Emotional regulation training for nursing students: effects on emotional adjustment and psychological distress

Abstract

Background

Nursing students often face psychological challenges such as anxiety, depression, and stress, especially when they start their clinical training. These challenges can impair their emotional adjustment and increase psychological distress. Emotional regulation programs may help reduce these negative effects. Therefore, this study aimed to evaluate the effect of an emotional regulation program on emotional adjustment and psychological distress among undergraduate nursing students.

Methods

This experimental study used a pre-test/post-test design with both an intervention and a control group. A total of 72 fifth-semester nursing students from Razi School of Nursing, Kerman, were recruited using convenience sampling and randomly assigned to the intervention (n = 36) or control (n = 36) group using a lottery method. The intervention group participated in eight sessions of the Gross model-based emotional regulation training. Both groups completed the Emotional Adjustment Measure (EAM) and the Kessler Psychological Distress Scale (K-10) before and one month after the intervention.

Results

An ANCOVA analysis showed that the intervention group had significantly higher emotional adjustment and significantly lower psychological distress at post-test compared to the control group (p < 0.001). These findings remained significant even after controlling for baseline scores and prior training.

Conclusion

Emotional regulation training effectively enhanced emotional adjustment and reduced psychological distress among nursing students. Integrating such programs into nursing education may promote mental health and improve clinical performance.

Clinical trial number

Not applicable.

Introduction

Nursing students typically undergo a rigorous academic program that helps them develop personally, professionally, and clinically [1]. However, the demanding coursework and emotionally intense clinical settings often lead to psychological difficulties such as anxiety and depression [2]. These challenges can adversely affect their mental well-being and academic success, potentially lowering their emotional resilience [3, 4]. Emotional adjustment is the ability to effectively manage and regulate emotional responses across various situations. Individuals with strong emotional adjustment can better handle psychological challenges and respond well to demanding circumstances [5]. This ability is crucial in nursing, a complex profession with a heavy workload. Nurses often face challenging circumstances, such as caring for critically ill patients and dealing with death and suffering [6]. Strong emotional adjustment skills not only protect nurses’ mental and physical well-being but also lead to better patient relationships [7], lower burnout rates, higher job satisfaction, and ultimately a higher quality of care [8].

Conversely, psychological distress is a state of emotional suffering. It includes symptoms such as depression and anxiety, as well as physical symptoms like insomnia, headaches, and fatigue [9]. This distress is a poor psychological response to life events [10] and is a major public health concern due to its detrimental effects on health, performance, and productivity [11]. Healthcare workers, particularly nurses, are highly vulnerable to psychological distress. Its presence can impair cognitive functions, decision-making, and clinical judgment, which then reduces the quality of healthcare and patient satisfaction [12]. Therefore, interventions aimed at enhancing emotional adjustment and reducing psychological distress are vital for improving both mental health and healthcare quality [13].

Various interventions have been employed to promote mental health and resilience among nursing students, including mindfulness, cognitive-behavioral strategies, and stress management programs [14–16]. One effective intervention is an emotional regulation program, often based on models like one by Gross (2002). This approach aims to reduce psychological distress, enhance coping skills, and improve emotional well-being. The Gross model explains that emotional regulation involves all strategies, both conscious and unconscious, used to influence which emotions one has, when to have them, and how to experience and express them. The model describes five stages of emotional regulation: situation selection, situation modification, attentional deployment, cognitive change, and response modulation. Interventions based on this model teach students to replace maladaptive strategies, such as rumination and avoidance, with adaptive ones [17]. Managing emotions properly is vital for enhancing mental and physical well-being, as well as increasing personal initiative and competence [18].

Literature reviews show that emotional regulation programs effectively improve emotional regulation skills and self-compassion in military nursing students [19]. Additionally, such training has been shown to reduce self-harm behaviors and psychological problems, while enhancing resilience in nursing student [20]. A study conducted in Iran revealed that emotional regulation training significantly increased psychological well-being and decreased academic burnout among nursing students [21].

