapy on empathy was not observed in this study. This is not consistent with previous studies^15,28,41. Sub-analysis of empathy showed that empathic concern was significantly higher in the experimental group than in the control group. Empathic concern is other-oriented feeling of sympathy and concern for unfortunate others²⁶. Reading fictions enables people to experience various feelings without resistance^2,5. The possible reason why the levels of empathy were not significant in this study is that most of the reading materials were picture books because students' reading time was minimal. Bal and Veeltkamp reported that reading fiction changes empathy of the reader as they are emotionally transported into the story⁴². Especially, high transportation led to higher empathy among fiction readers⁴². The story of picture books is simple, therefore, it may not be enough for readers to be emotionally transported into the story. In addition, patients’ illness narratives are known to be good sources for increasing empathy in medical students⁴² and nursing students^41,44. In this study, one novel and one illness narrative were given to the students. But many students reported that they had not finished reading given books beforehand. This can be another reason why this bibliotherapy was not effective on empathy. If novel or illness narrative were read thoroughly by the students, empathy would be increased significantly. Further studies using novels or illness narratives are necessary to identify the effects of bibliotherapy on empathy.

This study utilized random assignment to minimize selection bias. However, its generalizability might be limited due to its samples being taken from a single nursing college in Korea. Also the effectiveness of bibliotherapy may differ if other people provide same bibliotherapy program because professional therapist’s role is one of the important therapeutic factors in bibliotherapy³². Follow-up studies are needed to identify the long-term effects of bibliotherapy.

5. CONCLUSION:

Nursing students need to learn to establish therapeutic relationship with their patients to provide efficient and effective nursing care. This study showed that bibliotherapy was useful in promoting emotional awareness as well as self-esteem in nursing students. Therefore, we suggest that bibliotherapy can be integrated into nursing education to help students build therapeutic relationships with patients.

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Received on 22.06.2017 Modified on 08.07.2017

Research J. Pharm. and Tech. 2017; 10(7): 2379-2386.

DOI: 10.5958/0974-360X.2017.00421.8

Variables	Category	N (%)
Books that you prefer to read*	Novel, poetry, essay	163(69.7)
	Self development	78(33.3)
	Magazines, cartoons, newspapers	42(17.9)
	Philosophy, history, religion	10(4.3)
Reading time per week (hour)	<1	195(87.4)
Reading time per week (hour)	≥1	28(12.6)
Themes you want to deal with in the bibliotherapy†(n=36)	Understanding self	27(57.4)
	Understanding other	14(29.8)
	Developing career	6(12.8)
Books you want to read†(n=64)	Novel, essay	26(35.6)
	Books related to psychology	20(27.4)
	Self-development	15(20.5)
	Other	12(16.5)

Stage	Activity	Time(min)
Opening	-Greetings & ice-breaking -Summary of last session and introduction to current session(from 2^nd session) -Sharing any events, feelings and thoughts since last meeting (from 2^nd session)	10
Story finding	Choose books that fit the subject of the session	10
Storytelling	-Modeling an emotion while reading a book together (giving one book per two persons) -Having some time to review the book	10
Story Expanding	-Which part is the most impressive? -Who is your favorite character and why? -How does the story make you feel? -What questions do you have about the story?	60
Story Processing	-Do you have similar experience like in the book? -If you were in that situation, how would you feel and what would you do? -How would the story go on afterward?
Story Reconstructing	-How do you want to change the story? -What do you get from the story? -How can you apply the lesson in your life?
Ending	-Summary & feedback from the participants -Giving information about next session to motivate participation	10

Variable	Exp(n=21)	Cont(n=20)	t	p
Variable	Mean(SD)	Mean(SD)	t	p
Self-esteem	31.14(4.23)	28.35(4.25)	2.108	.041
Emotional awareness	65.47(5.91)	56.75(5.80)	4.767	<.001
Attention	21.95(2.42)	19.95(2.54)	2.584	.014
Clarity	43.52(4.82)	36.80(5.59)	4.131	<.001
Empathy	104.67(11.30)	100.40(5.65)	1.540	.134
Perspective taking	26.05(4.34)	25.35(3.01)	.595	.555
Fantasy	28.52(4.48)	26.95(3.17)	1.293	.204
Empathic concern	27.62(3.91)	26.45(3.24)	9.970*	.003
Personal distress	22.47(3.06)	21.65(2.41)	.957	.344

The Effects of Bibliotherapy in Nursing Students