case studies in nursing research

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• Oncology Nursing Forum
• Number 6 / November 2015

Case Study Research Methodology in Nursing Research

Diane G. Cope

Through data collection methods using a holistic approach that focuses on variables in a natural setting, qualitative research methods seek to understand participants’ perceptions and interpretations. Common qualitative research methods include ethnography, phenomenology, grounded theory, and historic research. Another type of methodology that has a similar qualitative approach is case study research, which seeks to understand a phenomenon or case from multiple perspectives within a given real-world context.

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Systematic reviews, preferred reporting items for systematic reviews and meta-analyses, nursing intervention research.

Step-By-Step Guide to Writing a Nursing Case Study

You now know all the key sections you need to include in a nursing case study. You also know what exactly you need to do in each section. It is now time to know how exactly to write a nursing case study. The process detailed below should be easy to follow because you now know the typical structure of nursing case studies.

When given a nursing case study assignment, the first thing you need to do is to read. You need to read two pieces of information slowly and carefully.

First, you need to read the prompt itself slowly and carefully. This is important because the prompt will have important bits of information that you need to know, including the style, the format, the word count, and the number of references needed. All these bits of information are important to know to ensure what you are writing is the right thing.

Second, you need to read the patient scenario slowly and carefully. You should do this to understand it clearly so that you do not make any mistakes in your analysis.

• Create a rough outline

Failure to plan is a plan to fail. So do not fail to plan. In other words, do not fail to create an outline for your case study analysis. Use the template provided in this essay to create a rough outline for your nursing case study analysis.

Make sure your outline is as detailed as it can be at this stage. You can do light research to achieve this aim. However, this is not exactly necessary because this is just a rough outline.

• Conduct thorough research

After creating a rough outline, you should conduct thorough research. Your research should especially focus on providing a credible and evidence-based nursing assessment on the patient problem(s). The evidence you should use should only be from recent nursing or medical literature.

You will also need to conduct thorough research to come up with an effective intervention or nursing care plan. So when researching the patient’s problem and its diagnosis, you should also research the most suitable intervention or you should do it right after.

When conducting research, you should always note down your sources. So for every piece of information you find and what to use, you should have its reference.

After conducting thorough research, you should enhance your rough outline using the new pieces of information you have discovered. Make sure it is as comprehensive as possible.

• Write your nursing case study

At this stage, you simply need to follow your comprehensive outline to write your case study analysis. If you created a good outline, you should find it very easy to write your nursing case study analysis.

If you did not, you will find it difficult to write your nursing case study. Whenever you are stuck when writing your case study analysis paper, you should re-read the part of this article where we explain what to include in every section of your analysis. Doing so will help you know what exactly to write to continue with your essay. Writing a nursing case study analysis usually takes only a few hours.

• Reference your case study

After writing your case study, make sure you add all in-text citations if you had not added them already. And when adding them, you should make sure you follow the style/format recommended in the assignment prompt (usually APA or Harvard style).

After adding in-text citations exactly where they need to be and in the right format, add all the references you have used in a references page. And you should add them correctly as per the rules of the style you were asked to use.

Do not forget to organize your references alphabetically after you are done creating your references page.

• Thoroughly edit your case study

After STEP 5 above, you need to edit your case study. You should edit it slowly and carefully. Do this by proofreading it twice. Proofread it slowly each time to discover all the grammar, style, and punctuation errors. Remove all the errors you find.

After proofreading your essay twice, check it one more time to make sure every sentence is very easy to understand. This is what will transform your ordinary case study into an A-grade case study. Of course, it must also have all the standard sections expected in a case study.

Just to make sure your case study is absolutely perfect, check it one more time using a grammarly.com or a similar computer grammar checker. Doing this will help you catch and eliminate all the remaining errors in your work.

• Submit your case study analysis

After you are done proofreading and editing your case study analysis, it will be 100% ready for submission. Just convert it into the format it is required in and submit it.

Published by laura

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Case Study Research Design in Nursing

Affiliation.

• 1 Author Affiliation: Senior Nurse Scientist, Department of Nursing Research and Innovation, Cleveland Clinic, Ohio.
• PMID: 33009110
• DOI: 10.1097/NUR.0000000000000554
• Nursing Research / methods*
• Research Design*

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Easterlow D, Hoddinott P, Harrison S Implementing and standardising the use of peripheral vascular access devices. J Clin Nurs.. 2010; 19:(5-6)721-727 https://doi.org/10.1111/j.1365-2702.2009.03098.x

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Gorski LA, Hadaway L, Hagle M Infusion therapy standards of practice. J Infus Nurs.. 2021; 44:(S1)S1-S224 https://doi.org/10.1097/NAN.0000000000000396

Guenezan J, Marjanovic N, Drugeon B Chlorhexidine plus alcohol versus povidone iodine plus alcohol, combined or not with innovative devices, for prevention of short-term peripheral venous catheter infection and failure (CLEAN 3 study): an investigator-initiated, openlabel, single centre, randomised-controlled, two-by-two factorial trial [published correction appears in Lancet Infect Dis. 2021 Apr 6]. Lancet Infect Dis.. 2021; 21:(7)1038-1048 https://doi.org/10.1016/S1473-3099(20)30738-6

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Ishikawa K, Furukawa K Staphylococcus aureus bacteraemia due to central venous catheter infection: a clinical comparison of infections caused by methicillin-resistant and methicillin-susceptible strains. Cureus.. 2021; 13:(7) https://doi.org/10.7759/cureus.16607

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Case Studies

Gema munoz-mozas.

Vascular Access Advanced Nurse Practitioner—Lead Vascular Access Nurse, The Royal Marsden NHS Foundation Trust

View articles · Email Gema

Colin Fairhurst

Vascular Access Advanced Clinical Practitioner, University Hospitals Plymouth NHS Trust

View articles

Simon Clare

Research and Practice Development Director, The Association for Safe Aseptic Practice

View articles · Email Simon

Intravenous (IV) access, both peripheral and central, is an integral part of the patient care pathways for diagnosing and treating cancer. Patients receiving systemic anticancer treatment (SACT) are at risk for developing infections, which may lead to hospitalisation, disruptions in treatment schedules and even death ( Centers for Disease Control and Prevention, 2021 ). However, infection rates can be reduced and general patient outcomes improved with the evidence-based standardisation of IV practice, and the adoption of the appropriate equipment, such as peripheral IV cannulas, flushing solutions and sterile IV dressings ( Easterlow et al, 2010 ).

Cancer treatment frequently involves the use of central venous catheters (CVCs)-also referred to as central venous access devices (CVADs)—which can represent a lifeline for patients when used to administer all kinds of IV medications, including chemotherapy, blood products and parenteral nutrition. They can also be used to obtain blood samples, which can improve the patient’s quality of life by reducing the need for peripheral stabs from regular venepunctures ( Taxbro and Chopra, 2021 ). CVCs are relatively easy to insert and care for; however, they are associated with potential complications throughout their insertion and maintenance.

