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Nursing Research

Research mindset, pico: patient (problem), intervention, comparison, outcome, steps in library research, search tips, limits or filters, subject headings.

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• Evidence-Based Practice
• Evaluating Health & Science Information
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Between clinical practice, care coordination, and study management, research is now vital to nurses’ career success. However, most clinical nurses are not properly prepared to undertake the responsibility of research. It is important to be able to know how to

• Develop a research question and complete a literature review
• Be able to synthesize knowledge and write abstracts
• Understand elements of a well designed study

Other opportunities in research include securing grant funding for clinical research projects, and teaching staff how to conduct clinical research projects and how to present and publish their work. Nursing research focuses on four key areas that concentrate on optimizing health across the spectrum, from discovery to translation:

Health Innovation : Advancing approaches using ideas, processes, products, procedures or interventions and health system changes to benefit the health of individuals, groups and populations.

Population Health : Improving health outcomes of groups of individuals, including families and communities, and reducing health disparities within and between groups.

Precision Health : Customizing evidence-based approaches to health that incorporates genomics, environment and lifestyle.

Data Science : Facilitating knowledge discovery in biomedicine by applying contemporary analytics to large data to inform decision making in healthcare.

• AACN Position Statement on Nursing Research
• National Institute of Nursing Research (NINR)

Develop a research mindset. Understand research as a process of asking questions and exploring. 

The quality of your research depends largely on the questions you ask. Practice asking a lot of them. Adopt the mindset of an explorer or investigator. What qualities and characteristics do successful explorers and investigators have?  Develop a plan; where will you start?  As you begin to explore, you will discover that research can be messy. Expect and welcome twists and turns, keep an open mind, and keep asking questions throughout the process. Use many different kinds of search tools and resources, and conduct many different kinds of searches. 

Research takes time and patience; it can also be fun and has value.

Developing your research skills will enable you to identify a problem, collect informational resources that can help address the problem, evaluate these resources for quality and relevance, and come up with an effective solution to a problem. Research skills develop critical thinking and equip you to write better research papers and craft better speeches. You will also improve problem solving skills required to tackle issues in your personal life and in the workplace. 

• Structured Searching PICO Helpful grid from Ovid; can be used with any database. (Link to PDF on website)
• Structured Searching PICO Helpful grid from Ovid; can be used with any database. (Stored PDF for download)
• PICO Handout from EbscoHost This two-page PDF handout includes a description of the PICO process and examples of PICO topics for nursing research.
• PICO: Research Questions for Health Sciences A tutorial from Arizona Statue University Library.

Follow these steps.

Keep an open mind. You may need to refine your topic, ask new questions, and repeat steps as you go along.

Identify and define your topic. Put your research topic into a question such as, "What is the debate surrounding vaccination refusal?" Now you can identify the main concepts and keywords, including alternate terms, for your topic.

Background reading will deepen your understanding and vocabulary around the topic, which will help you identify search terms and develop an effective research question. Subject encyclopedias (in print or in Credo Reference)   are excellent resources. 

Use ArcherSearch or the library catalog to find books . 

Use ArcherSearch or individual databases to find articles from magazines, journals and newspapers . Choose appropriate databases for your topic.

Search for credible website resources. Try the librarian-recommended websites on this guide.

Always evaluate what you find. Consider timeliness, relevance, authority, accuracy, and purpose.

Cite your sources . Citing gives proper credit to the authors of materials you use and allows your professors to verify your conclusions. 

Keyword Searching

Keyword searching is used by internet search engines, databases, and the library catalog. Keep in mind that the search will find matches for specific words, not concepts. The default in the library catalog (and most databases) is to find results that include every word in your search. Think of this as using AND between the words: 

• nursing AND careers AND education
• nursing careers education

The two searches above are the same, and will find all books in the library catalog that have all three words in the description of the book. 

If you want to find a specific phrase, with the words next to each other in order, use double quotation marks around the phrase:

• "nursing care plans" 

You might want to broaden your search to include synonyms or other related words. To find either of two words or phrases, use OR between them:

•  nutrition OR diet
• (nutrition OR diet) AND diabetes

You can also use truncation to search for different forms of a word. The asterisk * is used in the library catalog and many databases for this. 

• patient AND educat*
• (patient OR consumer) AND educat*

In the above searches, educat*  will find the words educate, educated, education,  etc. 

When combining searches, use parentheses () around different parts of the search, as in the examples above. 

• Pediatric nursing
• Nursing care plans
• Nursing ethics
• Alzheimer's disease
• Communicable diseases
• Heart -- Diseases
• Evidence-based nursing

Use the filters or limits to see just a subset of your search results. Depending on the tool you are using, search limits may show up in the left margin, at the top of the results, or below the search box. 

Date limits are especially useful to filter out older, outdated material. You can usually choose a preset limit such as "current 5 years," or set a custom range of publication dates. 

Scholarly/Peer-Reviewed Journals

This will limit to only journals that publish articles that have undergone a rigorous peer-review process. These are usually articles that report on a specific study, analysis, experiment, or other piece of the research. Some scholarly/peer-reviewed articles are systematic reviews  which survey a wide range of published peer-reviewed articles to give an overview of the current state of knowledge on the topic.

The Subject limit will help you narrow your results by subject terms. These are like tags or labels; they indicate that the book, article, or other source focuses on the subject of interest. Without this limit, you may find items that include your search words but are not about your topic. Keep in mind that different databases may use different subject terms.  

The Full-text limit is already applied for most searches. It is very useful to filter out articles where you only have access to a citation or a description of an article, not the full the full article. Unless you are required to find everything out there is published on a given subject, this limit should be applied every time you search. If you do find resources that are not full text but would be useful to you, STLCC Libraries may be able provide them. See the Borrowing from Other Libraries page for details and the form for requests. 

• Borrowing from Other Libraries

Subject Heading Searching

Think of subject headings as labels or tags that someone has used to identify the subject of a book or article. The subject headings are standardized so that only one term is used for a specific subject. For example, following the Library of Congress Subject Headings standard, we use Cerebrovascular disease instead of  S troke  in the STLCC Library Catalog. You can search directly by subject, or click on a subject heading in the description of a book you find by keyword searching. Instead of a list of search results, you'll get a list of subject headings to choose from.  Here are a few examples:

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• Last Updated: Feb 5, 2024 9:35 AM
• URL: https://guides.stlcc.edu/nursing

Nursing Students' Perceptions of Skills Learning: A Phenomenological Study

Affiliation.

• 1 Author Affiliations: Assistant Professor (Dr Aldridge) and Professor (Dr Hummel), School of Nursing, University of Northern Colorado, Greeley.
• PMID: 30028766
• DOI: 10.1097/NNE.0000000000000569

Background: Deliberate practice (DP) and cognitive load theory have renewed educators' interest in effective psychomotor skills teaching.

Purpose: The purpose of this research was to explore how prelicensure nursing students learned psychomotor skills.

Methods: Nine senior nursing students participated in this phenomenological study to capture how they experienced learning nursing skills. Colaizzi's method was used to analyze in-depth interviews of open-ended questions.

Results: Six themes emerged: (a) the umbrella of emotion, (b) practice, (c) learning through technology, (d) fidelity affects learning, (e) teaching matters, and (f) importance of peers. Students found creative ways to learn nursing skills. Research findings contributed to a greater understanding of student experiences in gaining competency in nursing skills.

Conclusions: Participants used aspects of DP, cognitive load theory, and technology to learn skills. These findings provide current information to nurse educators about skills learning and recommendations for effective skills teaching.

• Clinical Competence*
• Education, Nursing, Baccalaureate*
• Nursing Education Research
• Nursing Evaluation Research
• Psychomotor Performance*
• Qualitative Research
• Students, Nursing / psychology*
• Students, Nursing / statistics & numerical data
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Understanding Research for Nursing Students

• Peter Ellis
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useful updates of previous edition easy to use and pitched at the right level for Undergraduate Students

Very well organised text with good information, especially for students new to research and evidence based practice

Superb book, easy to read but with all the essential information that students and RN'S need to understand Research

A great addition to the books that I will recommend to our health and social care students. It deals with the technicalities and the practicalities of research methods and application to practice.

A clear and user friendly book that assists clarifying the important aspects for research in the health and social care area.

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Nursing Research Methodology Guide

Nursing research is an art of scientific investigation that aims to solve healthcare problems or nursing issues. It uses disciplined methods to collect and analyze data to develop meaningful findings that help solve problems.

Research helps provide evidence pertinent to making sound decisions in a clinical setting. To properly conduct research, one must select appropriate research methods that facilitate systematic study planning, data collection, and information inquiry. When designing nursing research, you must understand what research methodologies are.

This article will explore research methodologies, why they are essential in nursing, the different types of research methods, and their characteristics.

Importance of Research Methodologies in Nursing Education

Research methodologies outline all the procedures, methods, and techniques used in a research study. They allow for data collection, analysis, and interpretation.

Research methodologies are instrumental in answering questions that are encountered in clinical practice. It details the researcher's valid and reliable approach to fulfilling their goals and objectives.

A sound research methodology can help in providing the following benefits.

• Give other researchers enough information to replicate their research.
• In case of any criticism, the researcher can return to their methodology to explain the approach used.
• Provides a specific plan for researchers to follow.
• It allows researchers to select the proper methods to fulfill their objectives.

Role of Research in Nursing Practice and Education

In nursing, research is the systematic investigation of developing relevant knowledge about issues that are important to nurses, such as practice, education, and administration. Since nurses are healthcare professionals, they do not only work in hospitals.

The scope of nursing practice is broad, and the (nurses) work in different sectors. Some work in teaching, and others in community health, business, government agencies, etc. Hence, the scope of nursing is getting wider, with many responsibilities. The responsibility of taking care of patients is vested in nurses. They deal with nursing problems and know the treatment options required by each patient, which treatment they should focus on, and which to terminate.

Adequately conducted research can provide evidence that helps healthcare professionals provide quality healthcare to patients and support nursing practices.

High-quality research allows professional growth by giving them the most accurate tools and opportunities to advance their nursing specialty.

Nurses had difficulty caring for patients before clinical hospitals or hospices were more specialized. However, now they rely heavily on research findings to reduce mortality risk and improve patient outcomes.

Nursing research of high quality means the study has answered an important question. It also means that the findings have an actual impact in terms of how care will be carried out to patients and teaching nursing students.

Nurses also have to inform their patients about the recent development in healthcare that can help them make informed decisions about their health or that of their loved ones.

Nursing students pursuing the RN and BSN programs can learn how to retrieve data, review, critique, and apply the results from the research.

Some other reasons why research is vital in nursing practice and education include the following:

• Nursing staff can gain more profound knowledge of various topics
• Conduct a careful and comprehensive search on diagnosis and other patient problems
• Come up with new and better ways to take care of the patient
• Improve nursing standards
• Minimize daily nursing challenges
• Update information on various fields where nurses are involved
• To solve day-to-day obstacles

Hence, research is an integral part of nursing practice. Nurses should rely on research to improve their knowledge, answer pertinent patient questions and provide high-quality care to those under their care.

How Research Methodologies Help Nurses Develop Evidence-based Practice

Evidence-based practices use the best available facts and evidence to improve patient care and outcomes. Essentially, it is a holistic process that integrates the following key elements: scientific research, the expertise of a healthcare professional, and the patient's perspective and preferences.

Studies show that patient outcomes improve significantly when nurses do their work in an evidence-based manner.

Nurses must understand research methodologies because they help advance nursing practice. Nurses use these methodologies to collect evidence-based information in decision-making, enhancing medical delivery and care for patients.

Research findings will offer nurses evidence-based data to develop new ways to assess, evaluate and deliver nursing care.

Types of Research Methodologies in Nursing

Research in nursing must be of high quality to yield valuable results. Nurses must have extensive knowledge and apply relevant evidence in their practice. This evidence can sometimes be in the form of research findings, filling the gaps in knowledge and expertise.

The methods primarily used in nursing to collect and analyze research may be qualitative or quantitative. Selecting the preferred methods solely relies on the one conducting the research. These methods inform nursing practice. Some research questions are best studied through qualitative methods, while others work well with quantitative methods.

However, researchers have recently adopted the best and most desirable methods. However, this is not to say that other methods do not work.

All three methods contribute immensely to nursing. Data collected in quantitative research provides a deeper understanding of everything in the social world. Qualitative data helps in understanding people's feelings, thoughts, and behaviors. The mixed method uses both data to gain a much deeper understanding of complex matters.

Mixed Methods Nursing Research

Mixed method research, also known as multimethodology, involves using elements of both qualitative and quantitative research to find answers to research questions. This aims to help you develop a complete picture since it integrates all the benefits of both methods.

In this method, researchers collect qualitative and quantitative data to conduct a study. This method has grown so much in nursing because of the increasing complexity of delivering proper healthcare. Researchers draw the strengths of the two methods and use them to draw perspective on intricate research topics. Using this method can deepen the understanding of all nursing phenomena.

Mixed methods involve purposefully combining methods in data collection, analysis, and interpretation of findings. The key word here is mixing. Remember that mixed research does not just mean collecting qualitative and quantitative data. You must consider how you will integrate them to come up with coherent conclusions.

Characteristics of Mixed-methods Research

As mentioned, mixed methods are all about collecting and analyzing both qualitative and quantitative data. This mixing of data is a unique aspect of mixed-method research. Mixing data allows a researcher to understand more about a problem than using either data alone.

The following are characteristics of mixed research.

• It involves the analysis of both qualitative and quantitative data
• There is the collection of qualitative and quantitative data in response to a hypothesis
• There is a need for convincing and meticulous procedures when using qualitative and quantitative methods of research
• It involves carefully integrating these two data collected by either emerging or embedding them.
• There is the use of a research approach that is based on a theoretical foundation.
• Using a specific mixed-method plan involving a concurrent integration

The following are examples of studies in healthcare that used mixed-method research.

• A Mixed Methods Research Study of Parental Perceptions of Physical Activity and Quality of Life of Children Under Home Lock Down in the COVID-19 Pandemic
• A mixed methods study on evaluating the performance of a multi-strategy national health program to reduce maternal and child health disparities in Haryana, India
• A mixed methods case study exploring the impact of membership in a multi-activity, multicenter community group on the social well-being of older adults

Qualitative Research in Nursing

Qualitative research is collecting, analyzing, and interpreting information about non-numerical data. This data is observed but cannot be measured. It includes opinions, thoughts, feelings, words, and behaviors. This research helps in understanding concepts and thoughts.

Qualitative research is mainly used to understand concepts that are not familiar. In nursing, qualitative research helps in generating evidence and determining patient preferences. It helps provide a deeper understanding of others and interpret their meanings and behaviors.

Generally, one will use qualitative research if one wants to know more about:

• Perceptions
• Representations
• Or anything subjective

Characteristics of Qualitative Research Method

Any good research must start from a reasonable starting position or a theoretical perspective. Quantitative research involves a positivist perspective whereby a researcher objectively and systematically obtains evidence to prove a hypothesis.

The following are characteristics of qualitative research.

• Researchers collect information from the source of the problem. They go where the participants are to collect the data. This information is collected by directly talking to the participants and seeing them in their natural habitat.
• The qualitative researcher is the key instrument. What this means is that they collect information through observation or direct interviews. They do not rely on questionnaires used by other researchers.
• It involves building patterns of information and themes from the ground up. On the other hand, build it up from separate data to a reasonable conclusion.
• Data is collected from multiple sources rather than relying on a single source.
• The researchers strive to understand the meaning of the data collected from the participants instead of summarizing what other researchers have found out.
• Researchers use perspectives such as cultural concepts, gender differences, race, etc., to collect data.
• Researchers make their own interpretations of what they have observed, seen, and heard. Because of this, there are usually different interpretations from researchers.
• Qualitative researchers aim to create a complete picture of the problem or question they are studying.

The following are examples of nursing research that has used qualitative methods are:

• The Work of Breastfeeding Among Women of Low Socioeconomic Status: A Qualitative Meta-synthesis
• Stressors Among Healthcare Workers: A Summative Content Analysis
• End-of-Life Care for Transgender Older Adults

Quantitative Research in Nursing

Quantitative research, also known as empirical research, collects numerical data that helps understand an existing hypothesis. In other words, this research is based on what can be measured accurately and precisely. This method is important because it helps collect and analyze more information. A complex problem can be reduced and restructured to several variables, resulting in factual, reliable, and generalizable data. One must therefore have background knowledge in mathematics and statistical skills.

Generally, researchers should use quantitative research if they aim to understand more about the following:

• Measurable differences
• Or anything else that is objective

Characteristics of Quantitative Research

Quantitative research uses statistics to make sense of something. It also involves making generalizations from data used to test theories about attitudes and behaviors. Quantitative data aims at clarifying any fuzziness that exists in qualitative data. The numerical insights provided will help you formulate a conclusion.

Here are the characteristics of quantitative research.

• All the methods used in collecting data are adequately structured. They also contain items requiring measurability, such as age, highest education, salary range, etc.
• It uses typically structured data collection methods such as polls, surveys, and questionnaires. These methods help draw the preferences of the participants.
• It relies on large sample sizes to collect data. Researchers conduct their study on a large number of participants to ensure reliability.
• Participants in the research are subjected to close-ended questions. Therefore, the results of these findings are less vague and limit the chances of participants providing wrong information.
• The information collected in quantitative research can be used multiple times.
• It uses close-ended questions, which are more specific than open-ended questions. Responses to open-ended questions are specific and scattered. One must have specific skills to select the needed answers.
• The outcomes from quantitative research are always in numerical form. For example, the answers can be presented in percentage form.
• Many researchers use previous research to analyze previous studies' outcomes to develop their own hypotheses.
• The outcomes of the quantitative study are used to provide a generalization for the whole population. This is because the study is conducted on a large sample size.

