Iran Journal of Nursing

Introduction
Nurses are a large group of healthcare providers who play an essential role in the healthcare system. The nurses working in the intensive care units (ICUs) experience high job stress because of heavy responsibilities such as long-term and continuous care of critically ill patients and lack of human resources. So far, many studies have been conducted to reduce the stress of ICU nurses. The most effective method is the cognitive-behavioral therapy (CBT). One of the CBT tasks is to write about traumatic events. Narrative writing is a way for people to release their emotions by writing down their feelings and thoughts, which can improve physical and emotional health. Studies have shown the effect of narrative writing on stress caused by mental disorders such as anxiety, depression, post-traumatic stress disorder, psychosomatic disorders and physical diseases, but have different and sometimes contradictory results. Considering that the studies on the effect of this CBT method (narrative writing) in nurses are very limited and contradictory, this study was aimed to investigate the effect of narrative writing on the job stress of ICU nurses in Isfahan, Iran.

Methods 
This is a randomized clinical trial that was conducted from November 2021 to March 2022 on 66 nurses working in the ICUs of selected hospitals affiliated to Isfahan University of Medical Sciences (Al-Zahra, Amin, Khorshid, and Ayatollah Kashani). The nurses were randomly divided into two groups (33 in the control group and 33 in the intervention group). Then the researcher collected the stress level in three stages. By using French et al.’ Expanded Nursing Stress Scale (ENSS), the level of job stress of nurses in the two groups were measured before, immediately after, and one month after (follow-up phase) intervention. During a 20-minute session, the correct method of narrative writing was taught to the intervention group face-to-face. Then, they were asked to write down their feelings in a notebook at home in a private room. They freely wrote down their emotions and feelings during a month, at least once a week, each session for 15-30 minutes, and gave the notebook back to the researcher after one month. The collected data were analyzed in SPSS software, version 16 using independent t-test, paired t-test, chi-square test, and Fisher’s exact test. The significance level was set at 0.05.

Results
In the data analysis stage, 3 nurses were excluded from the study due to their unwillingness to complete narrative writing notebook and questionnaires within four weeks, and 3 nurses were excluded due to leaving ICU during the study. Therefore, the information of 60 nurses was finally analyzed. The results of independent t-test, chi-square test, and Fisher’s exact test showed that the groups were not significantly different in terms of demographic/clinical characteristics (P>0.05). The independent t-test results showed no significant difference in the mean ENSS score of nurses in any groups before the intervention (P=0.907), but there was a significant difference in the two groups in the post-test phase (P=0.001). The paired t-test results showed no statistically significant difference in the mean ENSS score before and after the intervention in the control group (P=0.731), while there was a significant difference in the intervention group (P=0.001). In the control group, there was no significant difference in the mean ENSS score before and one month after the intervention (P=0.808), while in the intervention group, the mean difference before and one month after the intervention was statistically significant (P=0.003).

Conclusion
According to the results, narrative writing can reduce the job stress of ICU nurses. Due to the fact that this program is easy to learn and can be used practically in all areas of life, it can be considered as one of the educational requirements during the nursing service, along with other educational and retraining courses. This method can also be taught to nursing students as a way to reduce stress during the study days and after graduation. The effectiveness of narrative writing on other variables such as job satisfaction, organizational commitment, job burnout, intention to leave job, patient safety, and quality of nursing care should be measured in the form of clinical trials.

Ethical Considerations
Compliance with ethical guidelines
This study was approved by the Ethics Committee of the School of Nursing & Midwifery of Isfahan University of Medical Sciences (Code: IR.MUI.NUREMA.REC.1400.170) and was registered by the Iranian Registry of Clinical Trials (ID: IRCT20211207053324N1). All study objectives and methods were explained to participants and their written informed consent was obtained. They were assured of the confidentiality of their information and were free to leave the study at any time. 

Funding
This study was extracted from a master thesis in critical care nursing, funded by Isfahan University of Medical Sciences.

Authors' contributions
All authors contributed equally to the conception and design of the study, data collection and analysis, interpretation of the results, and drafting of the manuscript. Each author approved the final version of the manuscript for submission.

Conflict of interest
The authors had no conflicts of interest. 

Acknowledgments
 The authors would like to thank all the participants for their contribution in this study.

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