Effect of forgiveness-based bibliotherapy on forgiveness, self-esteem and psychological symptoms in nursing students: A randomized controlled study

Background : Although forgiveness is a crucial virtue for both nurses' self-care and holistic patient care, forgiveness education is underrepresented in most nursing curricula. Aim : The primary outcome of the study was to assess the effect of bibliotherapy on forgiveness, while secondary outcomes included its effects on self-esteem, depression, anxiety, and stress in nursing students. Methods : This parallel-group, single-blinded, randomized controlled trial was conducted with nursing students between January 2024 and June 2024. A total of 413 students were screened for eligibility, with the final sample comprising 85 participants. Bibliotherapy was administered over six weeks, with one 120-minute session per week. Data were collected using the Personal Information Form, the Heartland Forgiveness Scale, the Coopersmith Self-Esteem Inventory, and the Depression, Anxiety, and Stress Scale. Results : Students in the bibliotherapy group had significantly higher forgiveness (eta(2) = 0.828) and self-esteem (eta(2) = 0.632) scores, and significantly lower depression (eta(2) = 0.480), anxiety (eta(2) = 0.501), and stress (eta(2) = 0.741) scores in both the post-test and follow-up test, compared to the control group (p < 0.05). These effect sizes indicate large effects, suggesting that bibliotherapy had a substantial impact on all measured outcomes. Conclusion : This study provides evidence that bibliotherapy can be an effective intervention to improve forgiveness and self-esteem, and to reduce psychological symptoms.