Nursing students frequently encounter significant emotional demands in both academic and clinical environments. The unique pressures of this field can substantially affect their mental health and both educational and clinical performance. Without effective coping mechanisms, these pressures can impair their emotional adaptation and overall psychological well-being. While emotional adjustment and psychological distress are key to students’’ mental health and academic performance, existing research rarely examines these two factors together in this population. Emotional regulation training is a fundamental mental health intervention that enhances resilience and fosters adaptive emotional responses. Given the emotionally intensive nature of nursing education and the direct influence of students’ mental health on their clinical performance and the quality of patient care, targeted and effective interventions are urgently needed. Moreover, while prior studies have addressed either emotional adjustment or psychological distress separately, there remains a notable gap regarding integrated approaches that address both simultaneously within nursing students. Accordingly, this study aimed to evaluate the impact of an emotional regulation program on emotional adjustment and psychological distress among nursing students.

Hypotheses

1. The emotional regulation program improves emotional adjustment in nursing students.

2. The emotional regulation program reduces psychological distress in nursing students.

Methods

Study design and setting

This experimental study with a pre-test and post-test design was conducted at Razi School of Nursing and Midwifery affiliated with Kerman University of Medical Sciences in southeastern Iran between January and April 2025.

Target population and sampling

The study included 72 third-year (fifth-semester) undergraduate nursing students from Kerman University of Medical Sciences. We selected these students using convenience sampling from the 80 nursing students admitted in the 2022 academic year. They were chosen because they had significant clinical experience and were simultaneously taking both theoretical and clinical courses. The 72 participants were then randomly assigned to either the intervention group (n = 36) or the control group (n = 36) using a lottery method.

Power analysis calculations with G*Power software indicated that 60 participants would be needed to detect an effect size of 0.2 (power = 90%, p = 0.05, number of groups = 2, and number of measurements = 2). Totally, 72 eligible students were assessed.

Inclusion criteria included willingness to participate in the study, absence of psychotic symptoms, and no history of suicide attempts or suicidal ideation, as self-reported before or during the study. Exclusion criteria included missing more than two sessions of the educational program, unwillingness to continue participation, or incomplete questionnaires.

Measuring tools

Data were collected using the following instruments:

Background Information Questionnaire gathered demographic information such as gender, marital status, age, and prior participation in emotional regulation courses within the past year.

The Emotional Adjustment Measure (EAM) is a 28-item scale developed by Rabiu et al. (2007) to assess emotional adjustment in Spanish psychology students. It utilizes a 6-point Likert scale ranging from strongly agree to strongly disagree (1 to 6), with items 21, 25, and 28 being reverse-scored. The EAM evaluates two key aspects: lack of regulation of emotional and physical stimuli and despair and wishful thinking. The total score ranges from 28 to 168, with higher scores indicating better emotional adjustment. The scale’s construct validity was confirmed via exploratory factor analysis (EFA), and its convergent validity demonstrated strong correlations with the Eysenck Personality Inventory (r = 0.86) and the Big Five Personality Traits Questionnaire (r = 0.77). The Cronbach’s alpha for the total scale was 0.89 [22].

Shokri et al. (2016) validated the scale in Iranian students, confirming its construct validity via confirmatory factor analysis (CFA). Its divergent validity showed a significant negative correlation with the Health-Promoting Lifestyle Profile-II (HPLP-II) scale, and its convergent validity showed a significant positive correlation with the Perceived Stress Reactivity Scale (PSRS). For reliability, internal consistency assessment showed Cronbach’s alpha coefficients of 0.91 for the entire questionnaire, 0.84 for the subscale of lack of regulation of emotional and physical stimuli, and 0.85 for the subscale of despair and wishful thinking [23].

In this study, the reliability of this instrument was examined among nursing students (who were not participants), and the Cronbach’s alpha values of the entire questionnaire and the subscales of lack of regulation of emotional and physical stimuli, and despair and wishful thinking were 0.89, 0.81, and 0.79, respectively.

Kessler et al. (2002) developed the Psychological Distress Scale (K-10) for the U.S general population. It consists of 10 items (K-10), scored on a 5-point Likert scale: 0 = never, 1 = rarely, 2 = sometimes, 3 = most of the time, and 4 = always. The total score ranges from 0 to 40, with higher scores indicating greater psychological distress. The scale demonstrated strong convergent validity, with a correlation coefficient of r = 0.95 using the Composite International Diagnostic Interview (CIDI) and the Cronbach’s alpha coefficient for the entire scale was 0.89 [24].