One serious complication of CVC use is catheter-related bloodstream infections (CRBSIs), which can increase morbidity, leading to prolonged hospitalisation and critical use of hospital resources ( Akhtar and Lee, 2021 ). Early-onset CRBSIs are commonly caused by skin pathogens, and so a cornerstone of a CRBSI prevention is skin antisepsis at the time of CVC insertion. Appropriate antisepsis (decontamination/preparation) of the site for CVC insertion can prevent the transmission of such skin pathogens during insertion, while reducing the burden of bacteria on the CVC exit site ( Loveday et al, 2014 ).

Evidence-based practice for the prevention of a CRBSIs and other healthcare-associated infections recommends skin antisepsis prior to insertion of a vascular-access device (VAD) using a 2% chlorhexidine gluconate and 70% isopropyl alcohol solution. This is recommended in guidelines such as epic3 ( Loveday et al, 2014 ), the Standards for Infusion Therapy ( Royal College of Nursing, 2016 ) and the Infusion Therapy Standards of Practice ( Gorski et al, 2021 ). A strong evidenced-backed product such as BD ChloraPrep™ ( Figure 1 ) has a combination of 2% chlorhexidine gluconate in 70% isopropyl alcohol that provides broad-spectrum rapid-action antisepsis, while the applicators facilitate a sterile, single-use application that eliminates direct hand-to-patient contact, helping to reduce cross-contamination and maintaining sterile conditions ( BD, 2021 ). The BD ChloraPrep™ applicator’s circular head allows precise antisepsis of the required area, and the sponge head helps to apply gentle friction in back-and-forth motion to penetrate the skin layers ( BD, 2021 ). BD ChloraPrep’s rapidacting, persistent and broad-spectrum characteristics and proven applicator system ( Florman and Nichols, 2007 ) make it a vital part of the policy and protocol for insertion, care and maintenance of CVCs in specialist cancer centres such as the Royal Marsden. Meanwhile, the use of BD PosiFlush™ Prefilled Saline Syringe ( Figure 2 ), a prefilled normal saline (0.9% sodium choride) syringe, is established practice for the flushing regime of VADs in many NHS Trusts.

The following five case studies present examples from personal experience of clinical practice that illustrate how and why clinicians in oncology and other disciplines use BD ChloraPrep ™ and BD PosiFlush ™ Prefilled Saline Syringe in both adult and paediatric patients.

Case study 1 (Andy)

Andy was a 65-year-old man being treated for metastatic colorectal cancer at the Royal Marsden NHS Foundation Trust specialist cancer service, which provides state-of-the-art treatment to over 60 000 patients each year.

Andy had a peripherally inserted central catheter (PICC) placed at the onset of his chemotherapy treatment to facilitate IV treatment. While in situ, PICCs require regular maintenance to minimise associated risks. This consists of a weekly dressing change to minimise infection and a weekly flush to maintain patency, if not in constant use. For ambulatory patients, weekly PICC maintenance can be carried out either in the hospital outpatient department or at home by a district nurse or family member trained to do so. Patients, relatives, carers and less-experienced nurses involved in PICC care (flushing and dressing) can watch a video on the Royal Marsden website as an aide memoir.

Initially, Andy decided to have his weekly PICC maintenance at the hospital’s nurse-led clinic for the maintenance of CVCs. At the clinic, Andy’s PICC dressing change and catheter flushing procedures were performed by a nursing associate (NA), who, having completed the relevant competences and undergone supervised practise, could carry out weekly catheter maintenance and access PICC for blood sampling.

In line with hospital policy, the PICC dressing change was performed under aseptic non-touch technique (ANTT) using a dressing pack and sterile gloves. After removal of the old dressing, the skin around the entry site and the PICC was cleaned with a 3 ml BD ChloraPrep™ applicator, using back-andforth strokes for 30 seconds and allowing the area to air dry completely before applying the new dressing. As clarified in a recent article on skin antisepsis (Clare and Rowley, 2020), BD ChloraPrep™ applicator facilitated a sterile, single-use application that eliminates direct hand-to-patient contact, which help reduce cross-contamination and maintaining ANTT. Its circular head allowed precise antisepsis around the catheter, and the sponge head helped to apply gentle friction in back-and-forth strokes to penetrate the skin layers.

Once the new dressing was applied, the NA continued to clean the catheter hub and change the needle-free connector. Finally, the catheter lumen was flushed with 10 ml of normal saline (0.9% sodium chloride) with a pre-filled saline syringe (BD PosiFlush™ Prefilled Saline Syringe). This involved flushing 1 ml at a time, following a push-pause technique, with positive pressure disconnection to ensure catheter patency. The classification of these syringes as medical devices enables NAs and other nonregistered members of the clinical team to support nursing staff with the care and maintenance of PICCs and other CVCs, within local policies and procedures. Using pre-filled syringes can save time and minimise the risk of contamination of the solution ( Ceylan et al, 2021 ).

The use of pre-filled 0.9% sodium chloride syringes facilitates home maintenance of PICCs for patients. When Andy did not need to attend hospital, his PICC maintenance could be performed by a family member. Patients and relatives could access the necessary equipment and training from the day-case unit or outpatient department. Home PICC maintenance is extremely beneficial, not just to providers, but also to patients, who may avoid unnecessary hospital attendance and so benefit from more quality time at home and a reduced risk of hospital-acquired infections. Many patients and relatives have commented on the convenience of having their PICC maintenance at home and how easy they found using the ChloraPrep™ and BD PosiFlush™ Prefilled Saline Syringe ‘sticks’.

Case study 2 (Gail)

Gail was as a 48-year-old woman being treated for bladder cancer with folinic acid, fluorouracil and oxaliplatin (FOLOX). She was admitted for a replacement PICC, primarily for continuous cytotoxic intravenous medication via infusion pump in the homecare setting. Her first PICC developed a reaction thought to be related to a sutureless securement device (SSD) anchoring the PICC. The device was removed, but this resulted in displacement of the PICC and incorrect positioning in the vessel (superior vena cava). Now unsafe, the PICC was removed, awaiting replacement, which resulted in a delayed start for the chemotherapy.

A second PICC placement was attempted by a nurse-led CVC placement team, and a line attempt was made in Gail’s left arm. Skin antisepsis was undertaken using a 2% chlorhexidine gluconate and 70% isopropyl alcohol solution (ChloraPrep™). A BD ChloraPrep ™ 10 ml applicator was selected, using manufacturer’s recommendations, as per best practice guidance for CVC placement ( Loveday et al, 2014 ) and to comply with local policy for the use of ANTT. The BD ChloraPrep™ applicator allowed improved non-touch technique and helped facilitate good key-part and key-site protection, in line with ANTT ( Clare and Rowley, 2021 ).

