Write to heal: the impact of an expressive writing intervention on stress in first-year nursing students

First-year nursing students are particularly vulnerable to elevated stress due to the simultaneous demands of learning complex theoretical content, developing clinical skills, and adapting to new academic and social environments. Recent syntheses show high prevalence of burnout, emotional exhaustion, and psychological distress among nursing students globally, often exceeding levels observed in non-health disciplines. These stressors are compounded by frequent assessments, exposure to patient suffering, and the expectation to rapidly adopt professional roles and responsibilities [1].

The transition to higher education itself represents a major developmental challenge that can disrupt established coping mechanisms and support networks. Difficulties in academic adjustment, social integration, and managing competing role demands have been linked to anxiety, depressive symptoms, and poorer academic performance in first-year cohorts. Within nursing programmes, these transitional stressors may be intensified by long study hours, clinical placements, and performance pressures, underscoring the need for brief, scalable interventions that can support students’ psychological adjustment during this critical period [1‐2].

Expressive writing, pioneered by Pennebaker and Beall [3], is a therapeutic technique in which individuals write about their deepest thoughts and emotions related to stressful or traumatic experiences. Grounded in Emotional Disclosure Theory, it suggests that articulating emotional experiences through language facilitates cognitive processing, emotional regulation, and psychological healing [4]. Evidence indicates that expressive writing can reduce stress and anxiety, improve immune function, and enhance academic performance [5, 6].

Expressive writing is conceptually related to other reflective practices used in health and higher education, such as “reflective diaries” commonly employed in the United Kingdom and structured “journaling” activities in North American and other international contexts [4]. Although these practices differ in structure, supervision, and assessment, they share core mechanisms of emotional disclosure, reflective processing, and meaning-making through narrative. In nursing and allied health education, reflective diary keeping has been used to foster critical thinking, self-awareness, and professional identity formation, which may indirectly support stress regulation and resilience [4‐5].

Recent meta-analyses underscore the prevalence of burnout and mental health issues among nursing students, with emotional exhaustion affecting 40–47%, depersonalization 20–32%, and reduced accomplishment 17–44%, particularly peaking in second-year students amid intensified clinical demands. First-year cohorts experience moderate-to-high stress levels, correlating with poorer quality of life, sleep disturbances, anxiety (prevalence 27%), and depression, often linked to curriculum transitions from secondary to higher education and cultural shifts in diverse settings like the UAE. These challenges impair academic performance, self-efficacy, and retention, necessitating targeted interventions like expressive writing to foster resilience during this vulnerable phase [7‐9].

Despite these findings, little is known about its use among nursing students in non-Western countries. Most studies originate from Western populations, with limited consideration of cultural, linguistic, and educational differences. In the Middle East, where academic stress is compounded by language barriers, high parental expectations, and limited mental health resources, expressive writing may offer a culturally adaptable and cost-effective solution [10‐12]. One of the few regional studies, conducted at Middlesex University Dubai, examined expressive writing in relation to hopelessness and social connectedness but did not address academic stress or nursing students [13].

Despite the proven benefits of expressive writing, its impact on stress levels among university students, particularly in multicultural settings such as the UAE, remains underexplored. Thus, the aim of this study was to evaluate the effectiveness of an expressive writing intervention in reducing stress and improving college adjustment among first-year nursing students in a multicultural higher education setting. The study hypothesized that students who engaged in expressive writing would show significantly greater reductions in overall and domain-specific stress compared with the controls.

Table 1 shows that both the study and control groups were comparable in terms of age, gender, medium of education, and nationality. The mean age of participants in both groups was similar (18.86 ± 1.27 vs. 19.30 ± 1.53 years). The distribution of females and males was almost equal across groups, with a predominance of females. Likewise, no major differences were observed regarding medium of education or nationality, suggesting that the two groups were homogenous and comparable at baseline.