The following are examples of nursing studies that used quantitative research.

• Quantitative research on the impact of COVID-19 on frontline nursing staff at a military hospital in Saudi Arabia

Steps in Conducting Nursing Research

Research findings help provide a deeper understanding of how to care for patients.

The following are steps that help in conducting high-quality nursing research.

Step 1: Identify the problem / develop a Hypothesis

When conducting research, researchers try to find answers to a problem. Therefore, it is logical that the first step should be to identify the problem and then come up with the research question. For instance, if the goal is to find out whether there is a link between taking milk chocolate and type II diabetes in adults, one can pose the following hypothesis: Adults who take 20mg of chocolate milk every day have a higher chance of getting type 2 diabetes than those who consume only 10mg a day.

Identifying the keywords in your question is important. In this case, Type II diabetes, 20mg more, adults.

One must consider stating the problem clearly and unambiguously. Remember that research problems show unmet healthcare needs and opportunities l to do better.

When identifying a problem, researchers will use the SMART mnemonic .

S – Specific

M – Measurable

A – Achievable

R – Relevant

T – Time Bound

These problems can be sparked by the following:

• Personal experiences of a nurse.
• Socially significant nursing issues affecting a given population.
• An event that occurs in the workplace.
• Personal interactions in a particular study area trigger the need for further investigation.

The problems double up as the topic of your nursing research. You must analyze each problem individually and settle for one that you can manage. The research problem can be any issue that requires a solution and, in this context, it should relate to the nursing profession. You must provide a rationale for the problem and how your study addresses the issues.  

Step 2: Formulating Research Objectives, Hypothesis, and Questions

The second step in the nursing research process entails developing the scope of your research. This can be achieved by formulating research objectives and developing a research question or hypothesis. In the case of nursing research, coming up with a PICOT question or a clinical question is imperative.

A research objective is the clear, concise, and declarative statement a researcher expresses to guide the study. It helps identify and describe the variables and their relationships. It helps bridge the gap between research purpose and design. It also helps guide the data collection and analysis plans. An objective summarizes the intent and scope of the research. It also keeps the researcher focused and helps build a link with the problem statement. It should be SMART.

The research question you select for your research study should be clear and well-defined. You can derive a good research question from a literature search, theoretical frameworks on nursing, and your working experience. Ensure that your clinical research question is feasible, interesting, novel, ethical, and relevant to your field of study, area of specialization, or personal/career interests.

Nursing research might or might not include a hypothesis. A hypothesis is the formulation of the expected relationship between two or more variables in a population. For example, a reasonable hypothesis is:  

Healthcare providers with knowledge of standard screening methods for postpartum depression will help identify symptoms early.

There is a predicted relationship between knowledge of using standard PPD screening methods and early detection of symptoms.

Hypotheses apply to quantitative studies such as quasi-experimental or experimental nursing research studies. Once you test the hypothesis, you can accept or reject it, which you will include in the report write-up.

There are various types of hypotheses:

• Directional hypothesis – predicts the outcome in a specific direction. An example is when you say that persons with Type II Diabetes who have more excellent knowledge of self-management will have higher rates of adherence to treatment and management plans compared to those with no knowledge.
• Non-directional hypothesis – indicates a difference or correlation without being specific. For example, Type II Diabetes Mellitus patients who follow structured self-management programs have a higher chance of treatment adherence. Here, you do not indicate the directional relationship as the directional hypothesis does.
• Null hypothesis (Ho) – states no difference exist between groups or that there is no correlation between variables.
• Alternative hypothesis (H1) – states that there is a difference or correlation between variables.

Variables are qualities, properties, attributes, or characteristics that change or vary, such as age, sex, satisfaction, success, pain, stress, etc.

The independent (treatment or experimental variables) influence other variables. They enable or contribute to an inevitable outcome. It refers to the intervention of treatment the researcher performs to see some change in the dependent variables. It is the input.

The dependent variables are the outcome variables that reflect the independent variable's results, response, outcome, or effect. Majorly, dependent variables receive the action and can disappear, diminish, increase, and appear. When determining the effects of sugar consumption on obesity, obesity is the dependent variable, while sugar consumption is the independent variable.

We also have uncontrolled extraneous variables that influence the research study's findings. They affect the independent and dependent variables. They are referred to as threats of internal and external validity since they might lead to a bias in the selection, time, and instrument used.

Finally, we also have the demographic variables, which are the attributes of a population such as age, sex, religious beliefs, or educational levels that a researcher cannot manipulate.

Step 3: Reviewing the Literature

This is an essential step in the nursing research process. A literature review accounts for what has already been published about a particular research topic.

Conducting a literature review can help provide precise, relevant, and timely information on the topic of interest. It allows one to explore the background of their topic's scientific findings.

Your literature review should show that you are familiar with previous studies for a better interpretation of your results. It should also help you determine if there are new approaches or stimulate you to develop new ideas. The literature review can also help you to review the research topic and determine the knowledge gaps to justify your problem statement.

You should also identify the theoretical frameworks, tools, models, and instruments useful for a research problem.

When writing the literature review, you should consider primary sources. You should also use secondary sources such as scholarly journals, books, conference and seminar papers, theses and dissertations, and government or institutional (organizational) documents.

Some sources for literature review for nursing topics include conference papers, theses, journals, electronic databases, and books.

Related Reading: Literature Review vs. Systematic Reviews

Step 4: Develop a Research Plan

Once the research question has been identified, it is time to develop a study plan. When selecting the most appropriate research method, consider the following:

• Type of research ­that is suitable for the investigation, for example, descriptive, experimental, etc.
• The research design is experimental, survey, descriptive, case study, ethnography, phenomenology, grounded theory, and historical research.
• Details of the data to be collected and all relevant variables.
• Where the samples can best be collected and the techniques to be used.
• All the relevant methods for collecting data, e.g., Polls, observation, questionnaires, etc. One should consider all the aspects that could affect reliability and validity.

A research plan will minimize the time, effort, and money spent acquiring meaningful evidence. A proper plan will help in the following categories:

• Exploration and Surveys
• Data Analysis
• Observation

Step 5: Describe the Sample Population

Population, in this case, refers to the group one intends to study. The research topic will determine the study group selected. Therefore, one must select a topic they are familiar with, one that aligns with their specialization or professional interests, and one they can manage.

When investigating a select group of people in a community, one could target a specific age group, an ethnic group, and a particular geographical location.

Step 6: Collecting Data

Collecting data is vital in getting the information required to provide answers to the raised question. The data is organized into structures to make it easy to execute.

Data must be collected from different sources: primary and secondary.

Primary sources include:

• Focus groups - involve interviewing and observing people
• Questionnaire - asking a group of people a bunch of questions
• Observation - collecting data without asking people questions
• Interview - asking people questions about what they know

Secondary sources are:

• Literature survey
• Reports : Official and unofficial
• Library resources, including old reports, books, etc .

Step 7: Data Analysis

After gathering data, the researcher begins to analyze or interpret the information collected. Data analysis summarizes the collected data to develop patterns or relationships between them. This process involves cleaning, transforming, and modeling data for helpful information.

The steps for analyzing data are as follows.

• Going through the research plan.
• Organizing all the data collected.
• Writing a rough draft of the findings and conclusion. This is important as it will help in organizing one's thoughts.
• Polishing the rough draft to the final findings. A researcher will probably do this several times to ensure the final draft has no errors as they prepare for the final part.

Take note that the goal of the analysis is not to come up with information supporting a hypothesis but to review all data objectively to determine the most accurate. One must ensure this information is easy to understand.

Step 8: Create a Report

A report is a well-written text that shows details about the research conducted. This report is written after the researcher has collected and analyzed all the data about the topic. It is a reliable source for recounting research. One must only include significant findings and avoid irrelevant information when writing it.

Researchers report their findings in either of the following formats:

• Formal Paper (capstone project, QI report, thesis, dissertation, white paper, conference paper, etc.).
• Published Article
• PowerPoint Presentation
• Audio or Video
• Spreadsheet

Take note that this part is crucial. One must effectively explain their research findings clearly and succinctly.

Tips and Resources for Conducting Research

Having the right research skills can be the difference between succeeding or failing in nursing school and every part of a nursing career. Learning how to conduct research is essential since nursing keeps evolving rapidly.

Being successful in nursing means one needs to learn how to use literature, search engines and analyze the collected data. The following tips will help in conducting high-quality research.

1. Choose the Right Research Topic

This is the first step and perhaps the most crucial part of conducting research. One must select a topic that is within the parameters of the assignment. Nursing instructions give students guidelines on what to do and things to avoid. Therefore, students follow these guidelines so that the instructor can accept the final report.

Additionally, one must choose a topic that interests them and one that they are familiar with. Doing this will make the research process enjoyable.

2. Locate the Research Materials

Conducting adequate research means locating all the materials and utilizing all the provided resources. Some resources are available online, while others are available in print. Nursing schools also have access to journals not published on the Internet.

A student should take advantage of what the school offers regarding resources, as it will significantly help in research.

3. Refine the Search Results

When conducting research online, one must filter out any unnecessary resources. Researchers should consider only locating search results relevant to their area of study. They should use Google searches and other nursing literature searchers to narrow down their search results. To locate newspaper articles and magazines, Students should use electronic periodical databases. Additionally, they should only use the database best suited for the chosen topic.

4. Evaluate All the Sources

There is a lot of information on the Internet, and some are not accurate or relevant. Unlike books or print resources, no one has approved some of the information before being made public. Therefore, students must evaluate all their resources to ensure it is of the right quality. The CARS Checklist for Information Quality provides tips on assessing the sources' worth. Remember that the instructor expects highly credible and reliable research findings.

5. Be Prepared for Surprising Answers

High-quality research involves finding answers but not verifying what is already known. So one must keep an open mind when collecting data to learn more.

6. Make Notes

One should note all the relevant information pertinent to your study during research. When collecting information from a specific group of people, researchers must pay attention to what they are saying. In addition, they should use all the data collection methods provided to ensure relevant and reliable data.

7. Cite All Sources

When writing a report, one must cite all the sources used when conducting research. Using in-text citations acknowledges all the sources of information used in your paper. Then at the end of the paper, one must write down the list of all cited sources.

Citing sources is also an excellent way to prevent plagiarism in the work. Therefore, it is crucial to learn how to cite sources in either APA or Harvard format, which are the main formatting styles that nursing schools prefer.

Ethical Considerations When Conducting Research

Ethical considerations are principles guiding the research process and practice. This part is among the most critical parts of research. Researchers must always adhere to a specific code of conduct when collecting data from the population. The research will be doomed if one fails to follow these considerations.

Research ethics matter for integrity, dignity, and human rights. They ensure that aver research is conducted voluntarily and safely for all the participants.

Following all ethical considerations is an essential part of research because of the following reasons.

• It helps critically evaluate all the research work to ensure no apparent errors.
• It allows one to plan their work well to avoid any misleading results and ensure that all the questions on ethical procedures are resolved.
• Ensures that the public can trust their work, thus supporting and funding it.
• Promoting the aims of the research, for instance, expanding knowledge
• Supporting all the required collaborative work ethics such as fairness, mutual respect, etc. This is key because nursing research depends on collaboration between different groups.
• Remaining accountable for all actions taken when conducting research.

Significant Ethical Challenges in Nursing Research

When conducting your research, there are specific challenges one will come across. These can make it harder to complete the research. Three value systems involving research are connected to each other: society, science, and nursing. Therefore, significant ethical issues during research are linked to these three.

The challenges one will likely encounter when carrying out nursing research are:

1. Informed Consent

This means that an individual has knowingly and voluntarily decided to consent. It is a means by which a person's autonomy is protected. Individuals have to make informed decisions before participating in any research in which there are risks involved.

2. Beneficence- Do Not Harm

Also known as "be of benefit, do no harm," this ethical principle means a researcher must do effective and high-quality research to promote the welfare of others better. This can something be challenging, especially when using qualitative research. If proven not beneficial according to the expectations, it can raise significant ethical considerations for nurses.

3. Anonymity and Confidentiality

Anonymity and confidentiality are closely linked to beneficence. A person's anonymity is guaranteed when their identity is not linked to personal responses if you cannot guarantee anonymity to the subjects.

Confidentiality means that participants are free to withhold their information as they please. It becomes a dilemma when one has to break confidentiality to share important information.

4. Research Integrity

Working in a research environment means facing a highly competitive and performance-based environment. While this is good, it can lead to researchers engaging in unethical issues, reflecting a lack of integrity.

5. Conflict of Interest

Nurses and the institutions involved in research have varied interests, which can sometimes lead to conflicts. The conflicts can arise from different sources, such as interpersonal conflicts, holding multiple roles, financial issues, third-party pressures, etc.

Final Remarks on Nursing Research Methodology

Research in nursing is essential in finding and improving the different ways of treating and caring for patients. Nurses are the ones who know patients best. They understand what is working for them and what is not.  Research findings inform decision-making and advance nursing practice. Research methodology provides a detailed plan, keeping nurses on track and ensuring the process is smooth and effective.

In designing a research methodology, one must consider the research objectives. Knowing what information is expected at the end of the study will make it much easier to select the suitable methodology. Additionally, one must consider the nature of the research. If the goal is exploratory, qualitative research methods should be chosen. On the other hand, choosing the quantitative method is a good idea if the goal is to measure something. However, to understand a problem much better, one must combine both methods in mixed-method research.

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• Open access
• Published: 20 October 2023

Effectiveness and learning experience from undergraduate nursing students in surgical nursing skills course: a quasi- experimental study about blended learning

• Yan Ran Li 1 ,
• Zong Hao Zhang 1 ,
• Pan Wang 1 ,
• Shu Wen Li   ORCID: orcid.org/0000-0001-5668-3697 1 ,
• Dan Su 1 &
• Ting Zhang 1  

BMC Nursing volume  22 , Article number:  396 ( 2023 ) Cite this article

1884 Accesses

Metrics details

Blended learning is increasingly being adopted, and yet a gap remains in the related literature pertaining to its skill performance, learning engagement and inner experience in undergraduate surgical nursing skills course.

To investigate the changes in skills performance and learning engagement in the application of blended learning, and what it actually brings to nursing students.

The study uses a historical control, two-armed, mixed and quasi-experimental design.

The blended learning version of the course was offered to the 2019 class of 334 nursing undergraduates. Quantitative and qualitative data were collected after the course to obtain a comprehensive understanding of the course effects compared with the 304 nursing undergraduates of grade 2017 who adapted traditional learning. Quantitative data were analyzed by descriptive and inferential statistics using IBM SPSS 26.0, and qualitative data were encoded using Nvivo11.0.

There were significant differences in skill performance and learning engagement between the class of 2017 and 2019 ( p  < 0.001). Combined with further analysis of the interview data, 3 first-level nodes and 8 secondary nodes were determined. Students’ opinions, comments and suggestions on the application of blended learning are refreshing.

Moving forward with blended learning: opportunities and challenges go hand in hand. Researchers need to continually modify their research designs to respond to variable educational environments.

Peer Review reports

Introduction

The traditional teacher-centered teaching patterns have been the mainstay of nursing education [ 1 ]. Traditional learning refers to the traditional method of education in which students enter a specific place at a specific time for face-to-face interaction with teachers and classmates [ 2 ]. The schedule and content of the course will be assigned by the teachers, and the classroom serves as the primary learning environment. It typically involves lectures, textbook readings, note-taking, and paper assignments [ 3 ]. Circulating knowledge is a one-way street in traditional teaching: teachers act as transmitters of knowledge and students are passive recipients [ 4 ]. The limitation of time and space greatly hinders students' study. Teaching drawbacks such as a single form of teaching, limited teaching activities, and poor student initiative and motivation have not been solved over time [ 5 ]. The emergence of online learning has, to a certain extent, facilitated the application of quality teaching resources and the diversification of education [ 6 ]. However, It has to be admitted that complete online learning isn't flawless either. For instance, users must have a high degree of self-control in order to take advantage of the benefits of online learning [ 7 ]. It's not always the way it should be. A study showed that coursework completion rates for single online instruction were less than 10% [ 8 ]. It has been recognized that neither singular online teaching nor traditional teaching can achieve specific pedagogical goals [ 9 ]. Even though traditional teaching has many drawbacks, there is no substitute for face-to-face teacher-student interaction and high-frequency collision of ideas in the classroom [ 10 ]. There is a mounting debate on how to combine traditional and online education for effective teaching and learning [ 11 ]. Blended learning formats will be the inevitable orientation of education in the future [ 12 ].

Blended learning takes multiple formats and can be elusive to define. There are primarily four interpretations relevant to blended learning [ 13 ]: (1) blending based on web-based technologies; (2) blending of various teaching methods; (3) combination of any form of instructional technology with face-to-face instruction by the instructor; and (4) integration of instructional technology with work tasks to form an effective combination of learning and work. The definition employed in our study is strongly interrelated with the third point above. Blended learning is described as a combination of traditional learning and a range of pedagogical approaches supported by information and communication technology [ 14 ]. This definition encompasses blended learning, distributed learning, decentralized learning, hybrid learning, and flexible learning [ 15 ]. Rather than a simple convergence of technologies in the true sense of the word, it creates a student-centered pedagogical model that combines the advantages of online learning (e.g., flexibility, wide range of educational resources, timely updating, and resource sharing) with the interactivity of traditional teaching [ 16 ]. In this pedagogical approach, students engage in both offline classroom activities and online learning experiences. They may participate in lectures, discussions, and collaborative work in the physical classroom, while also utilizing digital resources, video lectures, interactive modules, or online quizzes for learning [ 17 ]. Online learning content is usually delivered through a learning management system or other digital platforms. Blended learning allows students to access course materials at their convenience, review content as needed and engage in interactive online learning activities [ 18 ]. At the same time, this approach allows teachers to personalize instruction, track student progress and provide additional support [ 19 ].