Yaghubi et al. (2016) psychometrically evaluated this scale with 500 students at Tehran University of Medical Sciences. Confirmatory factor analysis supported a unidimensional structure of the K-10, with factor loadings ranging from 0.65 to 0.84. The Cronbach’s alpha coefficient was 0.93, and the test-retest correlation coefficient was 0.91 [25].

In this study, the reliability of the instrument was evaluated among a separate group of nursing students, yielding a Cronbach’s alpha value of 0.91.

Intervention

Pre-test administration

The objectives, procedures, and ethical considerations of the study were explained to the participants, and written informed consent was obtained from all. Then, The emotional regulation program was carefully designed based on a comprehensive literature review [20, 26]. The content validity of the training sessions was then reviewed, revised, and approved by five nursing faculty members at Kerman University of Medical Sciences (Table 1).

Table 1.

A summary of emotional regulation training sessions

Session	Content	Objective	Emotional regulation tchniques	Teaching method	Assignments	Duration (an hour)
1	Introducing the Gross model, the four main components of emotional regulation (identification, perception, regulation, and expression).	To understand emotions, the importance of emotional regulation, and introduce the Gross model	Emotional self-monitoring, emotion identification	Lecture, group discussion, initial emotional self-assessment, questions and answers.	Daily recording of emotional situations and reactions to them	1.5
2	Identifying emotional situations and triggers.	To identify the triggers of emotion in different situations	Emotional chain, trigger analysis	Emotional chain group exercise, pair work.	Completing the emotional chain form for real-life situations	1.5
3	Situation selection and change.	To change or avoid triggering situations.	Purposeful avoidance, problem solving, and situation planning	Role playing, situation analysis, and group feedback	Implementing a change strategy in a real situation	1.5
4	Attention direction	To direct attention in emotional situations.	Mindfulness practice, and observing without judgment	Group exercise, body observation, and group discussion	5-minute daily mindfulness practice in stressful situations	1.5
5	Cognitive revision	To change the perception of a situation to reduce negative emotions.	Cognitive Restructuring, how can I see again?	Individual exercises, case studies, group feedback	Recording automatic thoughts and replacing rational beliefs	1.5
6	Emotional response modulation	To reduce the intensity of emotional reactions in the moment	Progressive relaxation, diaphragmatic breathing, thought stopping technique	Case studies, individual and group exercises, group discussion	Doing relaxation and breathing exercises in real situations	1.5
7	Choosing the right strategy	To evaluate and select the most effective method of emotional regulation	Adaptive strategy, cost-benefit analysis of emotion	Group feedback, case studies, individual and group exercises	Analyzing three real-world situations and choosing a different strategy for each	1.5
8	Summary and future planning	Lessons learned, planning for long-term use.	Review of techniques, stabilization of skills	Open discussion, individual and group evaluation, practical recommendations	Designing a personal emotional regulation program for the next month	1.5

Implementation of the training program

The intervention was delivered according to a predetermined schedule in the conference room of the Faculty of Nursing. It consisted of eight sessions, each lasting 90 min (two sessions per week). Teaching methods included lectures, problem-solving activities, and video presentations, all conducted in a group workshop format. During this period, the control group received no intervention and continued with their routine training programs. A trained psychologist facilitated the sessions in a suitable environment and at appropriate times.

Data collection and blinding

Data were collected from both groups before and one month after the intervention. To ensure blinding, data collection was performed by an individual unaware of group assignments, and statistical analysis was conducted by a blinded statistician. In accordance with ethical standards, the control group was provided with an educational package after the study concluded.

Data analysis

Data analysis was conducted using SPSS 22. Descriptive statistics, including frequencies, percentages, means, and standard deviations, were calculated to describe qualitative variables. The Kolmogorov-Smirnov test was employed to assess data normality. The homogeneity of groups in terms of individual characteristics was examined using chi-square and independent t-tests. Paired t-test was used to compare pre- and posttest scores of emotional adjustment and psychological distress within each group. Independent t-test was used to compare the pre- and posttest scores for both emotional adjustment and psychological distress between the groups.