The inserting clinician failed to successfully position the PICC in Gail’s left arm and moved to try on the right. On the second attempt, Gail noted the use of BD ChloraPrep™ and stated that she was allergic to the product, reporting a severe skin rash and local discomfort. The line placer informed the Gail that she had used BD ChloraPrep™ on the failed first attempt without issue, and she gave her consent to continue the procedure. No skin reaction was noted during or after insertion of the PICC.

BD ChloraPrep™ has a rapid-acting broad-spectrum antiseptic range and ability to keep fighting bacteria for at least 48 hours ( BD, 2021 ). These were tangible benefits during maintenance of the CVC insertion site, in the protection of key sites following dressing change and until subsequent dressing changes. There are reported observations of clinicians not allowing the skin to fully dry and applying a new dressing onto wet skin after removing old dressings and disinfecting the exit site with BD ChloraPrep™. This has been reported to cause skin irritation, which can be mistaken for an allergic reaction and lead the patient to think that they have an allergy to chlorhexidine. In our centre’s general experience, very few true allergic reactions have ever been reported by the insertion team. Improved surveillance might better differentiate between later reported reactions, possibly associated with a delayed response to exposure to BD ChloraPrep ™ at insertion, and local skin irritation caused by incorrect management at some later point during hospitalisation.

Staff training is an important consideration in the safe and correct use of BD ChloraPrep™ products and the correct use of adhesive dressings to avoid irritant contact dermatitis (ICD). It is worth noting that it can be difficult to differentiate between ICD and allergic contact dermatitis (ACD). Education and training should be multifaceted (such as with training videos and study days), allowing for different ways of learning, and monitored with audit. Local training in the benefits of using BD ChloraPrep™ correctly have been reinforced by adding simple instructions to ANTT procedure guidelines for CVC insertion and maintenance. Education on its own is often limited to a single episode of training, the benefit of using ANTT procedure guidelines is that they are embedded in a programme of audits and periodic competency reassessment. This makes sure that, as an integral part of good practice, skin antisepsis with BD ChloraPrep ™ is consistently and accurately retrained and assessed.

Gail’s case illustrates the importance of correct application of BD ChloraPrep ™ and how good documentation and surveillance are vital in monitoring skin health during the repeated use skindisinfection products. Care should be taken when recording ICD and ACD reactions, and staff should take steps to confirm true allergy versus temporary skin irritation.

Case study 3 (Beata)

Beata was a 13-year-old teenage girl being treated for acute myeloid leukaemia. Although Beata had a dual-lumen skin-tunnelled catheter in situ, a peripheral intravenous cannula (PIVC) was required for the administration of contrast media for computed tomography (CT) scanning. However, Beata had needlephobia, and so the lead vascular access nurse was contacted to insert the cannula, following ultrasound guidance and the ANTT. After Beata and her mother gave their consent to the procedure, the nurse gathered and prepared all the equipment, including a cannulation pack, single-use tourniquet, skin-antisepsis product, appropriate cannula, PIVC dressing, 0.9% sodium chloride BD PosiFlush ™ Prefilled Saline Syringe, sterile gel, sterile dressing to cover ultrasound probe and personal protective equipment.

Prior to PIVC insertion, a 4x5 cm area of skin underwent antisepsis with a 1.5 ml BD ChloraPrep ™ Frepp applicator, with back-and-forth strokes for 30 seconds, and was allowed to air-dry. The vascular access team prefer to use BD ChloraPrep ™ Frepp over single-use wipes, as the former is faster acting and provides the right volume to decontaminate the indicated area using ANTT ( Clare and Rowley, 2021 ).

Following insertion, the PIVC was flushed with a 10 ml BD PosiFlush ™ Prefilled Saline Syringe syringe, using a pushpause pulsatile technique, with positive pressure disconnection. Local policy recommends the use of pre-filled saline syringes, as they save time and minimise infection risk compared with manually drawn saline flushes ( Ceylan et al, 2021 ). The Trust also permits competent non-registered members of staff to perform PIVC insertion, which is more cost-effective than depending on registered nurses.

In Beata’s case, the team considered the use of BD ChloraPrep™ and BD PosiFlush™ Prefilled Saline Syringe to be essential for the prevention of VAD-associated infections, as well as increasing the quality of nursing care by saving time in the day-case and inpatient settings alike.

Case study 4 (Emma)

Emma, a 43-year-old woman diagnosed with acute lymphoblastic leukaemia, was scheduled for an allogenic stem-cell transplant and associated chemotherapy. To facilitate this, she attended the vascular access service at University Hospitals Plymouth NHS Trust for the insertion of a triple-lumen skin-tunnelled catheter. This was identified as the best VAD for her needs, because of its longevity, multiple points of access and decreased infection risk compared with other devices, such as PICCs.

This was Emma’s second advanced VAD insertion, having previously received an apheresis line due to poor peripheral venous access, to facilitate the prior stem-cell harvest. She was yet to receive any treatment, and, therefore, no immunodeficiency had been identified prior to the insertion procedure.

Trust policy for skin disinfection prior to the insertion or removal of PICC lines is a 2% chlorhexidine gluconate and 70% isopropyl alcohol solution, BD ChloraPrep™. There is an exception for patient history of allergy or sensitivity to BD ChloraPrep™, where 10% povidone iodine is used instead. Emma had received BD ChloraPrep™ before, with no sign allergy or sensitivity, and so the vascular access team decided to use this product again for insertion. BD Chloraprep™ was used, in preference of other skin antisepsis options, due to the applicator’s ability to effectively penetrate the layers of the epidermis, as well as the ability to eliminate direct hand-to-skin contact between the operator and patient ( Clare and Rowley, 2021 ).

Insertion of a skin-tunnelled catheter first requires disinfection of a large area, including the neck and upper chest. Following the manufacturer’s coverage recommendations, a 10.5 ml BD ChloraPrep™ applicator was selected as most suitable to cover an area of 25x30 cm ( BD, 2022 a).

The applicator was activated by pinching the wings to allow the antiseptic solution to properly load onto the sponge. To ensure proper release of the solution, the applicator was held on the skin against the anticipated site of insertion until the sponge pad became saturated. Then, a back-and-forth rubbing motion was undertaken for a minimum of 30 seconds, ensuring that the full area to be used was covered. The solution was then left to dry completely, prior to full-body draping, leaving the procedural area exposed for the procedure. Generally, drying time takes from 30 to 60 seconds, but local policy is not restrictive, as allowing the solution to fully dry is of paramount importance ( Gunka et al, 2019 ). BD Chloraprep™ is effective against a wide variety of microorganisms and has a rapid onset of action ( Florman and Nichols, 2007 ). Therefore, it was felt to be the best option for procedural and ongoing care skin asepsis in a patient anticipated to be immunocompromised during treatment.