The novel coronavirus disease (COVID-19) pandemic has challenged nursing educators worldwide [ 20 ]. One of the goals of nursing education has been to accelerate the training of future nursing workers to respond to future public health emergencies. However, in local medical universities in developing countries, including China, school facilities and faculty numbers are not sufficient to match the rapid growth in enrolment [ 21 ]. Surgical nursing is one of the main courses in undergraduate nursing education. Besides a solid theoretical knowledge, it requires students to master a wide range of surgical nursing operations. However, traditional teaching methods are constrained by time and space, and not all students have the opportunity to participate directly in practical demonstrations, and relying solely on abstract verbal explanations and photographic displays, students often fail to grasp all the operation points. Therefore, we urgently seek an innovation in education to salvage the current situation.

Blended learning has already practiced in medical disciplines and its effectiveness has been verified [ 22 ]. "Effectiveness" generally refers to student performance in final examinations [ 7 ]. Blended learning strategies strengthen nursing students’ academic performance compared to traditional teaching in studies involving undergraduate nursing students [ 23 ]. However, it is debatable whether blended learning can improve the operational performance among undergraduate nursing students. A study found that blended learning is more effective than traditional teaching in terms of skill performance [ 12 ], but a meta-analysis showed some improvements in skills compared with traditional learning, but the difference was not statistically significant [ 24 ]. Hence it is not yet certain whether the integration of Information Technology (IT) into the traditional classroom will actually boost students' performance in surgical skills.

Getting to know how engaged students are with their learning is vital to assessing blended learning. Learning engagement is defined as a positive, fulfilling, and work-related state of mind characterized by vigor, dedication, and absorption [ 25 ]. When students are more engaged in their learning, they are more motivated, focused, and committed to achieving their goals [ 26 ]. This results in enhanced academic performance, higher retention rates, and greater academic satisfaction, conversely, when students are less engaged or less fully invested in their learning, they may struggle to learn new things, lose interest, or even drop out of classes [ 27 ]. The pedagogically orientated use of educational technology can superiority support student engagement compared to traditional learning [ 28 ]. Researches suggested that it may be related to increased independent learning, autonomy and interest in learning [ 29 , 30 , 31 ] Under these positive influences, students are motivated to follow the course rules, devote themselves to the course, take action to solve the learning problems and achieve learning success, which in turn leads to new emotional experiences, creating a virtuous cycle that enhances learning outcomes [ 32 ]. The indicator of learning engagement laterally reflects the effectiveness of blended learning. Compared to cold numbers, It's more "humane.", which pays more attention to the state of student learning and compensates for the deficiencies of numbers assessment [ 33 ]. Currently. There are few studies that directly point out that blended learning can increase student engagement.

What exactly does blended learning bring to students is the highlights of our research. The fundamental purpose of blended learning is to serve the students and We are more interested in discovering how students experienced the education model, such as cognition, attitude and opinions. Satisfaction is the most common indicator used by students to evaluate course teaching. Blended learning has been found to increase student satisfaction [ 34 ], however the use of satisfaction alone as an indicator is not comprehensive enough and there is no authoritative quantitative tool available to students for course evaluation. The introduction of qualitative research methods can do us well in addressing these issues. The mixed methods to research, combining quantitative and qualitative aspects, can maximize our understanding of the effectiveness and experience of blended learning among students [ 35 ]. At the same time, qualitative methods can compensate for quantitative gaps [ 36 ].

The main purposes of this study were to compare the skill performance and learning engagement of nursing students with different learning modes by adopting a quantitative methodology, and exploring the innermost experiences of blended learning users through qualitative research. These findings will help to provide lessons and implications for nursing education programs in universities worldwide, while maintaining and safeguarding the well-being of students.

Study design

The study uses a historical control, two-armed, mixed and quasi-experimental design. The experiment was conducted in different semesters; we implemented traditional teaching in 2019 and blended learning in 2021, and the study was conducted on third-year undergraduate nursing students with different entry dates. Quantitative data were collected on skill performance and learning engagement assessment scales, and qualitative data were collected by interviewing blended learning users. The detailed study design is illustrated in Fig.  1 .

Flowchart of experimental design

Sample size and estimated study power

G power 3.1 was used to calculate the sample size. To maximize statistical power, the sample size estimate was calculated with a mean effect size of 0.5 for the outcomes, an alpha set at 0.05, and a power of 0.80, and the result showed a requirement of 64 nursing students for each group [ 37 ]. A minimum of 80 participants per group were eventually enrolled, taking into account a 20% dropout rate.

Participants and recruitment

This study was conducted among undergraduate nursing students in different grades at a public medical university in China. First, a method for cluster sampling was adopted. A total of 304 nursing students from the class of 2017 were invited to attend a traditional surgical nursing skills course. A total of 334 nursing students from class of 2019 were invited to participate in the blended learning. Second, after the end of the course, according to gender and skill performance, 15 nursing undergraduates in Grade 2019 were selected for individual face-to-face interviews by purposive sampling. The specific inclusion criteria were as follows: 1) Full-time nursing students enrolled in the national unified examination; 2) Participants providing informed consent and voluntarily participating in this study; 3) Participation in the course to apply for leave and suspension from school, with a cumulative leave time of not more than 1 month; and 4) Normal cognitive and behavioral abilities.

Blended teaching program

Eight surgical nursing skill classes were offered to the 2017 undergraduate nursing students in 2019, all of which used traditional face-to-face teaching methods. The blended learning version of the course was offered to the 2019 class of nursing undergraduates in 2021, which combined synchronous and asynchronous online learning modules on the basis of traditional face-to-face teaching.

On the basis of the original course, 10 new chapters of online learning are added, and the original 8 traditionally delivered chapters are integrated into the online content to form a unique blended version of the teaching arrangement. The online learning module was developed using a variety of authoring software tools and screen play (pre-recorded), which were accessible through the learning management system. The same team offered both courses. The specific blended course arrangement is shown in Additional file 1 .

According to the characteristics of the content of the Surgical Nursing Skills course, the blended classroom teaching method of Preview before class—Classroom teaching—Review after class was established to help students understand and accept the content of the course and achieve satisfactory learning outcomes. An example is the care of a closed chest drain:

Preview before class: The instructor publishes a pre-recorded video on closed chest drainage through the platform, with 2–3 quiz questions interspersed in the short video. Students need to log in to the learning platform to complete the video and chapter quizzes before the offline course. In addition, teachers can set up clinical scenarios through the platform to introduce cases and inspire students to think. Students are free to form groups and complete single or team discussions.

Classroom teaching: the teacher explains the purpose, significance and etc. of closed chest drainage to students through clinical cases, and analyses the key and difficult parts in detail. In the teaching process, the learning platform is used for teacher-student interaction, such as setting up a quiz, random drawing and other special activities to enrich the teaching content. After the theoretical study, the teacher personally demonstrates the skill operation in the classroom and invites students to make a retest.

Review after class: Teachers release post-class assignments, such as online discussion on "What to do if the closed chest drain falls off", and track students' learning through the platform. Uploading extended resources to bridge the gap between clinical and actual teaching, as well as maintaining the operation of the platform. Students submit reports, complete discussions, practice operations on their own, and complete teaching evaluations. See particular in Fig.  2 .

Blended learning operation chart

Instruments

The quantitative survey collected demographic data, skill performance, and learning engagement. Demographic data included age, sex, professional distribution and organization participation.

Skill performance was determined by the proportion of final examination results and usual grades at 6:4, which were directly derived from the official platform of the university.

Learning engagement was measured using UWES-S (Utrecht Work Engagement Scale-Student scale) compiled by Schaufeli (2002) [ 25 ]. The scale consists of four dimensions and seventeen items, of which vigor and absorption include six items each and dedication includes five items. The scale was scored on a 7 points Likert-scale. The Cronbach’s α was 0.87.

The qualitative survey mainly adopted a self-made interview outline, and conducted one-on-one face-to-face interviews with 15 nursing undergraduates who used blended learning, around the six questions in the outline.

Trustworthiness

First of all, the researchers themselves are an invaluable tool in qualitative research. The researchers have received professional training in qualitative research courses during their school years, as well as learning related to qualitative research data collection, and have conducted pre-interviews under the guidance of their supervisors, mastering semi-structured in-depth interviewing techniques, data collection methods, and analytical methods. Second, relevant literatures according to the purpose of the study were explored, initially formulated the interview outline, and revised the outline after consulting four members of the Surgical Nursing teaching and research team (including one professor, one associate professor, and two lecturers); two students who met the criteria were selected to be pre-interviewed, and the interview outline was finally formed after the discussion of the research team. Third, the researchers, as students at the same school, joined the QQ group used for classroom management while the blended learning was underway. Not only did this allow the researchers to observe students’ responses in a timely manner, but it also facilitated the establishment of long-term relationships and shortened the length of the freeze-breaker required at the start of the later interviews. Finally, callbacks to interviewees is also a step towards ensuring the quality of qualitative research. After the interviews were completed and the recordings were converted into text, we confirmed the accuracy of the interviews with the interviewees through an online chat and asked them to evaluate the interview process for later improvement.

The specific interview outline is as follows:

Compared with the traditional learning mode, after a semester of blended learning, which one do you prefer? Give a reason.

Does the model of blended learning meet your needs for learning skills?

What do you think blended learning approach has brought to you?

What was your greatest feeling during the learning process?

Please rate the online and offline blended teaching mode from 0–100. Do you hope your younger brothers and sisters continue this learning method in the next semester?

Do you have any other suggestions or opinions?

Data collection

Through the ‘questionnaire Star’ platform, the demographic questionnaire and the UWES-S were compiled into an electronic version of the questionnaire. After obtaining informed consent from the participants, the participants filled out the questionnaire by ‘scanning the code’ which was distributed to the QQ group. The first survey object of the electronic questionnaire was undergraduate nursing students of Grade 2017 in 2020: a total of 304 questionnaires were sent out, of which 248 were effectively received. The second survey object was undergraduate nursing students of Grade 2019 in 2022: a total of 334 questionnaires were sent, and 276 valid questionnaires were collected. The scores of surgical nursing skills of two grades were obtained through the educational administration system and the rain classroom platform.

A phenomenological qualitative research method was adopted. Based on the interview outline, the researcher conducted a one-to-on in-depth interviews with 15 undergraduate nursing students of Grade 2019 face-to-face at the end of the course. Each time, the length was approximately 60–90 min, ambient noise was eliminated, and privacy was maintained. When dealing with the interview materials, the names were handled anonymously and replaced by a serial number of the English alphabets A–O.

Statistical analysis

Data were analyzed using the IBM Statistical Package for the Social Sciences (Statistics) version 26.0. Descriptive statistics of mean, standard deviation, and percentage were used for demographics, skill performance, and other study variables. independent t-test was used to examine the differences between blended and traditional learning methods in relation to students’ skill performance and learning engagement. Statistical significance was set at P  < 0.05. The interview data were imported into Nvivo11.0 in the form of word text, and encoded in open, associated, and selective modes. When the 12th interviewee was being interviewed, we found that no new coding content appeared with the input of word text materials, and three more interviewees were interviewed to verify whether the data had been saturated. We also rechecked the codes of interview materials, the node closest to the research topic was selected.

Demographics

Two hundred and forty-eight nursing students from Grade 2017 were enrolled as the traditional learning group, including 65 males and 183 females, with an average age of 20.42 ± 0.84 years, 276 students from the Grade 2019 were the blended learning group, including 53 males and 223 females, with an average age of 20.57 ± 1.11 years. A total of 154 nursing students in the traditional study group were transferred to the nursing program by their majors, and 56 students were class officers and were able to actively participate in various activities. In the blended learning group, 183 students were transferred and 68 were class officers. The baseline data of the two groups were consistent and comparable (see Table 1 for details). We ensured a rigorous experimental design as much as possible, in addition to comparable demographic information. In the teaching and learning process, the faculty, the school district environment, and the use of teaching materials were identical. At the same time, we used the evaluation indicators: grades, test paper questions drawn from the same question bank.

Skill performance and learning engagement

The final course grades were obtained from the university’s educational administration management system and the classroom platform. Table 1 shows the overall score of the blended group (81.19 ± 5.86) was better than traditional group (76.29 ± 8.06), with a statistically significant difference (t = -8.723, p  < 0.001). By comparing the results of the bar charts (Fig.  3 ), It can be seen that the integration of IT into traditional education has resulted in a decrease in the proportion of students in the lower band (skill performance < 70) and an increase in the proportion of students in the higher band (skill performance > 80). There is a tendency for students in almost every mark range to migrate to higher mark levels. This demonstrates that blended learning does not only help to improve overall scores by raising the performance of poor students, but also allows students in the higher bands to progress.

Score distribution map of surgical nursing skills

According to the data analysis results, the level of learning engagement of nursing students in blended (79.67 ± 14.99) was higher than traditional (48.73 ± 18.18), there were statistical differences in the overall score of learning engagement and scores of all dimensions between the two groups (t = -21.106, p  < 0.001) (see Table 1 for details).

Data analysis of students’ cognition, attitude, and opinions

A purposive sampling was conducted among the 2019 Grade nursing undergraduates based on gender and skill performance with a total of 15 students. Among them, the male-to-female ratio was 3:2. The skill scores are representative in all score segments (see Additional file 2 for details).

Combined with the analysis of the interview data, three first-level nodes were determined: 1) Conforming to the development of the times, reflection and worry about the blended learning, 2) The positive and negative changes that blended learning brings to students, and 3) Students' comments and suggestions on blended learning. In addition, there were 8 secondary nodes: 1) cause of occurrence, 2) reflection and worry, 3) advantage and disadvantage, 4) benefits and obstacles,5) satisfaction,6) platform usage, 7) resource updates, and 8) faculty capacity enhancement. The original information in the literature is the three-level node, namely, the reference point, which is the encoded text content in the qualitative data.

Theme 1: conforming to the development of the times, reflection and worry about the blended learning

Students affirmed that the emergence and development of blended learning is a major trend. Moreover, they thought about and looked forward to the prospects of blended learning.

A: This is in line with our development, that is, the progress of consistent development of the nursing discipline, which is also why blended learning can emerge. …

K: Offline platforms have been unable to meet the learning requirements of contemporary college students, which is the reason for the emergence of online platforms. …I really look forward to it. Will the future be a fully digital era !

O: What about our model after the end of the pandemic? What is suitable for the development of a society? Will it always change according to the needs of students? …

Theme 2: the positive and negative changes that blended learning brings to students

The students had a clear understanding of the advantages and disadvantages of blended learning. blended learning can meet the learning needs of students and make students have a sense of benefit and pleasure. While it also hinders their progress to a certain extent.

I: We can review knowledge repeatedly and learn the knowledge points more clearly and systematically. Videos and online materials are more convenient to review. Meanwhile, the online information is complete, mainly very authoritative, and sent by the teacher.

G: We have a little worry about online learning could to become a burden on students. E-learning requires high power consumption of electronic equipment and network fluency. when you watch the video, you will also be disturbed by some information from the outside world. A higher demand for autonomy may lead to a lower learning efficiency.

H: In traditional learning, the teacher sometimes speaks too fast to record or understand. the blended learning model can meet my learning needs in surgical nursing. I think that my study has made progress. My operations are more standardised, and my knowledge is more solid. …

Theme 3: students’ comments and suggestions on blended learning

The students clearly expressed their love for blended learning with a high score of satisfaction and expressed hope that the next class of students will continue this mode. they put forward their own suggestions on blended learning from platform usage, resource updates, faculty capacity enhancement.

A: Here, I will take Sudan, one of our excellent teachers, as an example. I hope that other teachers can learn from her in the future, develop unique teaching styles, and improve their teaching ability.

B: The video materials still need to be constantly updated, and I still feel that there is still a gap between the requirements and some specific clinical operations. …

F: I also feel that blended learning is very good, with a satisfaction rating of 98. I hope that the younger brothers and sisters of the next semester will continue this learning method.

O: As I mentioned earlier, how can we diversify resources? Not just by videos, such as bibliographic indices, but the entire resource platform. It lacks a unified guide for use. … Our classmates may not use the electronic resources of e-learning platforms much as they are more accustomed to the original teaching methods sometimes.

This study found that nursing students’ skill performance significantly improved after adopting blended learning. Most available studies suggest that blended learning is more effective in knowledge acquisition than traditional learning [ 38 ]. The nurse students strengthen their clinical skills by repeatedly watching clinical videos to establish a connection between theory and practice anytime and anywhere according to their own rhythm [ 29 ]. Blended learning fully considers the individual differences of students, and does not evaluate students’ academic performance purely by examination scores [ 39 ]. It adds several evaluation indices, such as online task completion, homework completion, and classroom participation, which can objectively and multi-dimensionally evaluate students’ learning performance. Completion of these indicators will be calculated as the student's usual grade into the final grade (4:6). The results emphasize the portability and overall benefit to student learning of clinical skills by introducing video podcasts into nursing curricula [ 40 ].

Undoubtedly blended learning can improve the degree of learning engagement among undergraduate nursing students. Because of the innovation in teaching methods, blended learning overcomes the limitations of classroom teaching, time, and space [ 41 ]. Teachers use the online platform for high-frequency interaction and cooperation with students to stimulate nursing students’ interest in this course. In the nursing learning of most medical colleges in China, the traditional learning materials are mostly paper materials and PowerPoint (ppt), but ppt is only displayed in class, making it inconvenient to take pictures or download. Rich and official learning resources and learning activities (such as videos, electronic question banks, group simulation homework, and expanding resources) make the boring traditional classroom more vivid and flexible, which can attract students’ attention and improve students’ interest in learning [ 42 ]. Therefore, we have every reason to believe that blended learning can improve students' interest in learning through the reform of teaching methods, thus increasing the frequency and depth of students' entry into learning state, and students who are more engaged in learning are more likely to get better grades.