Results

Demographic characteristics

This study included 72 undergraduate nursing students from Kerman University of Medical Sciences who were assigned into an intervention group (36) and a control group (35). One participant from the intervention group was excluded due to missing more than two educational sessions, resulting in a response rate of 99.8%. The number of female and male students was almost equal and most of the participants were single. The mean ages in the intervention and control groups were 22.54 and 22.63 years, respectively. Chi-square and independent t-tests indicated that the intervention and control groups were similar in terms of age, gender, and marital status. However, a notable difference was observed in prior experience with emotion regulation courses: 17.1% of participants in the intervention group had completed the course, compared to 52.8% in the control group (Table 2).

Table 2.

Comparison of absolute and relative frequency distribution of demographic variables between the control and intervention groups

Variable	Group	Experimental		Control		Statistical test	P-value
		Frequency	Percent	Frequency	Percent
Gender	Female	18	51.4	17	47.2	χ2 = 0.12	0.72
	Male	17	48.6	19	52.8
Marital status	Single	30	85.7	33	91.7	χ2 = 0.62	0.42
	Married	5	14.3	3	8.3
Completing the emotional regulation course in the past year	yes	6	17.1	19	52.8	χ2 = 0.32	0.002
	no	29	82.9	17	47.2
Age (year)		Mean	Standard deviation	Mean	Standard deviation	Statistical test	P-value
		22.54	2.82	22.63	2.97	t = -0.13	0.89

An ANCOVA was conducted to compare post-test emotional adjustment scores between the intervention and control groups, while controlling for baseline emotional adjustment and prior participation in emotion regulation courses. The analysis revealed a significant main effect of group (F = 3779.98, p < 0.001), indicating that participants in the intervention group reported substantially higher emotional adjustment at the post-test compared to the control group (Table 3)& (Fig. 1).

Table 3.

ANCOVA results for post-test emotional adjustment, while controlling for baseline scores and prior participation in emotion regulation courses

	Type III sum of square	df	Mean square	F	p-value
Intercept	2881.4	1	2881.4	127.61	< 0.001
Pre-intervention emotional adjustment	843.48	1	843.48	37.35	< 0.001
Completing the emotional regulation course in the past year	29.94	1	29.94	1.32	0.25
Group	85346.99	1	85346.99	3779.98	< 0.001
Error	1512.77	67	22.57

Fig. 1.

Comparison of pre- and post-test scores of emotional adjustment across experimental and control groups

An ANCOVA was performed to compare post-test psychological distress scores between the intervention and control groups, while controlling for baseline psychological distress and prior participation in emotion regulation courses. The analysis revealed a significant main effect of group (F = 2087.71, p < 0.001), indicating that the intervention group experienced significantly lower psychological distress at the post-test compared to the control group (Table 4) & (Fig. 2).

Table 4.

ANCOVA results for post-test psychological distress, while controlling for baseline scores and prior participation in emotion regulation courses

	Type III sum of square	df	Mean square	F	p-value
Intercept	2.99	1	2.99	0.64	0.42
Pre-intervention psychological distress	1.87	1	1.87	0.40	0.52
Completing the emotional regulation course in the past year	215.25	1	215.25	46.24	< 0.001
Group	9718.18	1	9718.18	2087.71	< 0.001
Error	311.88	67	4.65

Fig. 2.

Comparison of psychological distress scores between experimental and control groups at pre- and post-test

Discussion

This study aimed to evaluate the effect of an emotional regulation program on emotional adjustment and psychological distress among nursing students. The results revealed that following the intervention, the emotional adjustment score significantly improved in the intervention group compared to both their pre-intervention levels and the control group.

No existing studies specifically examine the impact of emotional regulation programs on emotional adjustment in nursing students. Therefore, we referred to research conducted with other populations and on related psychological outcome. Pilarik et al. (2024) in the Czech Republic showed the effectiveness of an emotional regulation program in improving emotional regulation and self-compassion in non-clinical postgraduate students [27]. The program helps people self-assess and identify negative emotions, which improves their emotional adjustment.

In the Gross model, training in emotion recognition, cognitive reappraisal, and self-compassion was most effective for these changes. Similarly, Mao et al. (2022) in China found that an emotional regulation program reduced alexithymia and enhanced resilience among nursing students [20]. This finding aligns with the present study because the intervention and research population are similar. The Gross model suggests that purposeful avoidance of emotional triggers and problem-solving skills were the most effective components. Purposeful cognitive avoidance helped nursing students prevent intense emotional reactions in clinical situations. Additionally, problem-solving skills enhanced their sense of competence, which reduced psychological distress and improved emotional adjustment.