It is the normal policy of the Trust’s vascular access service to flush VADs using BD PosiFlush™ Prefilled Saline Syringes with 0.9% sodium chloride. Likewise, BD PosiFlush™ Prefilled Saline Syringes Sterile Pathway (SP) are used to prime all VADs prior to insertion and to check for correct patency once inserted. BD PosiFlush ™ Prefilled Saline Syringe were used in preference of other options, such as vials or bags, due to the absence of requirement for a prescription in the local organisation. They are treated as a medical device and, therefore, can be used without prescription. The advantage of this is that flushes can be administered in a nurse-led clinic, where prescribers are not always available. Aside from the logistical advantages, the use of pre-filled syringes reduces the risk of microbial contamination through preparation error and administration error through correct labelling ( National Patient Safety Agency, 2007 ) In Emma’s case, three BD PosiFlush™ SP Prefilled Saline Syringes were used to check patency and/or ascertain venous location following the insertion of the skin-tunnelled catheter.

In this case, both BD ChloraPrep ™ and BD PosiFlush ™ Prefilled Saline Syringe proved simple to use and helped achieve a successful procedural outcome for the patient.

Case study 5 (Frank)

Frank was a 47-year-old man who had been diagnosed with infective endocarditis following a trans-oesophageal echo. A few days later, to facilitate his planned treatment of 6 weeks of intravenous antibiotics to be administered 4-hourly every day, he was referred to the vascular access service for insertion of longterm IV access. To facilitate this administration, the decision was made to place a PICC.

Frank’s referral included a history of illegal intravenous drug use and details of the consequent difficulty the ward-based team had in finding suitable veins to obtain vascular access. His medical history also included infected abscesses in the left groin and methicillin-resistant Staphylococcus aureus (MRSA) colonisation.

First, Frank was administered suppression therapy for MRSA decolonisation. Following this and prior to PICC insertion, the skin antisepsis procedure was undertaken using a 2% chlorhexidine gluconate and 70% isopropyl alcohol solution, BD ChloraPrep™, in adherence to Trust policy ( Loveday et al, 2014 ). Specifically, BD ChloraPrep™ applicators are selected for their single-use application. They have been demonstrated to reduce the risk of infectious complications (catheter colonisation and local infection) by 92% compared with 5% povidone iodine (PVI) 69% ethanol ( Guenezan et al, 2021 ). A 3 ml BD ChloraPrep™ applicator was considered suitable to decontaminate an area sufficient for the intended PICC insertion procedure, as recommended by the manufacturer ( BD, 2022 b). It was applied using a back-and-forth motion for a minimum of 30 seconds and left to fully dry ( Loveday et al, 2014 ). Staphylococcus aureus bacteraemia’s have a mortality rate of 20-40% and are predominantly caused by VAD insertion ( Ishikawa and Furukawa, 2021 ), and, therefore, the need to reduce this risk was of particular importance for this patient due to the history of MRSA colonisation.

In Frank’s case, the use of BD ChloraPrep™ during the insertion procedure and for each subsequent dressing change episode participated in an uneventful period of treatment. The clinical challenges posed by the patients’ presentation of MRSA colonisation meant the risk of infection was increased but, through correct antisepsis, no adverse events were noted, and the full course of treatment was successfully administered through the PICC.

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Nursing Students’ Views and Suggestions About Case-Based Learning Integrated Into the Nursing Process: A Qualitative Study

Rukiye burucu.

1 Department of Nursing, Necmettin Erbakan University, Seydişehir Faculty of Health Science, Konya, Turkey

Selda Arslan

2 Department of Nursing, Necmettin Erbakan University, Faculty of Nursing, Konya, Turkey

This study aimed to evaluate students’ views and suggestions about case-based learning.

: The research was planned by using qualitative method of phenomenological type. Case-based learning was integrated into the nursing process and implemented in four sessions, and then, students’ views and suggestions were collected. In the interview, a semi-structured interview form was used, in-depth interviews were made, and the data were evaluated by qualitative data analysis. Phenomelogical approach of Colazzi was used in the analyzes and Huberman method was applied. The COREQ was used to analyze and report the qualitative data. The sample consisted of second-year students in the nursing department of a public university in Anatolia in the academic year 2017-2018. Participants attended the case-based learning program. A focus group interview was conducted with 10 of the participants.

Participants are 10 students with a mean age of 19.86 ± 0.78 years. A total of 65 opinions and suggestions were presented during the focus group meeting. These were grouped under two main and seven sub-themes. Participants had positive views on the program and gave practical suggestions.

Case-based learning integrated into the nursing process is a practical nursing method that helps students learn and understand the nursing process better and approach patients from a holistic perspective.

Introduction

The goal of nursing education is to encourage students to develop personal and professional skills (Sharif & Masoumi, 2005). Using nursing students’ teaching methods of choice promotes learning, ensures learning retention, and improves academic performance (Vizeshfar & Torabizadeh, 2018). Different methods should be used for high-quality nursing education ( Azizi et al. , 2018 ; Holland et al. , 2017 ). One of these methods is case-based learning (CBL) ( Aluisio et al. , 2016 ; Hong & Yu, 2017 ), which allows students to acquire academic knowledge (Yoo & Park, 2015), develop critical thinking ( Chan et al. , 2016 ; Hong & Yu, 2017 ) and problem-solving skills (Yoo & Park, 2015), and improve professional self-efficacy ( Kim, 2018 ). Cases can be taught through brainstorming, group discussions, concept maps (Laver & Croxon, 2015), role play ( Kim, 2018 ; Tucker et al. , 2015 ), simulation and software ( Tucker et al. , 2015 ), and demonstration ( MacDonnell et al. , 2010 ).

CBL is a method of learning through analysis of a situation that has been or is likely to be experienced ( Kırımsoy et al. , 2013 ). It is a student-centered method that involves the teaching of a topic through a scenario, resulting in improved learning outcomes and decision-making skills (Kanbay & Okanli, 2017), and in permanent and in-depth learning ( Aluisio et al. , 2016 ). CBL promotes active engagement and self-assessment and decision-making, allowing students to gain insight into how they should react in real life situations (Oermann & Kuzu Kurban, 2015). Nurse education should be based on theoretical and practical training to provide students with the opportunity to put their knowledge to use. However, not all students get the chance to encounter all cases in clinical settings. To overcome this problem, nursing education should incorporate the CBL ( Altınbaş & Derya İster, 2020 ), which, however, has not been sufficiently studied so far ( Majeed, 2014 ). It is recommended that researchers provide the CBL to nursing students and then find out about their views and recommendations on it ( Altınbaş & Derya İster, 2020 ). Collecting and analyzing qualitative data is a recommended method of evaluating views and recommendations ( Chan et al. , 2016 ). Qualitative methods are used to collect data on the environment, processes, and perceptions ( Karataş, 2015 ), and can also be applied to data on teaching methods. Students’ views can provide important information about the effectiveness of a method and help create a framework to overcome its shortcomings ( Chan et al. , 2016 ; Kermansaravi et al. , 2015 ; Raymond et al. , 2018 b; van Hooft et al. , 2018 ). Investigating students’ opinions about a teaching method causes them to feel stressed, but also encourages them to improve themselves ( Gholami et al. , 2017 ). This study aimed to determine what nursing students thought about the CBL and what kind of suggestions they would offer to improve it.