Table 2 demonstrates that before the intervention, no significant differences existed between the study and control groups regarding adjustment to college domains (p > 0.05). However, immediately after, and at one- and three-month follow-ups, the study group showed significantly higher levels of happiness and adjustment to college life compared with the control group (p < 0.001). Similarly, feelings of sadness and depression significantly decreased in the study group across all post-intervention assessments (p < 0.001). These findings highlight the effectiveness of the intervention in enhancing college adjustment and reducing negative emotional States over time

Table 3 illustrates that pre-intervention stress levels across physical, interpersonal, academic, and environmental domains were not significantly different between the study and control groups (p > 0.05). Following the intervention, the study group exhibited a marked and sustained reduction in stress scores across all domains at immediate, one-month, and three-month assessments (p < 0.001). In contrast, the control group showed either stable or increased stress levels over the same period. Overall stress scores were significantly lower in the study group compared to the control group at all post-intervention assessments (p < 0.001), underscoring the strong positive impact of the intervention in reducing stress among participants.

This study evaluated the impact of expressive writing on stress reduction and college adjustment in first-year nursing students within a multicultural, bilingual academic environment.

The current study demonstrates that expressive writing interventions can contribute substantially to first-year nursing students’ adjustment to college life. Participants who engaged in daily expressive writing sessions reported greater happiness and improved emotional and social adjustment compared to controls, with benefits maintained over a three-month period. This is consistent with finding from Lumontod [16] who conducted a study on how first-year college students settle into their new surroundings, which discovered that happier and more academically successful students are the ones who are better at transitioning to their academic lives. This aligns with findings from Wilbanks [17], who observed that students who engaged in expressive writing about their transition to college experienced fewer depressive symptoms and lower sadness scores compared to those who did not participate. Similarly, another study by Alipio [18] supports that respondents adjust to college often in terms of academic, social, personal, emotional, and institutional attachment. Other studies confirm that difficulties in college adjustment, often linked to increased academic and social demands, can be mitigated through structured written emotional disclosure, thereby fostering a sense of coherence and belonging among new students [19‐22].

Expressive writing appears to facilitate adaptation by providing students with a safe, guided outlet to process emotions related to transition, promote reflective thinking, and clarify personal goals. This is consistent with Emotional Disclosure Theory, which posits that written emotional expression aids in cognitive processing and emotional regulation, supporting smoother adaptation and enhanced psychological resilience among university cohorts. Integrating expressive writing into orientation programs offers a practical, evidence-based tool to help students navigate the emotional complexities of adjusting to higher education, particularly in culturally and linguistically diverse settings such as the UAE [20, 22].

A student’s journey from school to university is a momentous occasion frequently marked by both hardships and excitement. In contrast to school, students must assume responsibility for their independent or self-directed learning as opposed to dependent learning. Additionally, they must learn how to manage their time better, conduct more critical analyses, and use an applied pattern of educational assessment. Transitions in social, emotional, and cultural adjustments were also considered. Expressive writing encourages students to cognitively process complex experiences and emotions connected to university transition, facilitating coherence and integration of new roles and responsibilities. By supporting emotional regulation and fostering a narrative sense of belonging, such interventions are uniquely positioned to strengthen adjustment outcomes, especially in multicultural academic settings. Embedding expressive writing in orientation curricula can thus serve as a low-cost strategy to bolster adaptation, self-efficacy, and retention.

The results also indicate that intervention was associated with significant reductions in perceived stress levels across all measured domains—physical, academic, interpersonal, and environmental—among expressive writing participants, while controls either remained stable or experienced increased stress over time. These findings directly support the research aim of mitigating transitional stress through brief, structured emotional reflection and confirm expressive writing as an effective mental health tool in demanding academic environments. This is corroborated by another study that reported expressive writing has a positive impact on mental health by providing a secure outlet for expressing negative emotions that were previously repressed [5]. The results of this research are in line with Oishi [8]; Mohamed et al. [6]; Azzahra, Ridfah, Nurdin MNH [23]; and Yu, Zhang [24] disclosed that expressive writing interventions helped the students to relieve stress and also improve their Grade Point Average (GPA). Similarly, Cayubit [25] showed that happiness and life satisfaction levels increased following the practice of expressive writing style. According to Pennebaker and Evans [4], writing about trauma can lead to positive changes in the social, psychological, behavioral, and biological domains. This also aligns with Burnham, Kocovski [26] has linked emotional and mental health advantages, such as decreased stress, anxiety, and sadness, as well as increased clarity and attention, to expressive writing, or writing to help make sense of one’s thoughts and feelings.