Qualitative research results bring new findings to blended learning. This study found that nursing students had an excellent sense of learning experience after adopting blended learning. They have a clear understanding of the occurrence and development of a new model and its advantages and disadvantages. Interestingly, students do not think that e-learning replaces traditional teacher-led training, but complements it. Blended learning is more consistent with the learning habits and motivation of contemporary college students [ 43 ]. Teachers upload detailed teaching videos through online modules and reinforce students’ memory points through offline classroom consolidation, which is undoubtedly a more official and convenient way to learn. Nursing students can choose to study anywhere any time and create a suitable learning environment according to their own learning habits. Almost all interviewees expressed their love for the application of blended learning in ‘surgical nursing skills’. These findings are consistent with the previous studies conducted by Li and Schaffner [ 24 , 44 ]. The information environment created by blended learning can benefit nursing students more [ 15 ]. The model in the application of surgical nursing skills can help the nursing students learn this course, but there are still some problems, such as lack of detailed operational guidelines and guide learning modules, hope for the latest clinical technology, etc. It is particularly noteworthy that some students have proposed that teachers’ personal abilities and styles are also factors affecting blended learning, which suggests that there is another requirement in the selection of talents for nursing discipline construction in the future. For students to put forward their opinions, nursing educators and technical support staff must adjust in a timely manner. Everything must be student-centered to obtain a better sense of learning experience.

There are some limitations to this study that should be acknowledged. First, the data were self-reported, which also limits the universality of the study results. Second, the participants were third-year nursing undergraduates of different periods in the same university, course changes were made from semester to semester based on advances in technology, student feedback, course evaluations, and the maintenance of academic integrity. Although we did our best to control for variables (e.g., consistent baseline demographics, same faculty, etc.), the utter randomization and pure experimental design were not possible in the surgical nursing skills course. Finally, the long-term effects of this experiment were not continuously tracked. In the future, we should test the results by conducting blended learning in more fields and different populations.

This study found that blended learning improves student achievement and engagement in learning and attempts to understand students' internal experiences from their perspective, some interesting conclusions were also drawn. It can be seen that blended learning is in fact a teaching strategy with a great deal of potential. However, there are many challenges as well, the chosen model (e.g. flipped classroom or scenario-based teaching), the use of technology, the process of switching between online and offline activities, and the control over the completion of online activities all add to the complexity of this approach. Consequently, moving forward with blended learning: opportunities and challenges go hand in hand.

Availability of data and materials

The data that support the findings of this study are available from the corresponding author upon reasonable request.

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Acknowledgements

We would like to thank the nursing students who participated in this study.

This study was funded by Anhui Medical University Nursing School curriculum construction project fund ((No. 2020xsxxkc240). This article’s investigation, data curation, resources, writing-original draft, project administration, and visualization., as well as the choice of whether to send it for publication, were all done without the involvement of any of the funding sources mentioned above.

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Yan Ran Li: Literature review, methodology, investigation, data curation, resources, writing-original draft, project administration, reviewing and visualization. Zong Hao Zhang: Methodology, investigation, formal analysis, data curation, writing, reviewing, and editing. Wen Li: Methodology, investigation, formal analysis, writing-review, and editing. Pan Wang: Methodology, investigation, formal analysis, data curation, writing, reviewing, and editing. Shu Wen Li: Conceptualization, methodology, formal analysis, investigation, data curation, resources, writing–review and editing, visualization, and funding acquisition. Dan Su: Conceptualization, writing-review, supervision, and funding acquisition. Ting Zhang: Conceptualization, writing-review, supervision, and funding acquisition.

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Additional file 1..

Content arrangement of the surgical nursing skill courses.

Additional file 2.

Demographic characteristics for 15 interviewees.

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Li, Y.R., Zhang, Z.H., Li, W. et al. Effectiveness and learning experience from undergraduate nursing students in surgical nursing skills course: a quasi- experimental study about blended learning. BMC Nurs 22 , 396 (2023). https://doi.org/10.1186/s12912-023-01537-w

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• Joyce Toriente Relloso, Nada Abdullah AbuAlula, Jocelyn Magtalas Medina, Edgar Gatioan Manood. Nursing Skills Laboratory as Milieu of Clinical Learning and Practice. American Journal of Nursing Research . Vol. 9, No. 4, 2021, pp 112-117. http://pubs.sciepub.com/ajnr/9/4/2 ">Normal Style
• Relloso, Joyce Toriente, et al. 'Nursing Skills Laboratory as Milieu of Clinical Learning and Practice.' American Journal of Nursing Research 9.4 (2021): 112-117. ">MLA Style
• Relloso, J. T. , AbuAlula, N. A. , Medina, J. M. , & Manood, E. G. (2021). Nursing Skills Laboratory as Milieu of Clinical Learning and Practice. American Journal of Nursing Research , 9 (4), 112-117. ">APA Style
• Relloso, Joyce Toriente, Nada Abdullah AbuAlula, Jocelyn Magtalas Medina, and Edgar Gatioan Manood. 'Nursing Skills Laboratory as Milieu of Clinical Learning and Practice.' American Journal of Nursing Research 9, no. 4 (2021): 112-117. ">Chicago Style

Nursing Skills Laboratory as Milieu of Clinical Learning and Practice

Objective: The study's objective is to assess the effectiveness of the university nursing skills laboratory if it functions as the milieu of clinical learning and practice. Methods: The research employed a mixed-method approach that included both quantitative and qualitative components. Results: The study revealed that most nursing students are still female and have already long experienced using nursing laboratories. The nursing skills laboratory assists in developing the psychomotor skills of the students (3.34) and builds confidence and overcome fear in performing nursing procedures' (3.26). The checklist used in the nursing skills laboratory is essential. The rubrics of the checklist provided accurately measure student skills (3.21); however, it should be based on or designed after the hospital setting (2.86). The respondents stressed that an additional time for an open laboratory hour enhances their nursing skills (3.06.). Some respondents feel the insufficient time to practice specific nursing skills for a particular session (2.78). Respondents stated that the availability of equipment and supplies affects the quality of their nursing skills performance (3.08). There was a significant difference in the assessment of the respondents when the year level was considered. Lastly, respondents stated that the challenges they face in the nursing laboratory are a lack of sufficient equipment and materials and a lack of time to practice the skills they have learned. Conclusions: Based on the study's findings, the nursing skills laboratory should have sufficient equipment and supplies in the simulation to use during the nursing skills demonstration and re-demonstration. Additional time should be given to the students to practice the skills they have learned, and the checklist should be designed after the hospital setting to reduce the risk and ensure patient safety.

1. Background

Skills laboratory prepares nursing students for their clinical placement and helps them to practice a scenario using the nursing skills countered in their workplace environment. It is described as a practice room, equipped with training facilities offering students in the medical field a safe environment to practice their clinical skills before the actual application . With that, it should be well established as it will support and facilitate students' psychomotor learning. Moreover, the problem may occur if the nursing skills laboratory are not enhanced in the school 1 .

Acquiring the necessary skills used for nursing care is an essential part of nursing education's psychomotor skills. However, well-rounded nursing education should be a combination of theory and psychomotor skills. It is not through theory alone that the student will develop the plausible characteristics of a competent nurse. That is why clinical competencies require integrating theory and practice of a real-life scenario honed in the skills laboratory.

Building a mental model for a particular nursing situation create a smooth transition; thus, laboratory exercises and activities are needed to boost nursing student confidence in working with the actual patient. Confidence in performing nursing care is significantly affected by the nursing student's prior knowledge of what he will do and how he will do it. Also, hands-on learning and experience before the actual patient care should take place to acquire such skills. The skills laboratory plays an integral part in overcoming nursing students' fear and anxieties of performing a nursing procedure. Hence this confidence in handling patients may be developed through learning and constant practice in the skill laboratory.

The nursing skills laboratory's teaching and learning process allow students to use the theoretical knowledge they have acquired and assimilate necessary skills to perform techniques correctly. Students need to simulate different steps and techniques in handling different equipment necessary in actual patient care. Therefore, a nursing laboratory shall be designed to provide students opportunities to handle equipment and develop their competency in performing skills. To achieve such objectives, a nursing skills laboratory should have the necessary system, checklist, scheduling, equipment and supplies, and materials to establish a real-life scenario of a hospital setting and possess the milieu of ideal clinical learning and practice. The system refers to the operational process of how nursing skills are performed in the laboratory. It should meet the objectives of the course-specific for each year level. Also, the nursing skills should have a standard, and the student's performance should be evaluated. As a result, a checklist should be provided to accomplish this. A checklist is a list of nursing skills procedures, how they are performed, and the factors that must be considered. Scheduling is also important, as time should be set aside for learning and practicing nursing skills. Finally, to make the learning more realistic, there should be equipment and supplies available.

Nursing students appreciated repetitive nursing skills practice on the continuous practice and skills that demonstrated improved knowledge and enhanced performance 2 . Contrary to other studies, nursing students' challenges in the clinical setting environment were deficient in practical skills 3 . A student may encounter difficulties in performing procedures in some situations due to the lack of necessary skills. It is vital to consider that each student must have an opportunity to perform a return demonstration to experience the actual learning experience. On the other hand, if the students were unprepared to perform the assigned skills, the faculty would discuss and lecture more time. There will be less time for the student to demonstrate the skills or practice for more proficiency 4 .

The study's objective is to assess the effectiveness of the university nursing skills laboratory if it functions as the milieu of clinical learning and practice. It investigates how this nursing skills laboratory serves as the ideal clinical setting for student clinical learning and practice. It also evaluated the significant difference in the respondents' assessment of the nursing skills laboratory as the milieu of clinical learning and practice when grouped according to their gender and year level. Additionally, it determined the challenges they encountered by the respondents in the nursing skills laboratory.

1. There is no a significant difference in the assessment of the respondents on the nursing skills laboratory as milieu of clinical learning based on their gender.

2. There is no a significant difference in the assessment of the respondents on the nursing skills laboratory as milieu of clinical learning based on their level in different academic.

Confidence and competency in performing the nursing procedure are much affected by the prior knowledge and skills inculcated to the nursing students. To achieve that, fear and anxiety should be addressed first so that the nursing students can perform the nursing procedure without apprehension. With that, clinical learning and practice should first take place in the nursing skills laboratory.

The nursing skill laboratory is a learning ground for all clinical skills. It is an important setting where the nursing students learn nursing procedures and at the same time practice what they have learned without worrying about the risk of harming the patient. A nursing laboratory should provide the necessary equipment, supplies and ensure that it is the ideal milieu for the students to have their clinical practice and learning. It should be somehow near to a real-life setting so that the student can confidently perform nursing procedures in the actual setting.

This study determines the nursing student's assessment of their nursing skills laboratory. It assessed the clinical needs for the practice, the laboratory's strength, and what needs to be improved to be the ideal milieu for nursing students to learn and practice their clinical skills.

The study used a mixed-method of a quantitative and qualitative approach. For the quantitative, the researchers utilized descriptive evaluative and descriptive comparative. Descriptive evaluative was used in the nursing skills laboratory assessment. The descriptive comparative seeks the significant difference in the respondents' assessment on the nursing skills laboratory as the milieu of clinical learning and practice when group according to their profile. The questionnaire also provided an open-ended question to determine the challenges encountered by the respondents in the nursing skills laboratory, which serves as the qualitative approach of the study.

The researchers designed a researcher-made questionnaire with an open-ended question. The researchers-made questionnaire consists of two (2) parts. Part I investigates the profile of the respondents focusing on their gender and year level only. Part II determined how the respondents assess their nursing skills laboratory as the milieu of clinical learning and practice in system, checklist, scheduling, and equipment and supplies. The respondents utilized the 4 Point-Likert scales.

An open-guided question was also used in the study to determine the problems encountered by the respondents in the nursing skills laboratory. These questions support and give more in-depth analysis as it asks more specific details of the respondents' assessment of their nursing skills laboratory. The instrument was translated into Arabic for easy comprehension, and Cronbach's alpha was used to measure its reliability. Moreover, the researchers conducted a pilot study with thirty (30) respondents not included in the study.

Table 1. Validity and reliability of the instrument

• Tables index View option Full Size Next Table

The study was conducted in one of the Universities in Madinah, Saudi Arabia. The respondents were nursing students who have an ongoing nursing skills lecture and laboratory and already have their clinical duties in the hospital. The total respondents were 287; eighty-five (85) male students and two hundred twenty-three (223) female students. Respondents are from sophomore (level 4) junior, (level 5 and 6), and senior (level 8). The respondent population and their levels are from the list of nursing students in the University administration.

The researchers wrote a letter to the Nursing Ethics Committee for the review of the study. A letter and sample questionnaire and interview were submitted to ensure that the tool will not violate the respondents' rights. After it is approved, the researchers asked the respondents for permission whether they are willing to participate in the study. They signed informed consent after providing a complete explanation of study requirements. The instruments of the study were given after the skills laboratory lecture of the respondents. Those who are absent during the data collection were not included in the study.

The frequency and distribution of nursing student’s demographic data demographic profiles are presented in Table 2 . Out of two hundred eighty-seven students, most are female (77.4 %) and in level 8 (45.3 %). The male nursing students are 22.6 %, and level 6 has only 40 students.

Table 2. Frequency and distribution of nursing student’s demographic data (n=287)

• Tables index View option Full Size Previous Table Next Table

Table 3. Mean scores of nursing skills laboratory as milieu of clinical learning and practice

Table 4. Relationship of nursing student’s demographic profile and nursing skills laboratory categories

• Tables index View option Full Size Previous Table

Table 3 depicts the mean scores of the nursing skills laboratory as the milieu of clinical learning and practice. It is sorted into four categories: system, checklist, scheduling, equipment, and supplies.

Based on the system category, the students were told that the psychomotor skills would be developed, which can be used in real situations. It received the highest mean score of 3.34 (SD=0.7665). Furthermore, it builds confidence and overcomes fear in performing nursing procedures' (WM=3.26, SD= 0.8387). However, the study revealed that providing an opportunity for each student to perform the skills taught in the laboratory has the lowest mean of 3.08 (SD=0.9645). Overall, the system category is an essential factor in ensuring the nursing skills laboratory's effectiveness as the milieu of clinical learning and practice (WM=3.18, SD= 0.6686).

Regarding the checklists used in the laboratory, students agreed that the rubrics of the checklist accurately measure their skills with the highest mean of 3.21(SD=1.5489). It is also clearly stated and fair (WM=3.11, SD= 0.9499). Although, they scored low (WM=2.86, SD= 0.9405) when asked if it is the same with the actual clinical or hospital setting scenario.

Concerning the nursing laboratory scheduling, the students revealed that an open laboratory hour enhances their nursing skills with 3.06(SD=0.9570). They agreed that a scheduled practice improves their confidence and competency (WM=3.03, SD=0.9732). However, they feel the time is not enough to practice specific nursing skills for a particular session, with the lowest mean of 2.78.

As for laboratory equipment and supplies, the study showed that the availability of equipment and supplies affects the quality of their nursing skills performance (WM=3.08, SD=0.9499). It is readily available for simulation (WM=3.0035, SD=0.9426); it provides realism of nursing practice (WM=2.9686, SD=0.8839); and ensures learning opportunities (WM=2.8432, SD=1.0625). However, the student stressed the importance of sufficient equipment and supplies in the simulation to use during the nursing skills demonstration and re-demonstration (WM=2.70, SD=0.9886).

Table 4 represents the Relationship between nursing student’s demographic profile and nursing skills laboratory categories such as system, checklist, scheduling, and equipment and supplies. In terms of gender and system (p=0.775), checklist (p=0.845), scheduling (p=0.685), and equipment and supplies (p=0.870) are more significant than 0.05 level of significance, the null hypothesis is accepted; therefore, there is no significant difference.

However, with regards to level and system (p=0.0000), checklist (0.0000), scheduling (p=0.0000), and equipment and supplies (p=0.0000) less than 0.05 level of significance, the null hypothesis are rejected. Hence, there is a significant difference.

4. Discussion

Most of the respondents in the study are female and in level 8. It implies that most of the nursing students are still female and have extensive experience with nursing laboratories. The study revealed that the nursing skills laboratory assists in developing the psychomotor skills of the students that they will use in the actual scenario. It can be concluded that nursing laboratories play a significant part in improving and developing nursing skills before exposing students to the real setting. Moreover, it enhances the student's psychomotor skills that will be later used in the patient. Clinical laboratories had become an important place in which nursing students can develop their practical skills through simulation exercises 5 . It provides a safe environment to acquire initial psychomotor skills while offering opportunities to socialize students into a nurse's professional role 6 .

Nursing skills laboratories also build confidence and overcome the fear in performing the nursing procedure of the student. It can be implied that nursing skills practice in the laboratory enhances student confidence and overcome fear in performing skills. Based on a study, students practicing in simulation labs are more confident 7 . These findings suggest that if students can participate in a level-appropriate, traditional, or simulated laboratory experience, their self-confidence may increase due to active participation and the ability to practice new skills in a supportive environment. Therefore, learning laboratory is essential to build professional confidence that graduates must begin their nursing careers 6 .

On the other hand, providing equal opportunity for each student to perform and practice a skill is also suggested to enhance their nursing skills. The current study recommends creating an equal opportunity for all the students to practice nursing skills. Students who have practiced more laboratory learning skills are more likely to adapt to the clinical setting. Nonetheless, it can be presumed that the system or operational process is an essential factor in ensuring the nursing skills laboratory's effectiveness as the milieu of clinical learning and practice.