Research Questions

• What kind of method do nursing students think the CBL is?
• What do nursing students suggest about the CBL?

Study Design

This was a qualitative study that employed phenomenology.

Nursing education varies across countries. Nursing programs in Turkey offer a 4-year undergraduate education. The sample for this study consisted of second-year nursing students from a public university in Turkey. Purposive sampling does not set a limit on the sample size, but it is believed that too large a sample can make interpretation challenging ( Baltacı, 2018 ). Therefore, this study was completed with 10 volunteers after the CBL intervention.

Data Collection

Prior to the CBL intervention, a detailed lesson plan was developed (Appendix 1) and integrated into the nursing process. Each CBL session lasted 100 minutes. An expert was consulted for the cases in the CBL program (Appendix 2). The integration of the cases into the CBL program was based on the Nursing Interventions Classification, Nursing Outcomes Classification, and NANDA-International (NANDA-I) ( Bulechek et al. , 2017 ; Carpenito-Moyet, 2012). The sample was divided into two for the CBL program, which was applied in classrooms between February and May 2018. One week after the CBL program, a focus-group interview (120 minutes) was conducted with 10 of the 37 participants. The focus-group interview was held using a semi-structured interview form (Appendix 3), for which an expert was consulted (Appendix 2). The interview was audio-recorded. Notes were taken during the interview. One of the researchers acted as a director, while the other acted as a reporter during the interview. Data were collected by the focus-group interview method. It is impossible to prevent respondents from interacting in the focus-group interviews. To minimize this, the researchers asked the interview questions and received answers in order. There were two focus groups of five respondents each. Data collection was terminated when no more data adding new information or insight was forthcoming (data saturation) (Yağar & Dökme, 2018). The interviews were held at the participants’ convenience, so that they would feel comfortable answering the questions. A semi-structured interview form was used during the interviews for consistency. An interview flow template was used for flow and order. Whenever the researchers were in doubt, they consulted with an academic specialized in qualitative research.

In this research, a semi-structured interview form was used to collect the data. There are four questions in this form;

• Can I learn your positive and negative feelings and thoughts about the “case-based teaching method?”
• Have you been taught such a lesson before?
• Compare the “case-based teaching method” with your current courses. What are the differences between the two courses?
• What are your suggestions for this method?

For confirmation, results should be corroborated by those of other studies (Creswell, 2017). Therefore, the researchers discussed the results in line with the related literature.

Reliability

Interrater reliability was calculated for both the semi-structured interview form and the themes using the formula [Reliability = (number of agreements)/(number of agreements + number of disagreements) × 100] (Arastaman et al., 2018; Guba, 1981 ; Ocak & Kutlu Kalender, 2017 ). The interrater reliability was higher than 80, indicating acceptable reliability. Both researchers analyzed the data independently and then combined it based on the order specified by encoders ( Table 1 ). The researchers consulted with an academic specialized in qualitative research to reach a consensus on the parts on which they had disagreed during coding. Bias was reduced using Colaizzi’s phenomenological methodology, which consists of seven steps: (1) recording data, (2) determining significant statements, (3) making sense of the statements, (4) classifying themes into groups, (5) improving the groups, (6) stating the phenomenon clearly, and (7) constructing a fundamental structure ( Onat Kocabıyık, 2016 ).

Colaizzi’s Method of Data Analysis

Statistical Analysis

Themes were developed and categorized. Data were analyzed using conventional qualitative data analysis ( Sönmez & Alacapınar, 2014 ). In the qualitative data analysis, Colaizzi’s phenomenological methodology was used to disclose the meaning attributed by respondents to the intervention in question ( Demir et al. , 2017 ). Colaizzi’s phenomenological methodology is used to reveal the meaning attributed by people to an event/phenomenon ( Onat Kocabıyık, 2016 ). The Consolidated Criteria for Reporting Qualitative Research, which is a 32-item checklist, was used to analyze and report the qualitative data ( Tong et al. , 2007 ).

Ethical Consideration

The study was approved by the Non-Clinical Research Ethics Committee of the Faculty of Health Sciences of Selçuk University (2017/58). Written permission was obtained from the department of nursing. Written informed consent was obtained from participants. The researchers kept the names of the respondents anonymous during data report and kept the audio-recordings and transcripts in encrypted files on their computers.

The focus-group interview was conducted with 10 participants (2 men and 8 women) with a mean age of 19.86 ± 0.78 years. In the focus-group interview, the respondents presented 65 views and recommendations, categorized into two main themes; “Opinions” and “Suggestions.” The theme “opinions” consisted of four subthemes; “The CBL program helped me acquire more academic knowledge and learn the nursing process better”; “The CBL program increased my motivation and appealed to me”; “It was good that the CBL classes were not crowded”; and “The question–answer (Q&A) during the CBL class was helpful.” Theme “suggestions” consisted of three subthemes; “The CBL should be integrated into the current curriculum”; “Nurses and instructors should be role models for students”; and “The CBL nursing education should be offered to other students as well.” The respondents stated that they had never had a case-based course before. Respondents 5 and 7 did not answer question 3, while respondent 8 did not answer question 4. Table 1 shows the distribution of the responses and themes.