Boediman and Haramain (2024) in Indonesia also reported that an emotional regulation program helped enhance emotional regulation skills and reduce stress levels in adolescents [28]. One possible reason for this similarity is that both studies included adolescents and young adults. The program teaches participants how to moderate emotional responses and reduce emotional intensity as they happen. Furthermore, Seyedfatmi et al. (2020) reported that an emotional regulation program effectively improved emotional regulation strategies among military nursing students [26]. The similar population and context explain this alignment. These programs appear to enhance emotional adaptation in stressful clinical environments by promoting adaptive strategies and reducing maladaptive ones. According to the Gross model, sessions that focused on replacing maladaptive thought (Session 5) and redirecting attention away from stress (Session 4) had the most significant impact. The program’s structured, 8-session format—using experiential exercises, group reflection, and role-play—offered practical tools that enhanced students’ self-awareness, emotional clarity, and flexible coping.

The results of our study demonstrated a significant improvement in psychological distress scores for the intervention group compared to their pre-intervention levels and control group. A study conducted in Indonesia during the COVID-19 pandemic showed that an emotional regulation program helped reduce anxiety and stress levels among emergency physicians [29]. Since both studies involve similar research populations and settings, these programs have the potential to be used widely in stressful and critical settings to effectively manage and reduce psychological distress. Similarly, O’Connell Kent et al. (2021) in Ireland reported that an emotional regulation program was effective in reducing students’ anxiety while also enhancing their self-compassion and resilience [30]. The shared population likely explains this similarity. The program appears to decrease feelings of hopelessness and psychological distress by fostering greater self-perception [31]. Its effectiveness can be attributed to its focus on core emotion regulation strategies, the structured format of the sessions, and the integration of experiential and reflective learning.

In Iran, Tourani & Ematzadeh (2025) concluded that an emotion regulation program effectively reduces burnout and fatigue among nurses in a general hospital. They suggest that the ability to regulate emotions significantly impacts an individual’s self-regulation, allowing individuals to identify, understand, and manage their emotions healthily [32]. Two other studies in Isfahan, Iran, also support these findings, confirming the effectiveness of emotional regulation programs on the mental health [33] and job performance [34] of doctors and nurses in a general hospital. Positive emotion regulation strategies enhance emotional awareness and appropriate expression of emotions (especially positive ones), which in turn reduces irrational stress and strengthens the mental health of healthcare professionals. According to the Gross model, the components related to cognitive reappraisal and response modulation appear to have had the greatest impact. Specifically, activities such as identifying and reinterpreting automatic negative thoughts (Session 5) and practicing adaptive emotional expression (Session 7) likely played a key role in enhancing emotional flexibility and reducing psychological distress.

A separate study by Feize et al. (2020) in Iran also showed that this program improves mental health and reduces academic burnout among nursing students [21]. This finding aligns with the present study due to the shared intervention and similar research population.

Specifically, by incorporating strategies based on mindfulness-based attention regulation and nonjudgmental observation of emotions, this training helps students develop awareness of their emotional experiences without resorting to extreme reactions or emotional suppression. Such awareness enhances their ability to manage academic stress and contributes to reduced psychological distress.

Furthermore, comparative studies have demonstrated the efficacy of emotional regulation programs against other psychological interventions. For example, Timulak et al. (2022) in Ireland found that the emotional regulation program was potentially a more promising treatment for anxiety disorders than cognitive-behavioral therapy (CBT) over a six-month follow-up period [35]. In Iran, two studies have shown that emotional regulation programs are as effective as cognitive behavioral therapy (CBT) in reducing occupational stress and aggression in nurses [36]. Another study demonstrated its effectiveness in improving the psychological well-being of intensive care unit nurses, with results comparable to other treatment approaches [37]. However, more research is needed to fully understand the program’s effectiveness, especially within Iran’s unique cultural and professional context.