A checklist for a nursing skills procedure is another point to consider. A checklist with rubrics accurately measures nursing skills according to the students. It set ideals for correctly and safely performing nursing procedures type. Like any evaluation tool, rubrics are helpful for some purposes. Rubrics' primary purpose is to evaluate student performance. It sets standards, curriculum goals, and educational goals and goals for what performance students should do. Effective rubrics show students how they know, and to what extent their performance matches each important criterion It can also show students what their next steps should be to improve the quality of their performance 8 .

However, students expressed that it should be designed after the hospital setting. The open laboratory is another factor to consider in laboratory practice and learning. The checklist should be based on or designed after the hospital setting. It reduces risks and improves patient safety. It will also assist students in being more self-assured and less stressed when dealing with the skill procedures they will encounter. Checklists that are well-designed standardize what, when, how, and by whom interventions are performed and reduce errors in routine and emergencies. It provides a general framework for ensuring compliance with clinical or procedural requirements 9 . Checklists, on the other hand, are not a cure-all for medical errors. Any system can either complicate or assist; the design of the checklist determines its utility. A poorly designed or overly lengthy checklist can detract from performance just as easily as a well-designed one can boost it 10 .

An additional time to practice in the laboratory revealed that it enhances student nursing skills. The open laboratory allows the student to practice nursing skills or procedures aside from their regular laboratory schedule. The laboratory-based open project can effectively improve teaching and laboratory service, motivate students' learning potential, and strengthen students' emergency and critical care abilities 11 . It is also effective in boosting nursing students' self-esteem and skill competency 12 . Moreover, insufficient time to practice specific nursing skills for a particular session may have a negative effect. To be able to optimize the effect of training and skills, practice is required. It is a way of becoming proficient in a new skill or behavior. Factors such as a lack of opportunities for hands-on practice can harm student performance in clinical practice 13 . Nursing students’ value repetitive nursing skill practice. One study showed that the practice of hand skills demonstrated improved students' knowledge and performance. They learned the value of repeatedly practicing as a tool for providing safe and ethical care to patients 14 .

Lastly, every nursing laboratory requires a certain amount of equipment and supplies. When performing skills or procedures, it is used as a guide or a tool. For a realistic and safe procedure, equipment and supplies should be present when performing specific nursing skills. With the current study results, the availability of equipment and supplies affects the quality of nursing skills performance. It has been said that the platform of laboratory practices is comprised of laboratory equipment, materials, and facilities 15 . It is possible that teaching and learning practical work in the absence of a well-equipped laboratory may impede students' learning 16 .

Having sufficient equipment and supplies in the simulation to use during the nursing skills demonstration and re-demonstration draws a critical point. Equipment shortages and unavailability have a negative effect 17 . To provide quality nursing care, nurses should have functional medical equipment. To provide quality nursing care, nurses should have functional medical equipment. Because of a lack of essential equipment and supplies for nursing care procedures, students avoid the clinical practice. According to the students, clinical practice provides better opportunities and a more conducive environment for applying theory to practice 18 .

Respondent's gender does not affect the student's clinical learning and practices as they have the same assessment of their nursing skills laboratory. However, there is a significant difference in the year level of the students and system, checklist, scheduling, and equipment and supplies. This result could be attributed to various factors, including the fact that each year level has a different course with different nursing procedures to perform. Furthermore, the laboratory experience of level 8 students is different from other lower levels. Although there is no clear literature that discusses the difference between level 4 and level 8 students in terms of nursing skills laboratory use, it is possible to conclude that level 8 students have more clinical practice experience in the laboratory than lower-level students.

Clinical practice allows students to apply their theoretical knowledge to delivering actual health care 18 . Therefore, the higher the student's level, the more extensive their clinical practice and learning in the laboratory in terms of its system, checklist, scheduling, and equipment and supplies. Furthermore, the student viewpoint on laboratory experiences revealed varying information based on individual experience.

5. Limitations

This study's sample size is its drawback. These factors influence data collection, interpretation, and, eventually, study results. The study excluded respondents who were not present in the university during the study period.

6. Challenges in the Nursing Skills Laboratory

Based on the responses on the challenges of in the nursing skills laboratory during clinical learning and practice along with its system, checklist, scheduling, and equipment and supplies. Identifying the challenges these students face in the clinical learning environment assists in resolving issues and contributing to their professional development and survival 19 . Failure to recognize the difficulties and issues students face in the clinical learning setting prevents them from learning and growing effectively 20 .

Respondents expressed the need to add more equipment and supplies for practice. Working in a simulation lab is the closest one can get to work with actual patients. Skill lab uses a simple task trainer, a high-fidelity medical manikin, or a classmate. (Marquette nursing university). Equipment and supplies are part of the nursing laboratory practice so that the skills are becoming realistic. With sufficient supplies, the students can practice more in a structured environment of a particular skill, performing it more safely and correctly. This response may also mean that there is a need to add new or updated equipment. Nowadays, technology is becoming more tightly integrated into patient care as it advances 21 . That is why updated equipment is needed to practice in a real scenario without fear of committing errors or harming the patient. On-campus laboratories with simulation technologies and medical mannequins can provide valuable and satisfying immersive opportunities for gaining the trust required to treat actual "live" patients. They provide students with completely immersive learning environments that include visual, auditory, and tactile learning 22 .

Another challenges the student faced in the nursing laboratory is not having enough time to practice the skills that have been taught. Students express concern and anxiety about their perceived lack of practice preparation due to a lack of time. Being a trained nurse necessitates mastery of clinical skills learning. Because clinical skills training in clinical practice is limited, undergraduate training at clinical skills laboratories is an integral part of nursing education 23 . The findings support the need to give more time for the student to practice a skill.

It is a fact that practical skills take time to develop, and students gain more confidence and mastery when they are given a more hands-on opportunity to practice skills. Learning became memorable because of hands-on opportunities related to practical skills.

7. Conclusions

The study findings revealed that the nursing skills laboratory assists in developing the students' psychomotor skills, build confidence, and overcome fear in performing nursing procedures. The checklist used in the nursing skills laboratory is essential. The rubrics of the checklist provided accurate measurement of student skills; however, it should be based on or designed after the hospital setting to reduce the risk and ensure patient safety.

Additional time for an open laboratory hour enhances their nursing skills. However, allotting sufficient time to practice specific nursing skills for a particular session needs to be addressed. The nursing skills laboratory should also have sufficient equipment and supplies in the simulation to use during the nursing skills demonstration and re-demonstration. Thus, the availability of equipment and supplies affects the quality of their nursing skills performance.

The gender of a student has no bearing on their clinical learning and practice. The underlying explanation may be that both male and female students have the same nursing skills laboratory assessment. Nevertheless, when the academic year level is considered, there is a significant difference in the responses. It may be due to various reasons, such as the fact that each year level has a unique course with unique nursing procedures to complete. Furthermore, level 8 students' laboratory experience differs from that of students in lower levels.

Published with license by Science and Education Publishing, Copyright © 2021 Joyce Toriente Relloso, Nada Abdullah AbuAlula, Jocelyn Magtalas Medina and Edgar Gatioan Manood

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• Volume 7, Issue 3
• Attributes, skills and actions of clinical leadership in nursing as reported by hospital nurses: a cross-sectional study
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• http://orcid.org/0000-0001-8401-4976 Majd T Mrayyan 1 ,
• http://orcid.org/0000-0002-6393-3022 Abdullah Algunmeeyn 2 ,
• http://orcid.org/0000-0002-2639-9991 Hamzeh Y Abunab 3 ,
• Ola A Kutah 2 ,
• Imad Alfayoumi 3 ,
• Abdallah Abu Khait 1
• 1 Department of Community and Mental Health Nursing, Faculty of Nursing , The Hashemite University , Zarqa , Jordan
• 2 Advanced Nursing Department, Faculty of Nursing , Isra University , Amman , Jordan
• 3 Basic Nursing Department, Faculty of Nursing , Isra University , Amman , Jordan
• Correspondence to Dr Majd T Mrayyan, Department of Community and Mental Health Nursing, Faculty of Nursing, The Hashemite University, Zarqa 13133, Jordan; mmrayyan{at}hu.edu.jo

Background Research shows a significant growth in clinical leadership from a nursing perspective; however, clinical leadership is still misunderstood in all clinical environments. Until now, clinical leaders were rarely seen in hospitals’ top management and leadership roles.

Purpose This study surveyed the attributes and skills of clinical nursing leadership and the actions that effective clinical nursing leaders can do.

Methods In 2020, a cross-sectional design was used in the current study using an online survey, with a non-random purposive sample of 296 registered nurses from teaching, public and private hospitals and areas of work in Jordan, yielding a 66% response rate. Data were analysed using descriptive analysis of frequency and central tendency measures, and comparisons were performed using independent t-tests.

Results The sample consists mostly of junior nurses. The ‘most common’ attributes associated with clinical nursing leadership were effective communication, clinical competence, approachability, role model and support. The ‘least common’ attribute associated with clinical nursing leadership was ‘controlling’. The top-rated skills of clinical leaders were having a strong moral character, knowing right and wrong and acting appropriately. Leading change and service improvement were clinical leaders’ top-rated actions. An independent t-test on key variables revealed substantial differences between male and female nurses regarding the actions and skills of effective clinical nursing leadership.

Conclusions The current study looked at clinical leadership in Jordan’s healthcare system, focusing on the role of gender in clinical nursing leadership. The findings advocate for clinical leadership by nurses as an essential element of value-based practice, and they influence innovation and change. As clinical leaders in various hospitals and healthcare settings, more empirical work is needed to build on clinical nursing in general and the attributes, skills and actions of clinical nursing leadership of nursing leaders and nurses.

• clinical leadership
• health system
• leadership assessment

Data availability statement

Data are available on request due to privacy/ethical restrictions. https://authorservices.taylorandfrancis.com/data-sharing/share-your-data/data-availability-statements/

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:  http://creativecommons.org/licenses/by-nc/4.0/ .

https://doi.org/10.1136/leader-2022-000672

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WHAT IS ALREADY KNOWN ON THIS TOPIC

Clinical leadership was limited to service managers; however, currently, all clinicians are invited to participate in leadership practices. Clinical leaders are needed in various healthcare settings to produce positive outcomes.

WHAT THIS STUDY ADDS

This study outlined clinical leadership attributes, skills and actions to understand clinical nursing leadership better. The current study highlighted the role of gender in clinical nursing leadership, and it asserts that effective clinical nursing leadership is warranted to improve the efficiency and effectiveness of care. The results call for nurses’ clinical leadership as essential in today’s turbulent work environment.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

Nurses and clinical leaders need additional attributes, skills and actions. Clinical nursing leaders should use innovative interventions and have skills or actions to manage current work environments. Further work is needed to build on clinical nursing in general and the attributes, skills and actions of clinical nursing leadership. Clinical leadership programmes must be integrated into the nursing curricula.

Introduction

Clinical leadership is a matter of global importance. Currently, all clinicians are invited to participate in leadership practices. 1 This invitation is based on the fact that people deliver healthcare within complex systems. Effective clinicians must understand systems of care to function effectively. 1 2 Engaging in clinical leadership is an obligation, not a choice, for all clinicians at all levels. This obligation is more critical in nursing with many e merging global health issues , 2 such as the COVID-19 pandemic.

The systematic literature review of Cummings et al 3 shows the differences in leadership literature. In early 2000, clinical leadership emerged in scientific literature. 4 It is about having the knowledge, skills and competencies needed to effectively balance the needs of patients and team members within resource constraints. 4 Clinical leadership is vital in nursing as nurses face complex challenges in clinical settings, especially in acute care settings. 4 Although developed from the management domain, leadership and management are two concepts used interchangeably, 5–9 leading to further misunderstanding of the relationship between clinical leadership and management. While different types of leadership have been evident in nursing and health industry literature, clinical leadership is still misunderstood in clinical environments. 8 Clinical leadership is not fully understood among health professionals trained to care for patients, as clinical leadership is a management concept, leaving the concept open to different interpretations. 10 For example, Gauld 10 reported that clinical leaders might be professionals (such as doctors and nurses) who are no longer clinically active, mandating that clinical leaders should also be involved in delivering care. 10

There is no clear definition of ‘clinical leadership’. However, effective clinical leadership involves individuals with the appropriate clinical leadership skills and attributes at different levels of an organisation, focusing on multidisciplinary and interdisciplinary work. 10 The main skills associated with clinical leadership were having values and beliefs consistent with their actions and interventions, being supportive of colleagues, communicating effectively, serving as a role model and engaging in reflective practice. 4–9 The main attributes associated with clinical leadership were using effective communication, clinical competence, being a role model, supportive and approachability. 4–9 Stanley and colleagues reported that clinical leaders are found across health organisations and are presented in all clinical environments. Clinical leaders are often found at the highest level for clinical interaction but not commonly found at the highest management level in wards or units. 4–9

With the increasing urgency to improve the efficiency and effectiveness of care, effective nursing leadership is warranted. 4 11–17 Clinical leaders can be found in various healthcare settings, 4 most often at the highest clinical level, but they are uncommon at the top executive level. 6–9 18–24 In the UK, the National Health Service (NHS) 25 empowers clinicians and front-line staff to build their decision-making capabilities, which is required for clinical leadership. This empowerment encourages a broader practice of clinical leadership without being limited to top executives alone. 25 26

Purpose and significance

This study assesses clinical nursing leadership in Jordan. More specifically, it answers the following research questions: (1) What attributes are associated with clinical nursing leadership in Jordanian hospitals? (2) What skills are important for effective clinical nursing leadership? (3) What actions are important for effective clinical nursing leadership? (4) What are the differences in skills critical to effective clinical nursing leadership based on the sample’s characteristics? (5) What are the differences in effective clinical nursing leaders’ actions based on the sample’s characteristics?

Nursing leadership studies are abundant; however, clinical leadership research is not well established. 8 27 Until fairly recently, clinical leadership in nursing has tended to focus on nursing leaders in senior leadership positions, ignoring nurse managers in clinical positions. 8 There has been significant growth in research exploring clinical leadership from a nursing perspective. 4 8 9 14–17 24 26–32 A new leadership theory, ‘congruent leadership’, has emerged, claiming that clinical leaders acted on their values and beliefs about care and thus were followed. 6–9 20 This study is the first in Jordan’s nursing and health-related research about clinical leadership. Clarifying this concept from nurses’ perspectives will support greater healthcare delivery efficiencies.

Search methods

The initial search was done using ‘clinical nursing leadership’ at the Clarivate database and Google Scholar database from 2017 to 2021, yielded 35 studies, of which, after abstracting, 14 studies were selected. However, Stanley’s work (12 studies), including those before 2017, was included because we followed the researcher’s passion and methodology of studying clinical leadership; also, some classical models of clinical leadership because they were essential for the conceptualisation of the study as well as the discussion, such as the NHS Leadership Academy (three studies; ref 25 33 34 ).

Another search was run using the words ‘attributes’, ‘skills’ or ‘actions’ using the same time frame; most of the yielded studies were not relevant, this search year was expanded to 2013–2021 because the years 2013–2015 were the glorious time of studying these concepts. Using ‘clinical leadership’ rather than ‘leadership studies’, 15 studies were yielded; however, Stanley’s above work was excluded to avoid repetition, resulting in using three studies (ref 29 30 35 ). A relevant reference of 2022 similar to our study (ref 36 ) was added at the stages of revisions. The remaining 16 of 49 references were related to the methodology and explanation of some results, such as those related to gender differences in leadership. The following limits were set: the language was English; and the year of publication was basically the last 5 years to ensure that the search was current.

Clinical leadership

Clinical leadership ensures quality patient care by providing safe and efficient care and creating a healthy clinical work environment. 4 10–17 27 31 32 It also decreases the high costs of clinical litigation settlements and improves the safety of service delivery to consumers. 4 11–17 32 For these reasons, healthcare organisations should initiate interventions to develop clinical leadership among front-line clinicians, including nurses. 8 9

Literature was scarce on clinical leadership in nursing. 4 8–10 14–17 27 28 31 Stanley and Stanley 8 defined clinical leadership as developing a culture and leading a set of tasks to improve the quality and safety of service delivery to consumers.

Clinical leadership is about focusing on direct patient care, delivering high-quality direct patient care, motivating members of the team to provide effective, safe and satisfying care, promoting staff retention, providing organisational support and improving patient outcomes. 31 Clinical leadership roles include providing the vision, setting the direction, promoting professionalism, teamwork, interprofessional collaborations, good practice and continued medical education, contributing to patient care and performing tasks effectively. 31 Moreover, the researchers added that clinical leadership is having the approachability and the ability to communicate effectively, the ability to gain support and influence others, role modelling, visibility and availability to support, the ability to promote change, advise and guide. 31 Clinical leadership competencies include demonstrating clinical expertise, remaining clinically focused and engaged and comprehending clinical leadership roles and decision-making. In addition, clinical leadership was not associated with a position within the management and organisational structure, unlike health service management. 31 33

Clinical leadership is hindered by many barriers that include the lack of time and the high clinical/client demand on their time. 8 9 Clinical leadership is limited because of the deficit in intrapersonal and interpersonal capabilities among team members and interdisciplinary and organisational factors, such as a lack of influence in interdisciplinary care planning and policy. 37 Other barriers include limited organisational leadership opportunities, the perceived need for leadership development before serving in leadership roles and a lack of funding for advancement. 38

This paper aligns with the theory of congruent leadership proposed by Stanley. 19 This theory is best suited for understanding clinical leadership because it defines leadership as a congruence between the activities and actions of the leader and the leader’s values, beliefs and principles, and those of the organisation and team.