Theme 1 Opinions

Subtheme: The CBL program helped me acquire more academic knowledge and learn the nursing process better: All respondents stated that the CBL program made them more aware and knowledgeable about academic content, nursing process, and care planning. The following are direct quotations from three respondents:

• Respondent 1: “...I‘ve learned to approach patients from a holistic perspective and to tackle not only complications but also psychological and social problems, and now I can combine parts and see things as a whole...”
• Respondent 2: “….I didn’t know how to use the nursing process when planning care, but the CBL is helping me manage care now, it‘s also increased my knowledge on medication and helped me understand what nursing diagnosis is…”
• Respondent 10: “…I can plan care more easily and distinguish between descriptive and related factors. I got to see what I’d been (doing wrong during care planning. I used to get bored planning care, but the CBL program helped me better understand the nursing process. The nursing diagnosis book is too general and confusing. It is too broad, but now I understand that I can go beyond that knowledge and that it is practically possible…”

Subtheme: The CBL program increased my motivation and appealed to me : The respondents noted that they felt more confident when they saw that they could easily reach the teacher and ask him/her questions to plan care without fear of being graded. The following are direct quotations from three respondents:

• Respondent 3: “…I was more efficient because I had no fear of being graded, I was more comfortable during the internship than usual ... The CBL classes were more active than others, I was more motivated and engaged because I had no fear of being graded…”
• Respondent 4: “… It was a privilege for me to participate in this training. No one had the chance to do as thorough an examination as the students attending this training, which was an advantage. …”
• Respondent 6: “…I liked it when I saw that I could plan care, it motivates me now…”

Subtheme: It was good that the CBL classes were not crowded: The respondents saw it as a great advantage that they had all their questions answered because the CBL classes were not crowded. The following are direct quotations from three respondents:

• Respondent 2: “…In other classes, we would ask our questions in haste and get some answers because the classes were too crowded, but in the CBL class we could ask our questions in detail.…”
• Respondent 6: “… the CBL class was less crowded than others, and so it was more like a Q&A type of class, so they were more efficient. Besides, the group of 37 was divided into two, which was very good for the CBL class.…”
• Respondent 10: “…we all asked and answered questions, everybody got to talk, which is not possible in other classes because they are too crowded…”

Subtheme: The Q&A during the CBL class was helpful: The respondents remarked that Q&A in the CBL class was better for them because all their questions were answered, which promoted their learning. The following are direct quotations from three respondents:

• Respondent 6: “…theoretical classes were very intense, and the instructors would think that we knew about theory, and so, they sometimes wouldn’t answer our questions, and those classes offered nothing much when it comes to practice, but in the CBL class we examined what was taught in theory, and I thought that I could put it into practice…”
• Respondent 7: “…we always had time constraints in other classes, but in the CBL class we got to ask all our questions one by one and got answers, I mean we kind of had to ask questions, but in the end, we learned…”
• Respondent 10: “…we had Q&A throughout the CBL class, which was very productive, I got to ask all the questions I had in mind and got answers to all of them …”

Theme 2 Suggestions

Subtheme: the CBL should be integrated into the existing curriculum: All but respondents 1 and 8 recommended that the CBL should be integrated into clinical practice or offered by the current curriculum as an elective course. The following are direct quotations from three respondents.

• Respondent 2: “…the CBL should be integrated into the curriculum, there is no need to make extra time for it, I mean, I had to come to school for the CBL class apart from the courses I already have, so it was kind of a hurdle for me…”
• Respondent 5: “… the CBL should be offered as an elective course, and students could be split into groups of 30 and work on cases …”
• Respondent 7: “…In the first week of clinical practice, the instructor should bring a case and present it to her students, just like what we have in the CBL, and tell them that she expects the same from them …”

Subtheme: Nurses and instructors should be role models for students: Respondents 1, 6, 7, and 10 stated that clinical nurses and instructors should adopt a common language and serve as role models for the nursing process and care planning. The following are direct quotations from three respondents:

• Respondent 1: “…nurses should be role models for this…”
• Respondent 6: “… instructors should use a common language and be role models when it comes to planning care.”
• Respondent 7: “… we plan care, but each instructor says something different about it and has different styles... We don‘t even know which one is right and which one is wrong, but they are supposed to serve as models…”

Subtheme: the CBL nursing education should be offered to other students as well: Respondents 4, 7, 9, and 10 highlighted that the CBL program should be offered to all students because they all have difficulty in learning the nursing process and planning care. The following are direct quotations from three respondents:

• Respondent 4: “…we now know it and can put it into practice, but we couldn‘t do it at all in our first year, so nursing students of all grades should attend the CBL program...”
• Respondent 7: “… I believe that other students should also learn these things because no one had taught them to us before, and we didn‘t get to learn them in other classes. There should be a case group or something like that could discuss cases with younger students once a week…”
• Respondent 9: “…care planning is hard for all students, so older students should help younger students with it, so peer education could be helpful …”

The discussion is based on the summarized data in Table 2 .

Distribution of Participants’ Opinions and Suggestions

Note: * Themes and subthemes.

CBL makes nursing students more knowledgeable and prone to teamwork, helps them with better clinical performance, develops more positive attitudes toward clinical practice, helps them understand the holistic approach better and improve themselves professionally ( Forsgren et al. , 2014 ), resulting in higher learning retention, quality of care, and patient safety ( Ward et al. , 2018 ). The more the students know, the more motivated they are, further facilitating learning ( Holland et al. , 2017 ). People who acquire new knowledge are likely to develop more positive attitudes and better skills ( Patiraki et al. , 2017 ). Adequate and comfortable learning environments support motivation ( Palumbo, 2018 ; Raymond et al. , 2018 a), minimize communication problems, and contribute to high-quality care (Sharif & Masoumi, 2005).

Aluisio et al. (2016) divided Indian nursing students into three groups (CBL, standard training, and simulation) to teach them about disasters. They found that the CBL group had the highest knowledge score (55.3 ± 11.3), followed by the simulation (46.9 ± 10.6) and standard training (43.8 ± 11.0) groups. Lee et al. (2020) provided nurses working in nursing homes with the CBL (integrated with online and simulation training) on interventions for heart attacks, and found that the participants felt more competent after the training (post-CBL = 4.11 ± 0.37) than before (pre-CBL = 3.79 ± 0.41) and had higher post-CBL knowledge scores (12.82 ± 2.03) than pre-CBL knowledge scores (10.06 ± 2.28). Therefore, they concluded that the CBL integrated with online and simulation training improved nurses’ knowledge and promoted their learning. Kim and Yang (2020) provided nurses with training based on a case of dementia and found that the training helped nurses learn more about dementia ( z = −4.86, p < .001) and interventions for dementia ( z = −4.55, p < .001) and develop more positive attitudes toward people with dementia ( t = −3.04, p = .003). Nursing students are expected to acquire knowledge and put them into practice in the nursing process. Therefore, we can state that the CBL integrated into the nursing process can contribute to nurses’ education.

Cases appeal to students ( Chan et al. , 2016 ; Gholami et al. , 2017 ) and satisfy their expectations ( Hong & Yu, 2017 ). CBL helps nurses make fewer mistakes ( Patiraki et al. , 2017 ; Uysal et al. , 2016 ) and makes them more motivated ( Cui et al. , 2018 ), and therefore, it should be an integral part of nursing education ( McLean, 2016 ). Focus-group interviews are of significance for detecting the strengths and weaknesses of nursing interventions, correcting errors, eliminating deficiencies, and developing new programs. Opinions and suggestions about methods are sound guides that allow us to see the errors and weaknesses of interventions, helping us generate strategies for reform and revise curricula ( Azizi et al. , 2018 ).