Limitations

This study has several limitations and recommendations. The results are specific to Iranian nursing students, which requires caution when generalizing the results. Therefore, it is necessary to investigate the effectiveness of the emotion regulation program on nursing students and nurses in other cultures. Also the challenge of generalizing findings derived from non-nursing populations to nursing students, given the unique emotional and clinical demands of the nursing profession. It is recommended that future studies implement the emotional regulation program intervention with a larger sample size, including other healthcare workers and medical students. Additionally, we found a significant pre-existing difference in prior emotional regulation training between the control and intervention groups, meaning these pre-existing experiences, not just the intervention, may have influenced the observed results. The reliance on self-reported data could introduce response bias and data inaccuracies. The instruments used may not be adequately localized for the specific study population, which could reduce the generalizability of the findings. Implementing the intervention exactly as designed proved challenging. Variations in how facilitators delivered the program, differing levels of participant motivation, and environmental factors may have influenced the results. The lack of complete control over these variables could also reduce the generalizability of the findings. The absence of a long-term follow-up period makes it impossible to assess if the intervention’s effects are sustainable. Future studies should use a mixed-methods approach, incorporate objective assessments, and adopt longitudinal designs with follow-up periods of at least six months to improve the validity and generalizability of their results. Finally, future studies should consider recruiting participants with similar baseline characteristics or controlling for prior training through stratified sampling or statistical adjustments.

Implications for clinical practice

The findings of this study highlight the potential effectiveness of emotion regulation programs in improving emotional adjustment and reducing psychological distress among nursing students. To maximize their effectiveness, these programs should be delivered through structured formats such as interactive workshops, online modules, or blended approaches. Ideally, they should be incorporated into the nursing curriculum during clinical rotations or the early stages of nursing education. This purposeful integration can enhance psychological resilience and adaptive coping strategies among students, helping them become emotionally competent healthcare professionals and ultimately improving the quality of patient care.

Conclusion

The present study found that an emotional regulation program effectively improves emotional adjustment and reduces psychological distress in nursing students. These are crucial skills for providing holistic and empathetic patient care. The challenging educational and clinical environments of nursing can disrupt students’ ability to regulate their emotions, which may negatively impact their communication with patients and the overall effectiveness of their care. Strengthening emotional regulation skills can enhance a nurse’s mental focus, improve clinical decision-making, and facilitate effective patient communication. Given these findings, we recommend that emotional regulation training be integrated into the nursing curriculum. This can be done through structured formats such as interactive workshops, online modules, or blended learning early in a student’s theoretical education or clinical internships. Additionally, we suggest that future studies use mixed methods to design and evaluate comprehensive emotional regulation programs that are specifically tailored to the unique educational and clinical demands of the nursing profession. This would help professionally empower students and ultimately improve the quality of patient care. In addition, the observed effect sizes, particularly in the experimental group, were notably substantial, indicating a significant impact of the emotion regulation program on participants’ emotional adjustment and psychological distress. These findings highlight the clinical relevance of the intervention. Therefore, the present study provides a more comprehensive understanding of the effect of emotion regulation training on emotional adjustment and psychological distress among nursing students.

Abbreviations

ACT

Acceptance and commitment therapy

CBT

Cognitive-behavioral therapy

CIDI

Composite International Diagnostic Interview

K-10

Kessler consists of 10 items

CFA

Confirmatory factor analysis

HPLP-II

Health-Promoting Lifestyle Profile-II

PSRS

Perceived Stress Reactivity Scale

EAM

Emotional Adjustment Measure

Author contributions

DB, FN and MT contributed to conceiving and designing the research. The data were collected, analyzed, and interpreted by DB, FN and MT DB, FN and MT contributed equally to writing and revising the manuscript and approved the final manuscript.

Funding

This research received no specific grant from any funding agency in the public commercial or not-for-profit sectors.

Data availability

The data are available upon request to the corresponding author after signing appropriate documents in line with ethical application and the decision of the Ethics Committee.

Declarations

Ethical approval

This research was conducted in accordance with ethical guidelines and regulations, as approved by the Ethics Committee of Kerman University of Medical Sciences (Ethics No: IR.KMU.REC.1403.406). All steps and procedures were performed in accordance with the Declaration of Helsinki and the Committee on Publication Ethics (COPE). Necessary permissions were presented to the study setting prior to the study. At the beginning of the study, all participants provided written informed consent to participate. The participants were assured of the confidentiality of their information and voluntary participation; they could withdraw from the study at all stages without any negative consequences.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.