Attributes of clinical leadership

The clinical leadership attributes needed for nurses 8 28 to perform their roles effectively are: (1) personal attributes: nurses are confident in their abilities to provide best practice, communicate effectively and have emotional intelligence; (2) team attributes: encouraging trust and commitment to others, team focus and valuing others’ skills and expertise; and (3) capabilities: encouraging contribution from others, building and maintaining relationships, creating clear direction and being a role model. 8 28 Clinical leadership attributes are linked to communicating effectively, role modelling, promoting change, providing advice and guidance, gaining support and influencing others. 28–30 Other attributes to include are clinical leaders’ engagement in reflective practice, 29 provision of the vision; setting direction, having the resources to perform tasks effectively and promoting professionalism, teamwork, interprofessional collaborations, effective practice and continued education. 27 28 31

Skills of clinical leadership

Clinical leadership skills include (1) a ‘clinical focus’: being expert knowledge, providing evidence-based rationale and systematic thinking, understanding clinical leadership, understanding clinical decision-making, being clinically focused, remaining clinically engaged and demonstrating clinical expertise; (2) a ‘follower/team focus’: being supportive of colleagues, effectively communicating communication skills, serving as a role model and empowering the team; and (3) a ‘personal qualities focus’: engaging in reflective practice, initiating change and challenging the status quo. 17 30 32 Clinical leaders have advocacy skills, facilitate and maintain healthier workplaces by driving changes in cultural issues among all health professionals. 17 29 Moreover, the overlap between the attributes and skills of clinical leaders includes being credible to colleagues because of clinical competence and the skills and capacity to support multidisciplinary teams effectively. 17 29 32

Actions of clinical leadership

A clinical leader is anyone in a clinical position exercising leadership. 26 The clinical leader’s role is to continuously instil in clinicians the capability to improve healthcare on small and large scales. 26 Furthermore, Stanley et al 9 demonstrated that clinical leaders are not always managers or higher-ups in organisations. Clinical leaders act following their values and beliefs, are approachable and provide superior service to their clients. 9 Clinical leaders define and delegate safety and quality responsibilities and roles. 14 32 39 They also ensure safety and quality of care, manage the operation of the clinical governance system, implement strategic plans and implement the organisation’s safety culture. 14 32 39 The Australian Commission on Safety and Quality in Health Care 39 also reported that clinical leaders might support other clinicians by reviewing safety and quality performance data, supervising the clinical workforce, conducting performance appraisals and ensuring that the team understands the clinical governance system.

In summary, clinical leadership attributes, skills and actions were outlined to understand clinical nursing leadership. The literature shows limited nursing research on clinical leadership, calling for clinical leadership that paves the road for nurses in the current turbulent work environment.

Study design

A descriptive quantitative analysis was developed to collect data about the attributes and skills of clinical nursing leadership and the actions that effective nursing clinical leaders can take. A cross-sectional design was employed to measure clinical leadership using an online survey in 2020. This design was appropriate for such a study as it allows the researchers to measure the outcome and the exposures of the study participants at the same time. 40

Sample and settings

The general population was registered nurses in medical centres in Jordan. The target population was registered nurses in teaching, public and private hospitals. Most nurses in Jordan are females working at different shifts on a full-time basis in different types of healthcare services. The baccalaureate degree is the minimum entry into the clinical practice of registered nurses. As previous nurses, we would like to attest that nurses in Jordanian hospitals commonly use team nursing care delivery models with different decision-making styles. The size of the sample was calculated by using Thorndike’s rule as follows: N≥10(k)+50 (where N was the sample size, k is the number of independent variables) (attributes, skills, actions), the minimum sample size should be 80 participants. 40 From experience, the researcher considers the sample’s demographics and subscales as independent variables (k=17); the overall sample should not be less than 220.

Research participants were recruited through a ‘direct recruitment strategy’ from the hospitals where the nursing students were trained. A survey was used to collect data using non-random purposive sampling; of possible 450 Jordanian nurses, 296 were recruited from different types of hospitals: teaching (51 of possible 120 nurses), public (180 of possible 210 nurses) and private (65 of possible 120 nurses), with a response rate of 66%, which is adequate for an online survey. The inclusion criteria were that nurses should work in hospital settings, and any nurses who work in non-hospital settings were excluded. No incentives were applied.

Using a direct measurement method, Stanley’s Clinical Leadership Scale ( online supplemental file 1 ) was used to collect the data using the English version of the scale because English is the official education language of nursing in Jordan. 8 9 The original questionnaire consists of 24 questions: 12 quantitative and qualitative questions relevant to clinical leadership, and 12 related to the sample’s demographics. Several studies about clinical leadership among nurses and paramedics in the UK and Australia used modified versions of a survey tool 5 8 9 18–24 ; construct validity was ensured using exploratory factor analysis or triangulation of validation. Cronbach’s alpha measures the homogeneity in the survey, and it was reported to be 0.87 8 9 and 0.88 in the current study.

Supplemental material

Several questions were measured on a 5-point Likert scale in the original scale, and others were qualitative. The survey for the current study consists of 12 quantitative and qualitative questions related to clinical leadership and 14 questions related to the sample’s demographics. However, the qualitative data obtained were scattered and incomplete; thus, only the quantitative questions were analysed and reported, and another qualitative study about clinical leadership was planned. For the current study, three quantitative questions only focused on clinical leadership, leadership skills and the actions of clinical leaders, and 14 questions focused on the sample’s characteristics relevant to the Jordanian healthcare system developed by the first author. The sample characteristics were gender, marital status, shift worked, time commitment, level of education, age, years of experience in nursing, years of experience in leadership and the number of employees directly supervised. Other characteristics include the type of unit/ward, model of nursing care, ward/unit’s decision-making style, formal leadership-related education (yes/no) and formal management-related education (yes/no). Before data collection, permission to use the tool was granted.

Ethical considerations

Nurses were invited to answer the survey while assuring the voluntary nature of their participation. The participants were told that their participation in the survey was their consent form. Participants’ anonymity and confidentiality of information were assured; all questionnaires were numerically coded, and the overall results were shared with nursing and hospital administrators. 40

Patient and public involvement

There was no patient or public involvement in this research’s design, conduct, reporting or dissemination.

Data collection procedures

After a pilot study on 12 December 2020, which checked for the suitability of the questionnaire for the Jordanian healthcare settings, data were collected over a month on 23 December 2020. Data were collected through Google Forms; the survey was posted on various WhatsApp groups and Facebook pages. Using purposive snowball sampling, nurses were asked to invite their contacts and to submit the survey once. To assure one submission, the Google Forms was designed to allow for one submission only.

No problem was encountered during data collection. The two attrition prevention techniques used were effective communication and asserting to the participants that the study was relevant to them.

The researchers controlled for all possible extraneous and confounding variables by including them in the study. A possible non-accounted extraneous variable is the organisational structure; a centralised organisational structure may hinder the use of clinical nursing leadership.

Data analyses

After data cleaning and checking wild codes and outliers, all coded variables were entered into the Statistical Package for Social Sciences (SPSS) (V.25), 35 which was used to generate statistics according to the level of measurement. A descriptive analysis focused on frequency and central tendency measures. 40 Part 1 of the scale comprises 54 qualities or characteristics to answer the first research question. Responses related to skills were measured on a 1–5 Likert scale; thus, means and SDs were reported to answer the second research question. Eight actions were rated on a 1–5 Likert scale; thus, means and SDs were reported to answer the third research question. Independent t-tests using all sample characteristics were performed to answer the fourth and fifth research questions.

The preanalysis phase of data analysis was performed; data were eligible and complete as few missing data were found; thus, they were left without intervention. The assumption of normality was met; both samples are approximately normally distributed, and there were no extreme differences in the sample’s SDs.

Characteristics of the sample

There were 296 nurses in the current study from different types of hospitals: teaching (51 nurses), public (180 nurses) and private (65 nurses), with a response rate of 66%. Most nurses were females (209, 70.6%), single (87, 29.4%), working a day shift (143, 48.3%) or rotating shifts (92, 31.1%), on a full-time basis (218, 73.6%), with a baccalaureate degree (236, 79.7%), aged less than 25 years (229, 77.4%) and 25–34 years (45, 15.2%), respectively. Also, 65.1% (166) of nurses reported having less than 1 year of experience in nursing; thus, they have few nurses under them to supervise (145, 49% supervise one to two nurses), and 23.3% (69) of nurses reported having 1–9 years of experience in leadership. Nurses reported that their unit or ward has a primary (81, 27.4%) or team nursing care delivery model (162, 54.7%), with a mixed (94, 31.8%) or participatory decision-making style (113, 38.2%), and had formal leadership-related education (191, 64.5%), and had no formal management-related education (210, 70.9%) ( table 1 ).

• View inline

Sample’s characteristics (N=296*)

Attributes of clinical nursing leadership

Nurses were asked to think about the attributes and features of clinical leadership. Based on Stanley’s Clinical Leadership Scale, 8 9 nurses were given a list of 54 qualities and characteristics and asked to select the most strongly associated with clinical leadership, followed by those least strongly associated with clinical leadership. Table 2 shows the respondents’ ‘top ten’ selected qualities in ranked order.

'Most’ and ‘Least’ important attributes associated with clinical nursing leadership (N=296)

Skills of effective clinical nursing leaders

On a Likert scale of 1–5, respondents were asked to rank the skills of effective clinical leaders from ‘not relevant’ or ‘not important’ to 5=‘very relevant’ or ‘very important’. The top skills were having a strong moral character, knowing right and wrong and acting appropriately which received a high rating, with a mean of 4.17 out of 5 (0.92). Being in a management position to be effective was ranked as the least skill of an effective leader, with a mean value of 3.78 out of 5 (1.00). As indicated by respondents, other skills of effective clinical leaders are shown in table 3 .

Skills of effective clinical nursing leaders (N=296)

Actions of effective clinical nursing leaders

On a Likert scale of 1–5, respondents were asked to rank the actions of effective clinical leaders. Leading change and service management achieved a high rating of 4.07 out of 5 points (0.90). Influencing organisational policy was rated last, with a mean score of 3.95 out of 5 (1.01), which may reflect the very junior nature of the majority of the sample. As described by respondents, some of the other actions of effective leaders are shown in table 4 .

Actions effective clinical nursing leaders can do (N=296)

Significant differences in skills of effective clinical nursing leaders based on gender

Independent t-tests using all sample’s characteristics were performed to answer the fourth research question. Gender was the only characteristic variable that differentiated clinical leadership skills. An independent t-test demonstrates that males and females have distinct perspectives on 3 out of 10 items measuring clinical leadership skills. Female participants outperform male participants in terms of ‘working within the team (p value=0.021)’, ‘being visible in the clinical environment (p value=0.004)’ and ‘recognizing optimal performance and expressing appreciation promptly (p value=0.042) ( table 5 )’.

Significant differences in skills and actions of effective clinical nursing leaders based on gender (n=296)

Significant differences in actions of effective clinical nursing leaders based on gender

Independent t-tests using all sample’s characteristics were performed to answer the fifth research question. Gender was the only characteristic variable that differentiated clinical leadership actions, and it was discovered that five of the eight propositions varied in their actions: the way clinical care is administered (p=0.010); participating in staff development education (p=0.006); providing valuable staff support (p=0.033); leading change and service improvement (p=0.014); and encouraging and leading service management (p=0.019). The independent t-test results revealed that female participants scored higher in those acts, corresponding to effective leaders’ competencies. The mean values of participants’ responses to the actions of effective clinical leaders are shown in table 5 .

The characteristics of the current sample are similar to those of the structure of the task force in Jordan. The remaining question is how men in Jordan be supported in nursing to develop clinical leadership skills on par with females. Al-Motlaq et al 41 proposed using a part-time nurses policy to address nurses’ gender imbalances. Although this is necessary for both genders, we propose to develop a clinical leadership training package to promote working male nurses’ clinical leadership. In Jordan, we apply the modern trend of using leadership in nursing rather than management. About 65% of the nurses reported having formal leadership-related education, while around 71% reported no formal management-related education.

The findings clearly showed what nurses seek in a clinical leader. They appear to refer to a good communicator who values relationships and encouragement, is flexible, approachable and compassionate, can set goals and plans, resource allocation, is clinically competent and visible and has integrity. They necessitate clinical nursing leaders who can be role models for others in practice and deal with change. They should be supportive decision-makers, mentors and motivators. They should be emphatic; otherwise, they should not be in a position of control. These findings align with other research on clinical leadership. 7–9 21 Clinical leaders should be visible and participate in team activities. They should be highly skilled clinicians who instil trust and set an example, and their values should guide them in providing excellent patient care. 8 9

Participants chose other terms or functions associated with leadership roles less frequently or perceived as unrelated to clinical leadership functions. Management, creativity and vision were among the terms and functions mentioned. The absence of the word ‘visionary’ from the list of the most important characteristics suggests that traditional leadership theories, as transformational leadership and situational leadership, do not provide a solid foundation for understanding clinical leadership approaches in the clinical setting. This result can also be influenced by the junior level of the majority of the sample.

Skills of clinical nursing leadership

Numerous studies have documented the characteristics and skills of clinical leaders. 27 29 31 Clinical leaders’ skills include advocacy, facilitation and healthier workplaces. 27 29 31 Our participants were rated as having high morals (similar to other studies) 27 29 31 and worked within teams. 29 In turn, they were flexible and expressed appreciation promptly. 7–9 21 They were clinically competent; thus, they improvised and responded to various situations with appropriate skills and interventions. They recognised optimal performance, initiated interventions, led actions and procedures and had the skills and resources necessary to perform their tasks.

The lowest mean was ‘ being in a management position to be effective ’. This lowest meaning ‘ somehow ’ makes sense; all nurses can be effective leaders rather than managers, assuming effective clinical leadership roles without having management positions. 28 42

Actions of clinical nursing leadership

Influential nursing leaders are clinically competent and can initiate interventions and lead actions; these skills translate to actions. Clinical leaders are qualified to lead and manage the service improvement change (similar to Major). 42 This role will not suddenly happen; it requires clinical nursing leaders who encourage and participate in staff development education (consistent with Major). 42 This is an essential milestone and an example of providing valuable staff support. As these were the lowest reported actions, clinical nursing leaders should initiate and lead improvement initiatives in their clinical settings, 42 resulting in service improvement. They also have to influence evidence-based policies to improve work–life integration 43 and enhance patients, nurses and organisational outcomes. These outcomes include quality of care, nurses’ empowerment, job satisfaction, quality of life and work engagement. 4 11–17 32

Female nurses had more clinical leadership skills. Because the findings of this study have never been reported in the previous clinical leadership research literature, they are considered novel. This finding indicates that one possible explanation is that the overwhelming majority of respondents were females, with the proportion of females in favour (70.6%) exceeding that of males (29.4%). Furthermore, the current findings could be explained because the study was conducted in Jordan, a traditionally female-dominated gender nursing career.

This study discovered that there are gender differences in the characteristics of nurses and their clinical leadership skills, with female clinical nursing leaders scoring higher on the t-test than male clinical nursing leaders in the following areas: this is contrary to Masanotti et al , 43 who reported that male nurses have a greater sense of coherence and, in turn, more teamwork than female nurses, who commonly have job dissatisfaction and less teamwork. These could apply to female clinical nursing leaders. These female nurses had more ‘visibility in the clinical environment’, as expected in female-dominated gender nursing careers. As they were commonly dissatisfied as nurses, 43 clinical nursing leaders would be competent in caring for their nurses’ psychological status. These leaders know that even ‘thank you’ is the simplest way to show appreciation and recognition; however, this should be given promptly.

In Arab and developing countries, the perception that females have more skills with effective clinical leadership characteristics than males is consistent with Alghamdi et al 44 and Yaseen. 45 They found that females outperform males on leadership scales, which may also apply to clinical leadership. This study shows consistency between female and male clinical nursing leaders’ general perceptions of clinical leadership skills in female-dominated gender nursing careers but not in male-dominated, gender-segregated countries, including Jordan.

Female nurses had more clinical leadership actions, which differed in five out of eight actions. Female clinical nursing leaders were better at impacting clinical care delivery, participating in staff development education, providing valuable staff support, leading change and improving service.

It is aware that the nursing profession has a difficult context in some Arab and developing countries. For example, a study conducted in Saudi Arabia could explain the current findings that male nurses face various challenges, including a lack of respect and discrimination, resulting in fewer opportunities for professional growth and development. 46 The researchers reported that female clinical nursing leaders are preferred over male nurses because nursing is a nurturing and caring profession; it has been dubbed a ‘female profession’. 46 Additionally, this study corroborates a study that found many males avoid the nursing profession entirely due to its negative connotations 47 ; the profession is geared towards females. These and other stereotypes have influenced male nurses to pursue masculine nursing roles.

The study’s findings are unique because they have never been published in the previous clinical leadership research literature. However, these results can be explained indirectly based on non-clinical leadership literature. Consistent with Khammar et al , 48 as it is a female-dominated profession, it is apparent that female clinical nursing leaders are better at delivering clinical care. This result could also be related to female clinical nursing leaders having a better attitude towards clinical conditions and managing different conditions. 48 Female clinical nursing leaders, in turn, are better at influencing patient care and improving patient safety 36 and overall care and services. This improvement will not happen suddenly; it should be accompanied by paying more attention to providing continuous support, especially during induced change.

The current study reported that female clinical nursing leaders supported staff development and education because it is a female-oriented sample. Yet, Khammar et al 48 reported that men had more opportunities to educate themselves in nursing; this is true in a male-dominated country like Jordan. They also noted that males could communicate better during nursing duties. Regardless of gender, all of us should pay attention to our staff’s working environment and related issues, including promoting open communication, providing support, encouraging continuing education, managing change and improving the overall outcomes.