Class size is an important factor affecting education and communication during education because the greater the class size, the less time the teacher has for each student ( Raymond et al. , 2018 a), resulting in reduced learning and motivation. However, because class size remains be an important factor, correct planning ( Kocaman & Yurumezoglu, 2015 ; Palumbo, 2018 ) and Q&A is recommended to overcome this problem. Q&A-based classes can increase students’ awareness, concentration, confidence, and self-assessment capacity ( Kaddoura, 2011 ). In short, educational conditions (setting, time, class size, etc.) play a key role in learning ( Gholami et al. , 2017 ). Therefore, education programs should be based on small class size.

The nursing process and care planning provide a common language for nurses and improve the profession through evidence-based protocols ( Patiraki et al. , 2017 ). Nursing students make more mistakes than are acceptable because they cannot clarify the nursing diagnosis while performing the nursing process ( Andsoy et al. , 2013 ). A common language makes nursing care more visible, standardized and record-based, and better understood. This helps both healthcare professionals and instructors meet at a common point and serve as role models ( van Hooft et al. , 2018 ). Nursing students think of the nursing process as too abstract, hard-to-understand, and challenging. This suggests that we need a more concrete educational paradigm ( Zamanzadeh et al. , 2015 ), and we believe we can use the CBL to teach the nursing process.

Nurses and instructors should serve as role models and use a common language to help students put the nursing process into practice. Especially, first- and second-year students find it difficult to comprehend the nursing process and planning care, and therefore, need support ( Andsoy et al. , 2013 ; Patiraki et al. , 2017 ; Uysal et al. , 2016 ). Student communities play an important role in making students socially aware and collaborative, and thus support learning ( Mohan Bursalı & Aksel, 2016 ). Case communities and peer education can provide nursing students with the support in question. Integrating the CBL into the curriculum can be a promising alternative for nursing students.

Conclusion and Recommendations

CBL promotes nursing students’ learning and makes them more motivated because they enjoy Q&A sessions and interaction during CBL-based lectures. They believe that the CBL should be integrated into the existing curriculum and that instructors and nurses should be role models as they put the nursing process in practice. CBL turns abstract concepts of the nursing process into tangible and visual representations. Nursing students think that sharing with younger students what they learn from CBL-based lectures can help those students learn the nursing process more easily.

As a result, it would be appropriate for CBL to be integrated into the existing curriculum and used to train both students and nurses in small groups.

Ethics Committee Approval

Ethics committee approval was obtained from the Non-Clinical Research Ethics Committee of the Faculty of Health Sciences of Selçuk University (2017/58).

Author Contributions

Concept – R.B., S.A.; Design – R.B., S.A.; Supervision – S.A.; Resources – R.B., S.A.; Materials – R.B., S.A.; Data Collection and/or Processing – R.B., S.A.; Interpretation – R.B., S.A.; Literature Search – R.B.; Writing Manuscript – R.B.; Critical Review – S.A.

Appendix 1: CBL Sample Curriculum

Case presentation and analysis (100 Min)

• Showing the case electronically to the group one day prior to intervention
• Remembering the case (10 Min)
• Presenting the theory of disease (10 Min)
• Presenting medications used (15 Min)
• Sorting out the patient problems (15 Min)
• Diagnosis Nursing of NANDA and determining interventions (35 Min)
• Identifying descriptive and etiological factors (10 Min)
• Evaluation and summary (5 Min)

Objectives of the CBL Program

Appendix 2: expert list.

• Prof. Veysel Sönmez, Hacettepe University, Faculty of Education, retired
• Prof. Füsun Gülderen Alacapınar, Necmettin Erbakan University, Faculty of Education
• Assoc. Prof. Selda Arslan, Selçuk University, Faculty of Nursing
• Assoc. Prof. Şerife Kurşun, Selçuk University, Faculty of Nursing
• Assoc. Prof. Pınar Zorba Bahçeli, Selçuk University, Faculty of Nursing

Appendix 3: Semi-structured Interview Form Items

• Could you please tell us about your positive and negative emotions and thoughts about the case-based learning program?
• Have you ever had such a course before?
• Please, compare the case-based learning program with your current courses. What is the difference between them?
• What suggestions can you make concerning the case-based learning program?

Funding Statement

The authors declared that this study has received no financial support.

Informed Consent: Written consent was obtained from students who participated in this study.

Conflict of Interest: The authors have no conflicts of interest to declare.

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• Open access
• Published: 17 April 2024

Deciphering the influence: academic stress and its role in shaping learning approaches among nursing students: a cross-sectional study

• Rawhia Salah Dogham 1 ,
• Heba Fakieh Mansy Ali 1 ,
• Asmaa Saber Ghaly 3 ,
• Nermine M. Elcokany 2 ,
• Mohamed Mahmoud Seweid 4 &
• Ayman Mohamed El-Ashry   ORCID: orcid.org/0000-0001-7718-4942 5  

BMC Nursing volume  23 , Article number:  249 ( 2024 ) Cite this article

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Metrics details

Nursing education presents unique challenges, including high levels of academic stress and varied learning approaches among students. Understanding the relationship between academic stress and learning approaches is crucial for enhancing nursing education effectiveness and student well-being.

This study aimed to investigate the prevalence of academic stress and its correlation with learning approaches among nursing students.

Design and Method

A cross-sectional descriptive correlation research design was employed. A convenient sample of 1010 nursing students participated, completing socio-demographic data, the Perceived Stress Scale (PSS), and the Revised Study Process Questionnaire (R-SPQ-2 F).

Most nursing students experienced moderate academic stress (56.3%) and exhibited moderate levels of deep learning approaches (55.0%). Stress from a lack of professional knowledge and skills negatively correlates with deep learning approaches (r = -0.392) and positively correlates with surface learning approaches (r = 0.365). Female students showed higher deep learning approach scores, while male students exhibited higher surface learning approach scores. Age, gender, educational level, and academic stress significantly influenced learning approaches.

Academic stress significantly impacts learning approaches among nursing students. Strategies addressing stressors and promoting healthy learning approaches are essential for enhancing nursing education and student well-being.

Nursing implication

Understanding academic stress’s impact on nursing students’ learning approaches enables tailored interventions. Recognizing stressors informs strategies for promoting adaptive coping, fostering deep learning, and creating supportive environments. Integrating stress management, mentorship, and counseling enhances student well-being and nursing education quality.