Our study provides supportive evidence that expressive writing may be effective in reduction of stress among first-year nursing students. This agrees with Stephen [27] who showed that writing interventions not only enhance emotional regulation but also improve academic performance and student retention. Embedding such reflective practices into the curriculum can foster resilience, self-awareness, and a sense of psychological safety, which are critical for students’ success in demanding academic environments. Expressive writing promotes effective stress management by encouraging students to externalize and reinterpret adverse experiences, supporting emotional catharsis, and adaptive coping. Its enduring benefits stem from activating self-regulatory processes, strengthening resilience, and creating psychological safety in rigorous academic settings [28]. Incorporating expressive writing into wellness programming represents a scientifically sound and practically scalable solution to student mental health challenges in health sciences education, particularly in multicultural environments where conventional supports may be limited.

Participant origins—local (43.3%), Arab (38.3%), non-Arab (18.3%)—mirror UAE nursing programs’ multicultural profile, with no baseline stress differences across groups (Table 1), supporting the intervention’s generalizability within this context. However, non-Arab students may face heightened transitional stress from greater cultural distance and English proficiency demands, potentially amplifying expressive writing’s benefits via emotional disclosure tailored to acculturative strain [29]. These patterns highlight opportunities for origin-stratified analyses in future trials, as collectivist orientations among Arab participants could enhance narrative meaning-making compared to individualistic non-Arab cohorts [11, 30].

Impact of setting on outcomes, the supervised classroom setting likely contributed positively to intervention outcomes through several mechanisms: Accountability & Adherence: Classroom supervision achieved 100% completion rate across all four sessions (no dropouts), compared to 20–30% attrition in self-administered expressive writing studies [20]. Structured Environment: The classroom provided distraction-free focus, time-blocking, and immediate access to prompts, enhancing fidelity to the 15-minute protocol [31]. In addition to potential group cohesion effects: Although no explicit group interaction occurred, participants witnessed peers completing the task, potentially normalizing emotional expression and reducing perceived stigma around academic stress writing as well as researchers modeled professionalism and reinforced privacy, creating a safe container for vulnerability without a therapeutic alliance.

The findings of this study have important implications for curriculum design and student- support services in higher education. Integrating expressive writing into orientation programs or wellness modules can provide first-year students with a structured, low-cost tool to manage academic stress. This is particularly relevant in health sciences education, where students often face intense workloads and emotional challenges. Institutions in the UAE and similar multicultural contexts can benefit from incorporating expressive writing into their academic support frameworks, especially for students transitioning from Arabic-medium to English-medium instruction curricula.

This study was conducted exclusively among first-year nursing students at a single health sciences university, which may limit the generalizability of the findings to other student populations in other universities. The unique academic demands and stressors experienced by nursing students may differ from those experienced by students in other medical, paramedical, or non-health disciplines. Therefore, further research is needed to explore the effectiveness of expressive writing in a broader range of academic programs and institutions. Another limitation, while sustained effects were observed at one and three months, it is unknown whether students continued the practice independently. Future studies should include follow up questions on continued journaling/reflective writing to better understand mechanisms of sustained benefit. Another limitation of the study is that the demographic questionnaire did not capture participants’ engagement in creative activities or hobbies, which could serve as potential confounding factors influencing stress and adjustment outcomes. Future studies are encouraged to include measures of participation in creative or other stress‑relieving activities to more accurately account for their potential effects on these relationships. Additionally, concurrent use of other mental health resources during the study was not systematically recorded, and such support may have contributed to changes in stress and adjustment for some participants.

This study provides new evidence that expressive writing is an effective, culturally adaptable intervention for reducing stress and supporting college adjustment among first-year nursing students. By situating the intervention within a Middle Eastern academic setting, the research contributes original insights into the applicability of expressive writing beyond Western contexts. Practically, these findings suggest that universities can incorporate expressive writing into student support services, orientation curricula, and wellness modules as a low-cost strategy to improve resilience, academic adjustment, and psychological well-being. Future research should employ randomized controlled designs, include diverse student populations across multiple institutions, and explore digital adaptations of expressive writing to enhance accessibility and engagement. Together, these steps will help establish expressive writing as a validated, scalable tool for promoting student mental health in higher education.