Limitations

Even though the study’s findings are intriguing, further investigation is needed to comprehend them. Because of the cross-sectional design used in the current study, we cannot establish causality. For this reason, the results should be interpreted with caution. Also, the purposive sample limits the generalisability; thus, this research should be carried out again with a broader selection of nursing candidates and clinical settings. Moreover, the sample consists mostly of nurses with minimal experience compared with nurses in other international countries such as Canada, the UK and the USA. 5 The current study also included nurses in their 40s and above, with male nurses less represented, and this causes misunderstanding of the true clinical leadership in nursing.

Implications

For practice, our sample consists of nurses with minimal experience compared with nurses in other developed counties. Our sample reported ‘influencing organizational policy’ as the last clinical leadership skill, which reflects the very junior nature of the sample. Unlike our study, in their systematic review, Guibert-Lacasa and Vázquez-Calatayud 36 reported that the profiles of the care clinical nurses’ experience usually varied, ranging from recent graduates to senior nurses. If our nurses were more experienced, it might lead to different results. More nurses’ clinical experience would increase nurses’ abilities at the bedside, especially in areas related to reasoning and problem solving. 36 More experienced nurses tend to work collaboratively within the team with greater competency and autonomy. 36 More experienced nurses would provide high-quality care, 36 resulting in patient satisfaction. To generate positive outcomes of clinical nursing leadership, such early-career nurses should be qualified. Guibert-Lacasa and Vázquez-Calatayud 36 suggested using the nursing clinical leadership programme based on the American Organization for Nursing Leadership 34 competency model, pending the presence of organisational support for such an initiative. 36

‘Most’ important clinical nursing leadership attributes should be promoted at all organisational and clinical levels. Clinical nursing leadership’s ‘least’ important attributes should be defeated to achieve better outcomes. Clinical nursing leaders should use innovative interventions and have skills or actions conducive to a healthy work environment. These interventions include being approachable to enable their staff to cope with change, 28 using open and consistent communication, 28–30 being visible and consistently available as role models and mentors and taking risks. 28 Hospital administrators must help their clinical leaders, including nursing leaders, to effectively use their authority, responsibility and accountability; clinical leadership is not only about complying with the job description. A good intervention to start with to promote the culture of clinical leadership is setting an award for the ‘ideal nursing leaders’. This award will bring innovative attributes, skills and actions.

Moreover, as they are in the front line of communication, nurses and clinical nursing leaders should be involved in policy-related matters and committees. 49 An interventional programme that gives nurses more autonomy in making decisions is warranted. In turn, various patient, nurse and organisational outcomes will be improved. 13–17 32

The study’s findings revealed statistically significant differences in the skills and actions of effective clinical leaders, with female nurses scoring higher in many skills and actions. Hence, healthcare organisations must re-evaluate current leadership and staff development policies and prioritise professional development for nurses while also introducing new modes of evaluation and assessment that are explicitly geared at improving clinical leadership among nurses, particularly males.

For education, this study outlined clinical leadership attributes, skills and actions to understand clinical nursing leadership in Jordan better. Nevertheless, nurses and clinical leaders need additional attributes, skills and actions. Consequently, undergraduate nursing students might benefit from clinical leadership programmes integrated into the academic curriculum to teach them the fundamentals of clinical leadership. A master’s degree programme in ‘Clinical Nursing Leadership’ would prepare nurses for this pioneering role and today and tomorrow’s clinical nursing leaders. However, all nurses are clinical leaders regardless of their degrees and experience. Conducting presentations, convening meetings, overseeing organisational transformation and settling disagreements are common ways to hone these abilities.

For research purposes, it is worth exploring the concept of clinical leadership from a practice nurse’s perspective to provide insight into practice nurses’ feelings and perceptions. Thus, a longitudinal quantitative design or a phenomenological qualitative design might be adopted to assess the subjective experience of the nurses involved. It is better in future research to focus on both young and veteran clinical leaders; some of our nurses were aged 45 years and above, and those nurses may not be clinically focused.

Summary and conclusion

The current study put clinical leadership into the context of the healthcare system in Jordan. This study highlighted the role of gender in clinical nursing leadership. Nurses’ clinical leadership is a milestone for influencing innovation and change. The current study identified the ‘most’ and ‘least’ important attributes, skills and actions associated with clinical leadership. However, the male and female nurses found substantial differences in effective clinical nursing leadership skills and actions. This study is unique; little is known about the collective concepts of attributes, skills and actions necessary for clinical nursing leadership.

Nurses need leadership attributes, skills and actions to influence policy development and change in their work environments. Leadership attributes can help develop programmes that give nurses more autonomy in making decisions. As a result, nurses will be more active as clinical leaders.

Ethics statements

Patient consent for publication.

Not applicable.

Ethics approval

This study involves human participants and was approved by The Hashemite University, Jordan (IRB number: 1/1/2020/2021) on 18 October 2020. Participants gave informed consent to participate in the study before taking part.

Acknowledgments

The researchers thank the subjects who participated in the study, and Mrs Othman and Mr Sayaheen who collected the data.

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Supplementary materials

Supplementary data.

This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.

• Data supplement 1

Contributors MTM developed the study conception, abstract, introduction, literature review and methods; collected the data and wrote the first draft of this research paper and the final proofreading. HAN analysed the data and wrote the results. AA wrote the discussion and updated the literature review. OK wrote the limitations, implications, and summary and conclusion. IAF and AAK did the critical revisions and the final proofreading. All authors contributed to the current work.

Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Competing interests None declared.

Provenance and peer review Not commissioned; externally peer reviewed.

Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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What are the experiences of nurses delivering research studies in primary care?

Azaria ballintine.

1 University of Birmingham (Contingent Key Worker)/The Royal Wolverhampton NHS Trust (Research Nurse), UK

Rachel Potter

2 Warwick Medical School, UK

Background:

Clinical research provides evidence to underpin and inform advancements in the quality of care, services and treatments. Primary care research enables the general patient population access and opportunities to engage in research studies. Nurses play an integral role in supporting the delivery of primary care research, but there is limited understanding of nurses’ experiences of this role and how they can be supported to facilitate the delivery of research.

To explore the experiences of nurses delivering research studies in primary care settings.

We identified studies published between 2002 and June 2021 from key electronic databases. A two-level inclusion/exclusion and arbitration process was conducted based on study selection criteria. Data extraction and quality appraisal were performed simultaneously. Data were analysed in the form of a narrative synthesis.

The key themes identified included: (1) what nurses value about primary care research and their motivations for study engagement, (2) the role of nurses in research, (3) working with research teams, (4) study training, (5) eligibility screening, data collection and study documentation, (6) nurse/participant dynamic, (7) gatekeeping, (8) relationships with colleagues and impact on recruitment, (9) time constraints and workload demands, and (10) health and safety.

Conclusions:

Nurses are integral to the delivery of research studies in primary care settings. The review highlights the importance of good communication by study teams, timely and study-specific training, and support from colleagues to enable nurses to effectively deliver research in primary care.

Introduction

Primary care research increases opportunities for the general patient population to access studies and plays an important role in providing evidence to support improvements in patient care (Hyland and Clarke Moloney, 2016 ). In the United Kingdom, primary care research is mainly delivered in general practice but can include other primary care providers such as pharmacies and dental practices. Primary care services are strongly linked with wider community services such as community mental health, community nursing and residential and nursing homes who also contribute to the delivery of research (National Institute for Health Research (NIHR), 2021 ).

The NIHR Clinical Research Network (CRN) Primary Care Strategy outlines a vision to embed a coherent research theme within primary care through collaboration with the NIHR and wider strategic stakeholders, to encourage and support the delivery of high-quality research in a setting accessible to almost all the population (NIHR, 2022 ). However, delivering research in primary care has specific challenges, such as clinicians located across multiple sites and patients who access general practitioner (GP) services inconsistently (Graffy et al. , 2010 ). The absence of research infrastructure in many general practices can call for ingenuity on the part of practice staff to deliver studies effectively (Young et al. , 2009 ). High-quality research nurse support, prior to and during study delivery, is integral to the ability of GPs to support research activity (Gemzoe et al. , 2020 ).

In the United Kingdom, the day-to-day delivery of research in primary care is often nurse-led, with clinical oversight from a lead GP. Practice nurses may be an underutilised resource in the ambition to expand primary care research delivery (Shaw et al. , 2005 ). Due to the interdependency of primary care and community care services, a variety of nurses can be involved in the delivery of primary care-based research studies, including but not limited to practice nurses, community nurses, specialist nurses, hospice nurses and clinical research nurses. Nurses supporting research studies in primary care may be involved with recruiting patients, receiving informed consent, collecting data from patient records, conducting patient follow-up appointments and maintaining patient safety throughout study duration.

The aim of this review is to explore the experiences of nurses delivering research studies in primary care to understand how best to support nurses in this role.

Search strategy

We searched for studies published from 2002 to June 2021 from the following electronic databases: Ovid MEDLINE, Ebsco Cinahl, Proquest, Ovid PsycINFO, Web of Science; generic web searches (Google Scholar); grey literature (digital theses on UBIRA EThesis); and from reference lists of retrieved articles.

The search strategy used free text and medical subject headings; see Table  1 . An initial scoping search used the SPIDER tool (sample, phenomenon of interest, design, evaluation and research type) to help define search terms.

Search terms

Inclusion criteria:

• Qualitative and mixed-method studies
• Focus groups, interviews and surveys
• Conducted in primary care and community settings
• Nurses involved in the delivery of research studies
• Published in English

Exclusion criteria:

• Quantitative studies
• Conference abstracts
• Research conducted in underdeveloped countries.

Key recommendations

• Nurses should be asked rather than nominated to take part in research studies.
• Minimise the burden of work involved in delivering research studies.
• Study teams should provide regular communication and a recognised point of contact.
• Timely and study-specific training.
• Good communication, and support and understanding by colleagues.
• Protected/funded time for research activities when possible.
• Awareness of inadvertently acting as a gatekeeper to patients taking part in studies.

Data management and screening

Search outputs were uploaded to Endnote 20, and duplicates were removed. References were imported to Rayyan software for a two-level inclusion/exclusion and arbitration process. Titles were screened, and full copies of relevant papers were sought. The main reviewer (AB) screened records for inclusion and the second reviewer (RP) checked decisions to see if they concurred. Any disagreements were resolved by discussion. See Figure  1 for reasons for exclusion at full-text level.

Flow diagram of included studies

Data extraction and quality assessment

A customised data extraction spreadsheet was developed from an adapted version of the Joanna Briggs Institute (JBI) Data Extraction Tool for Qualitative Research (Aromataris and Munn, 2020 ). The main reviewer extracted data and the second reviewer checked the data extracted, with regular, ongoing communications to ensure agreement with decisions reached. The Critical Appraisals Skills Programme (CASP) checklist (Critical Appraisal Skills, 2018 ) was integrated into the data extraction spreadsheet to assess the quality of the studies and risk of bias.

We used a narrative synthesis to analyse and present our main findings. We considered a narrative synthesis appropriate to allow us to explore the similarities and differences between studies and provide a critical and objective analysis of the findings. Other methods of analysis could have been chosen, such as thematic synthesis, to identify commonality across studies. However, narrative synthesis was selected because the approach helps to clearly contextualise and characterise studies and can make heterogeneity between studies more apparent (Barnett-Page and Thomas, 2009 ).

A summary of the 14 studies identified for the review are presented in Table  2 . The studies were published between 2002 and 2021 and from the United Kingdom (eight), United States (two), Australia (two) and Sweden (one), with geographical locations not specified in a systematic review (one). Studies were conducted in general practice (four), a nursing home (one), patients’ homes and/or clinic environments (five) or delivered across both primary and secondary care settings (four).

Summary of studies included in the review

Study methods included focus groups (three), individual interviews (five), surveys (two), mixed methods (three) and a systematic review (one).

Most studies (eight) included nurses as their sole participants: practice nurses (two), community nurses (two), nurses employed specifically to support the delivery of studies (one), health visitors and community midwives (one), nurses conducting their own research (one) and student nurses (one); herewith referred to collectively as nurses. The remaining six studies included nurses plus other health professionals, herewith referred to as ‘nurses and other staff’.

Nurses were either employed solely to work on research studies (five), or the nurses incorporated research delivery alongside their routine clinical work (eight); in the remaining study, this was unclear.

We identified 10 key themes relating to the experience of nurses supporting research in primary care:

• What nurses value about primary care research and their motivations for engaging in research?

Nurses appreciated the importance of primary care research and wanted to increase their knowledge and involvement in research processes (Hange et al. , 2015 ). Some nurses considered supporting research as essential to their professional role, believing that evidence-based research findings could enhance clinical practice and patient care (Rose et al. , 2021 ).

Motivation for taking part in research often centred on perceived improvements in patient care. Nurses referred to extended consultation times, access to new treatments and equipment, and the enjoyment they gain from additional patient contact (Shaw et al. , 2005 ). Nurses reported positive patient outcomes such as improved wound healing or helping patients come to terms with a disease (Newall et al. , 2009 ; Potter et al. , 2009 ).

Nurses attested the experience of taking part in research had positively changed their practice by providing an opportunity to reflect on their normal clinical approach (Boase et al. , 2012 ). Some nurses thought the status of their organisation would rise due to the credibility afforded from taking part in quality research, and that their participation in research could raise the profile of nursing (Newall et al. , 2009 ).

There was some evidence that how nurses felt about delivering research was affected by whether they were asked if they wanted to contribute to the delivery of a research study (Newall et al. , 2009 ). Nurses who were nominated to recruit patients to a study felt burdened, whereas nurses who were asked reported positive experiences of study involvement (Potter et al. , 2009 ).

• The role of nurses in research

Not all nurses felt confident in their new role of delivering research studies and needing to acquire new knowledge and competencies (Hange et al. , 2015 ). Some nurses found autonomous working whilst supporting research studies less of a transition from a previous post which had involved independent working. Nurses and other staff acknowledged that skills from their previous employment (e.g., communication and phlebotomy) were transferrable and an asset to supporting trial delivery (McNiven et al. , 2021 ).

Nurses made decisions about multiple existing agendas in order to manage research delivery in a real-world setting (Boase et al. , 2012 ). Nurses found designation of roles during the study helpful, but they also found it challenging to combine clinical work with research (Hange et al. , 2015 ). Some nurses indicated that the research topic being addressed needed to be relevant to their roles and duties and identified the potential for role conflict (Rose et al. , 2021 ).

Nurses reported finding it challenging to take on a new role (research identity), encountering conflict between their roles, being a health professional with loyalty to patients and seeking to meet the demands of the practice, plus being part of the research team and striving to meet the obligations of a study (Boase et al. , 2012 ). McNiven et al. ( 2021 ) acknowledged that although a nurse employed specifically to do research may enter a clinical setting solely to conduct research-related duties (e.g., data collection and patient recruitment), they may be inclined to approach these obligations from a general nursing perspective. Nurses, therefore, need to be able to adapt to their new role and recognise that they are no longer working in the capacity of a member of the clinical team but are on site to support research.

• Working with research teams

Nurses reported wanting to be regarded as collaborators in research that is clinically relevant to practice and to be offered the opportunity to contribute to study design to optimise recruitment and increase sense of ownership (Fletcher et al. , 2012 ; Hange et al. , 2015 ). Nurses who enjoyed participating in the planning and design stages of the study and helping to identify and resolve potential issues shared this viewpoint (Newall et al. , 2009 ).

Communication between staff delivering the study and the research team was noted to impact on study promotion, staff engagement and study recruitment. Nurses reported a lack of encouragement from research teams as a barrier to supporting research, and communicative and visible study teams as a motivator (Rose et al. , 2021 ). Nurses expressed reduced contact with researchers during trial recruitment resulted in lost opportunity to ask study-related questions, fewer recruits and decreased motivation (Hange et al. , 2015 ). Nurses considered it of great importance to establish a connection with the research team and valued having a point of contact (Lamb et al. 2016 ).

• Study Training

The importance of assigning adequate time and resources for study training and study processes was identified by Boase et al. ( 2012 ). Rose et al. ( 2021 ) described how researchers should involve nurses in the design of training for a study and re-evaluate study training to ensure it continues to meet the needs of those for whom it is intended. Reducing the amount of time between receipt of study training and the commencement of recruitment could improve study engagement (Long et al. , 2020 ).

Training should cover study processes, recruitment, study rationale and the research topic (Rose et al. , 2021 ); information on methodology may also be beneficial (Fletcher et al. , 2012 ). Specialised research terminology used in the initial training session in the study by Boase et al. ( 2012 ) was unfamiliar to nurses and may have added to their anxiety. Repeats of study training (Hange et al. , 2015 ), additional booster sessions and mock recruitment exercises may all be beneficial (Mentes and Tripp-Reimer, 2002 ).

Kyte et al. ( 2016 ) highlighted several issues around training on patient-reported outcome measures (PROMs). Nurses felt they received little PROM training, and that additional training would enhance their ability to explain to participants why PROM data is collected and why it is important for a study. Nurses thought PROM training should include how to answer ambiguous questions and what to record when participants’ answers do not match available responses.

• Eligibility screening, data collection and study documentation

Screening patients for study eligibility was more intensive than anticipated, and nurses struggled to find suitable patients (Long et al. , 2020 ). Nurses sometimes found eligibility criteria too restrictive as they excluded patients who most presented with the health complaint being studied (Newall et al. , 2009 ). Confusion amongst nurses and other staff about study eligibility criteria and which version of the protocol was being used led to one nurse feeling undermined when her initial decision to exclude patients was questioned by a colleague (Long et al. , 2020 ).

Having additional time to interview potential participants for inclusion could have been advantageous, and time constraints meant nurses were unable to ask enough questions about patients’ symptoms, reducing opportunities for inclusion (Hange et al. , 2015 ). Some nurses developed helpful strategies to promote research studies, such as notices about the study in clinic rooms and computer screen alerts (Potter et al. , 2009 ).

Instruction on data collection processes needs to be clear and in the most appropriate form for nurses to access. Clear guidance in the study protocol can help avoid differences in interpretation and inaccuracy of data collection (Long et al. , 2020 ; Kyte et al. , 2016 ).

Obtaining study data can be time-consuming, particularly in community settings when patients’ medical records are not readily to hand (Long et al. , 2020 ), with some nurses reporting to get fed up with data collection (Newall et al. , 2009 ). High staff turnover, inflexible staff work schedules and challenging study population characteristics (e.g., cognitively impaired) can hamper data collection efforts (Mentes and Tripp-Reimer, 2002 ).

The initial research information provided to practices should succinctly describe the study, and the study methodology should be easy to understand and convey to patients (Fletcher et al. , 2012 ). Terminology used in study documentation can be open to potential bias, for example, nurses regarded one participant’s information leaflet as emphasising the intervention more than the control (Long et al. , 2020 ). Study information should be comprehensive and accessible to equip nurses with the knowledge needed to answer patient queries, without requiring them to spend additional time reading about the research subject (Rose et al. , 2021 ).

Scripted protocols are a guided dialogue provided by study teams to recruiting staff to standardise their communications with patients. However, scripted protocols may result in less personal and more robotic communications (Morgan et al. , 2017 ). Nurses found using a scripted protocol formulaic, repetitive, uncomfortable and patronising towards patients (Boase et al. , 2012 ).

• Nurse/participant dynamic

Nurses prioritised developing trust with potential participants, empowering patient decision-making around whether to take part in a study out of choice rather than obligation (Lamb et al. , 2016 ; Morgan et al. , 2017 ). Nurses thought patients may be less likely to take part in a study without the presence of an amicable relationship (Lamb et al. , 2016 ). Participants recommended taking part in the study to friends and family based on their perception of the nurse/staff member, rather than the study itself (Morgan et al. , 2017 ).

Nurses believed a good relationship with prospective participants could be developed, and disengaged participants may be disarmed, by adopting a highly polite manner, using formal forms of address, and showing appreciation by thanking individuals for giving up their time to engage in research. Nurses commonly went above and beyond to accommodate participants (e.g., maximising appointment flexibility and seeing late arrivals), which improved nurses’ ability to recruit and retain participants (Morgan et al. , 2017 ).

Nurses and other staff found it challenging to get across salient points about a study to patients, yet were aware their choice of language, and ease in communicating with patients with whom they identify (e.g., similar social class) could be influential (Fletcher et al. , 2012 ). Some likened explaining the process of randomisation to a sales pitch, or a description of the lottery, with winners and losers. McNiven et al. ( 2021 ) highlight that how a clinician conveys the patient information sheet to a participant (using vocabulary they understand) contributes to how well it is understood. The consequences of effective communication were demonstrated in the study by Newall et al. ( 2009 ) in which some nurses were surprised that patients were more tolerant of compression bandaging than they had anticipated and attributed this to better explanation of its efficacy.

Nurses considered it important to appreciate and address the patient’s own agendas before recruiting them as a study participant (Boase et al. , 2012 ). This was evident in the study by Newall et al. ( 2009 ) where resistance to study involvement was sometimes voiced by patients who thought participation may limit their freedoms and lengthen their district nurse visits.

• Gatekeeping

Nurses acted as gatekeepers, not approaching all patients who met study eligibility criteria, but only those who they deemed suitable (Fletcher et al. , 2012 ; Rose et al. 2021 ). When assessing patient eligibility, some nurses introduced additional factors to include or exclude a patient (Lamb et al. , 2016 ). For example, nurses were more inclined to approach patients who demonstrated good communicability, motivation, enthusiasm, interest and a good nurse/patient relationship (Lamb, Backhouse and Adderley, 2016 ). Conversely, some nurses tended to select patients who were non-compliant with their treatment in the hope that the study may help them reconsider their outlook (Potter et al. , 2009 ). Nurses were dissuaded from inviting patients with frailty/poor health, impaired mental capacity, social issues (isolation or recent bereavement), environmental issues posing concern for nurse safety (Lamb et al. , 2016 ), a lot of care input or who had been on the nurse caseload for a long time because they thought patients would not like it (Potter et al. , 2009 ).

Fletcher et al. ( 2012 ) explored some of the reasons gatekeeping took place. Nurses were concerned that study invitation may affect their dynamic with patients and did not want to be perceived as pushing patients to take part. Nurses grappled with the potential risks/side effects posed to patients versus the wider population gain research produces. Nurses factored in the timing and emotional burden of research involvement for patients who are terminally ill or with a poor prognosis.

Although nurses may be well intentioned, this additional pre-screening element potentially creates sample bias, a loss of patient autonomy, and a loss of valuable data on a hidden population (for which the size and demographic are unknown to both the researcher and patient) and limits generalisability of research findings (Lamb et al. , 2016 ).

• Relationships with colleagues and their impact on recruitment

Engaging colleagues in the research process can positively affect study delivery. Staff working collaboratively, with good communication and a shared research vision, can help to minimise resentment by non-study staff and promote patient recruitment.

It was important for participating practice teams to wholly adopt a shared research vision (Boase et al. , 2012 ) and for all nurses, not just those working on the study, to be kept updated on the research processes to minimise feelings of resentment or exclusion (Newall et al. , 2009 ). Facilitators to effective collaboration include sharing knowledge and experiences of good practice during study recruitment, joint working on study activities (recruitment and data collection), and the ability for nurses to be flexible, compatible and accommodating (Mentes and Tripp-Reimer, 2002 ). By implementing weekly progress reviews of trial recruitment, Newall et al. ( 2009 ) noted that this might lead to effectual collaborative working, information sharing and problem-solving. Challenges to collaborative working include time needed to liaise with other health professionals, unreliability of other health professionals to support research activity because of their clinical priorities (Long et al. , 2020 ), and the presence of hierarchical positions within GP practices, with a lack of collaborative decision-making (Shaw et al. , 2005 ).

Long et al. ( 2020 ) described how nurses spent a large proportion of time trying to raise the profile of a study by phoning and emailing trust staff and visiting clinical areas, yet engagement from colleagues to support the study was inconsistent. Nurses reported miscommunications with care home staff about sample collection, with staff ‘selectively hearing’ about trial obligations (Mentes and Tripp-Reimer, 2002 ).

Practice nurses reported feeling isolated working in a research capacity, with some being the only member of the team involved with the study. They reported experiencing resentment or concern from other nurses in the team who perceived clinical tasks as not prioritised due to research demands (Boase et al. , 2012 ). One nurse was concerned that colleagues regarded her as sitting and ‘doing nothing’ when attending to research obligations (Hange et al. , 2015 ).

• Time constraints and workload demands

Time is a well-documented barrier to the ability to support the delivery of studies (Fletcher et al. , 2012 ) and was reported in 9 of the 14 studies. Research duties may not be prioritised over existing obligations of achieving service targets (Mentes and Tripp-Reimer, 2002 ; Fletcher et al. , 2012 ).

Boase et al. ( 2012 ) found that when practice nurses were not allocated protected time for study activities, this compounded pressure on both their clinical and research work. In research-naïve practices, the challenges of securing allocated protected research time, separate to clinical duties, created tensions in work relationships (Shaw et al. , 2005 ).

Funded protected research time for nurses and other staff may improve recruitment and enable detailed explanation of the study to participants (Fletcher et al. , 2012 ). Potter et al. ( 2009 ) acknowledged that despite fees being paid to support practices with recruitment, dedicated time for recruitment only featured at a few sites. Nurses who allocated dedicated time for patient recruitment were more successful at recruiting participants.

High workload, competing priorities and the unpredictability of recruitment made it challenging to resource the research study with nurse time (Newall et al. , 2009 ). High workload can result in insufficient time for nurses and other staff to perform research activities (Hange et al. , 2015 ). For nurses not solely delivering research studies, study duties (e.g., assessing eligibility and receiving informed consent) created additional work over and above their usual workload (Fletcher et al. , 2012 ). Some nurses felt research funding should cover them for protected time to approach potential participants about study participation, rather than conducting research on top of their existing workload (Rose et al. , 2021 ). Study commitments in addition to usual workload can overwhelm nurses, especially when they are particularly pressured (Mentes and Tripp-Reimer, 2002 ).

Research teams should minimise the burden of work for nurses delivering research (Newall et al. , 2009 ). If funded protected time cannot be achieved, then reduction of workload related to study recruitment is critical to improving study recruitment (Fletcher et al. , 2012 ). Administrative staff could reduce the amount of time nurses spent recruiting patients and arranging follow-up visits (Boase et al. , 2012 ).

• Health and safety concerns

Barr and Welch ( 2012 ) explored workplace health and safety issues for nurses conducting research in the community. Most participants perceived their risk of harm to be minimal and tended to only complete perfunctory risk assessments that they saw as a requirement for their employers rather than for their own safety. Yet participants shared examples of their experiences of health and safety issues that arose when delivering studies including lone working risks, being stalked by a research participant and concerns for the welfare of others. The authors recommended that nurses would benefit from more understanding of the purpose of risk assessments and tips to disengage from researcher–participant relationships.

Nurses placed varying degrees of importance on conducting healthcare research influenced by: whether they considered research an incumbent part of their role; if they had been asked or nominated to support a research study; whether their contributions were adequately acknowledged; or whether the study covered a subject area they were interested in. The latter point supports findings by Rait et al. ( 2002 ) who recognised that practice nurses were keen to participate in research relevant to their practice population, and Davies et al. ( 2002 ) who observed that practice nurses doing their own research opt to study long-term health problems high in prevalence in their local patient population.

Barriers to nurses engaging in research included insufficient time, lack of support from colleagues and poor access to higher education resources (Davies et al. , 2002 ). Motivators included: perceived improvements to patient care, patient outcomes and clinical practice; personal benefit; career development; and raising the calibre of one’s organisation or nursing discipline.

The review highlighted the need for nurses to be involved in study design and study training, helping to identify and mitigate potential issues and shore up the efficient running of a study. Training can help nurses develop skills to face the challenges of study delivery, ensuring safe and ethical care is provided to research participants and high-quality data are collected (Hernon et al. , 2020 ). Study training should address the research topic, the rationale for conducting the study, study processes and recruitment. Ideally, training should be study-specific and practice-based (Rait et al. , 2002 ). Staff should receive training that includes some explanation of the rationale behind aspects of the protocol (e.g., inclusion/exclusion criteria) and the consequences of misconduct on the study and research objectives (True et al. , 2011 ). Specific training on PROM assessment methods, which are frequently used data collection methods, was also considered important.

Whether nurses delivered the research as their sole role, or in addition to an existing clinical role, impacted on the workload demands placed on nurses. Young et al. ( 2009 ) describe how ever-increasing workloads, insufficient support from medical colleagues and competing demands featured as major obstacles for nurses in research active general practices. Competing and organisational pressures can make it difficult to deliver research in primary care (Gaglio et al. , 2006 ), with clinical commitments posing the greatest barrier to research participation (Rait et al. , 2002 ). The literature review found that measures to reduce nurse workload have favourable outcomes on study delivery, and that nurses who allocated protected time were more successful with recruitment.

Hernon et al. ( 2020 ) described how clinical research nurses experienced isolation and a lack of understanding from colleagues about their role, creating difficulties for study recruitment. The review identified that fostering a good relationship with the wider working team can help nurses deliver research studies efficiently and minimise feelings of isolation and resentment. Regular and supportive dialogue between study teams and nurses bolsters study promotion, staff engagement and recruitment.

Nurses may find changing to a research role challenging and draw solace from existing, transferable nursing skills and experiences. Spilsbury et al. ( 2008 ) specify obstacles nurses associate with the role transition, namely lack of confidence, role conflict and difficulties encouraging clinical nursing staff to comply with study protocols, whilst maintaining their own motivation.

The review highlights the conflict nurses encounter being both a clinician and staff member supporting the delivery of research. Nurses were internally juxtaposed with being a patient advocate, whilst adhering to a study protocol. Tinkler et al. ( 2018 ) acknowledge the ethical issues nurses face when they feel patients may not truly understand the implications of taking part in a research study. Duncan et al. ( 2009 ) describe the tensions research staff encounter between encouraging open disclosures from research participants in qualitative interviews and acting on shared information in the best interest of the participant. Nurses felt especially pressured and like reluctant salespeople when working on industry-funded studies where recruitment targets were high (Tinkler et al. , 2018 ).

The review identified some key factors that can affect data collection by nurses: staff designation to the task; study eligibility criteria; characteristics of the study population; accessibility of study data; and whether guidance on data collection processes was clear. It was important for nurses that study documentation was comprehensive and easily understood, and scripted protocols were off-putting for some nurses. Data collection was more challenging, and health and safety risks were more notable for community nurses.

The professional regulatory body for nurses in the United Kingdom, the Nursing and Midwifery Council (NMC), stipulates that nurses should practice in accordance with best available evidence and collect, treat and store all research findings befittingly (NMC, 2018 ). Nurse-led research and studies delivered by nurses can propel change. Evidence procured through research moulds the profession of nursing, informing policy and professional decision-making. Cultivating an environment for nurses to flourish in leading, and to participate in and deliver research for patient benefit is a key objective outlined in the chief nursing officer (CNO) for England’s strategic plan for research (National Health Service, 2021 ). Exploring nurses’ experience of delivering research studies in primary care is an important step to understanding how best to support nurses in contributing to the CNO’s strategic plan.

Study limitations

A possible limitation of this review is that it only includes studies written in English, potentially omitting relevant studies and contributions to the subject area.

Our inclusion criteria included publications from the last 20 years, a period of significant changes to nursing roles and the healthcare system. The earlier publications could, therefore, seem less relevant. However, some of the issues identified in the earlier publications remain pertinent today and help to reinforce the relevance of the review. Evidence from the earlier publications exploring the historic experiences of nurses supporting and delivering research studies in primary care should help inform contemporary work moving forward.

Nurses are integral to the delivery of primary care research studies. This review explored the experiences of nurses delivering research studies in primary care and identified potential challenges and facilitators to effective study delivery. The review highlighted the importance of good communication by study teams, timely and study-specific training, and support and understanding from colleagues. Nurses value their relationships with patients and the benefits that research participation can achieve, but some nurses may inadvertently introduce bias when considering patient suitability for trial involvement. Offering nurses protected time to conduct research tasks improves trial recruitment and reduces conflict with competing demands.

Acknowledgements

The authors wish to acknowledge and thank the University of Birmingham for covering manuscript publication costs.

Authors’ contribution

Both authors made substantial contributions to the conception and design of the review as well the collection, analysis and interpretation of data. Both authors have been involved in drafting the manuscript and revising it critically for important intellectual content. Both authors have read and approved of the final manuscript version to be published.

Financial support

This research received no specific grant from any funding agency, commercial or not-for-profit sectors. Funding for the open access charges for the publication of this protocol was provided by the University of Birmingham.

Competing interests

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Nevada Today

Researchers develop innovative method of teaching self-help skills to preschoolers who are deafblind, study demonstrate the effectiveness of system of least prompts (slp) as part of an intervention.

MaryAnn Demchak, Ph.D., BCBA-D, supporting Jill Grattan, Ph.D., as she successfully defended her dissertation for her doctoral degree.

A groundbreaking approach to teaching essential self-help skills to preschoolers who are deafblind has been developed by researchers. Led by MaryAnn Demchak, Ph.D., BCBA-D. , professor of special education at the University of Nevada, Reno, and Jill Grattan, Ph.D. this innovative method employs the System of Least Prompts (SLP) .

“Very little research occurs with students who have severe, multiple disabilities that include deafblindness,” Demchak said. “This study extends prior research to this population and provides teachers and other practitioners with effective educational strategies.”

In their study, the researchers focused on teaching three crucial self-help skills – hand washing, hand drying and entry routines – to preschoolers aged 3 to 5 with vision and hearing impairments, along with multiple disabilities. Remarkably, 75% of the participants showed increased independence in mastering these targeted skills.

Self-help skills play a pivotal role in daily life, impacting health and shaping social acceptance. However, until now, research in this area for deafblind preschoolers with multiple disabilities has been limited.

The findings of this study demonstrate the effectiveness of SLP as part of an intervention package in teaching self-help skills to young children with multiple disabilities, including deafblindness. Although the mastery criterion wasn't universally achieved, the significant increase in independence among 75% of the participants is noteworthy.

“Interacting with the students and seeing their progress as a result of systematic teaching using SLP was very rewarding,” Grattan said.

Preschoolers with multiple disabilities, including deafblindness, often require extensive support in their daily activities. Therefore, any progress toward independence, even with some level of support or modification, is significant. Educators working with this population can now rely on evidence from this study to inform their teaching strategies, particularly emphasizing the effectiveness of SLP.

Jill Grattan, who earned her doctoral degree in Education: Special Education and Disability Studies from the University of Nevada, Reno, has collaborated with Demchak on various research studies focusing on individuals with disabilities.

“It is a privilege to collaborate with current and former doctoral students to make contributions to the field of severe, multiple disabilities, including the area of deafblindness,” Demchak said.

This study offers valuable insights, demonstrating that self-help skills can be effectively taught to deafblind preschoolers. This not only promises to foster healthy habits and well-being but also lays the foundation for future independence, ultimately enhancing the quality of life for both the children and their caregivers.

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