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Introduction

Nursing education is a demanding field that requires students to acquire extensive knowledge and skills to provide competent and compassionate care. Nursing education curriculum involves high-stress environments that can significantly impact students’ learning approaches and academic performance [ 1 , 2 ]. Numerous studies have investigated learning approaches in nursing education, highlighting the importance of identifying individual students’ preferred approaches. The most studied learning approaches include deep, surface, and strategic approaches. Deep learning approaches involve students actively seeking meaning, making connections, and critically analyzing information. Surface learning approaches focus on memorization and reproducing information without a more profound understanding. Strategic learning approaches aim to achieve high grades by adopting specific strategies, such as memorization techniques or time management skills [ 3 , 4 , 5 ].

Nursing education stands out due to its focus on practical training, where the blend of academic and clinical coursework becomes a significant stressor for students, despite academic stress being shared among all university students [ 6 , 7 , 8 ]. Consequently, nursing students are recognized as prone to high-stress levels. Stress is the physiological and psychological response that occurs when a biological control system identifies a deviation between the desired (target) state and the actual state of a fitness-critical variable, whether that discrepancy arises internally or externally to the human [ 9 ]. Stress levels can vary from objective threats to subjective appraisals, making it a highly personalized response to circumstances. Failure to manage these demands leads to stress imbalance [ 10 ].

Nursing students face three primary stressors during their education: academic, clinical, and personal/social stress. Academic stress is caused by the fear of failure in exams, assessments, and training, as well as workload concerns [ 11 ]. Clinical stress, on the other hand, arises from work-related difficulties such as coping with death, fear of failure, and interpersonal dynamics within the organization. Personal and social stressors are caused by an imbalance between home and school, financial hardships, and other factors. Throughout their education, nursing students have to deal with heavy workloads, time constraints, clinical placements, and high academic expectations. Multiple studies have shown that nursing students experience higher stress levels compared to students in other fields [ 12 , 13 , 14 ].

Research has examined the relationship between academic stress and coping strategies among nursing students, but no studies focus specifically on the learning approach and academic stress. However, existing literature suggests that students interested in nursing tend to experience lower levels of academic stress [ 7 ]. Therefore, interest in nursing can lead to deep learning approaches, which promote a comprehensive understanding of the subject matter, allowing students to feel more confident and less overwhelmed by coursework and exams. Conversely, students employing surface learning approaches may experience higher stress levels due to the reliance on memorization [ 3 ].

Understanding the interplay between academic stress and learning approaches among nursing students is essential for designing effective educational interventions. Nursing educators can foster deep learning approaches by incorporating active learning strategies, critical thinking exercises, and reflection activities into the curriculum [ 15 ]. Creating supportive learning environments encouraging collaboration, self-care, and stress management techniques can help alleviate academic stress. Additionally, providing mentorship and counselling services tailored to nursing students’ unique challenges can contribute to their overall well-being and academic success [ 16 , 17 , 18 ].

Despite the scarcity of research focusing on the link between academic stress and learning methods in nursing students, it’s crucial to identify the unique stressors they encounter. The intensity of these stressors can be connected to the learning strategies employed by these students. Academic stress and learning approach are intertwined aspects of the student experience. While academic stress can influence learning approaches, the choice of learning approach can also impact the level of academic stress experienced. By understanding this relationship and implementing strategies to promote healthy learning approaches and manage academic stress, educators and institutions can foster an environment conducive to deep learning and student well-being.

Hence, this study aims to investigate the correlation between academic stress and learning approaches experienced by nursing students.

Study objectives

Assess the levels of academic stress among nursing students.

Assess the learning approaches among nursing students.

Identify the relationship between academic stress and learning approach among nursing students.

Identify the effect of academic stress and related factors on learning approach and among nursing students.

Materials and methods

Research design.

A cross-sectional descriptive correlation research design adhering to the STROBE guidelines was used for this study.

A research project was conducted at Alexandria Nursing College, situated in Egypt. The college adheres to the national standards for nursing education and functions under the jurisdiction of the Egyptian Ministry of Higher Education. Alexandria Nursing College comprises nine specialized nursing departments that offer various nursing specializations. These departments include Nursing Administration, Community Health Nursing, Gerontological Nursing, Medical-Surgical Nursing, Critical Care Nursing, Pediatric Nursing, Obstetric and Gynecological Nursing, Nursing Education, and Psychiatric Nursing and Mental Health. The credit hour system is the fundamental basis of both undergraduate and graduate programs. This framework guarantees a thorough evaluation of academic outcomes by providing an organized structure for tracking academic progress and conducting analyses.

Participants and sample size calculation

The researchers used the Epi Info 7 program to calculate the sample size. The calculations were based on specific parameters such as a population size of 9886 students for the academic year 2022–2023, an expected frequency of 50%, a maximum margin of error of 5%, and a confidence coefficient of 99.9%. Based on these parameters, the program indicated that a minimum sample size of 976 students was required. As a result, the researchers recruited a convenient sample of 1010 nursing students from different academic levels during the 2022–2023 academic year [ 19 ]. This sample size was larger than the minimum required, which could help to increase the accuracy and reliability of the study results. Participation in the study required enrollment in a nursing program and voluntary agreement to take part. The exclusion criteria included individuals with mental illnesses based on their response and those who failed to complete the questionnaires.

socio-demographic data that include students’ age, sex, educational level, hours of sleep at night, hours spent studying, and GPA from the previous semester.

Tool two: the perceived stress scale (PSS)

It was initially created by Sheu et al. (1997) to gauge the level and nature of stress perceived by nursing students attending Taiwanese universities [ 20 ]. It comprises 29 items rated on a 5-point Likert scale, where (0 = never, 1 = rarely, 2 = sometimes, 3 = reasonably often, and 4 = very often), with a total score ranging from 0 to 116. The cut-off points of levels of perceived stress scale according to score percentage were low < 33.33%, moderate 33.33–66.66%, and high more than 66.66%. Higher scores indicate higher stress levels. The items are categorized into six subscales reflecting different sources of stress. The first subscale assesses “stress stemming from lack of professional knowledge and skills” and includes 3 items. The second subscale evaluates “stress from caring for patients” with 8 items. The third subscale measures “stress from assignments and workload” with 5 items. The fourth subscale focuses on “stress from interactions with teachers and nursing staff” with 6 items. The fifth subscale gauges “stress from the clinical environment” with 3 items. The sixth subscale addresses “stress from peers and daily life” with 4 items. El-Ashry et al. (2022) reported an excellent internal consistency reliability of 0.83 [ 21 ]. Two bilingual translators translated the English version of the scale into Arabic and then back-translated it into English by two other independent translators to verify its accuracy. The suitability of the translated version was confirmed through a confirmatory factor analysis (CFA), which yielded goodness-of-fit indices such as a comparative fit index (CFI) of 0.712, a Tucker-Lewis index (TLI) of 0.812, and a root mean square error of approximation (RMSEA) of 0.100.

Tool three: revised study process questionnaire (R-SPQ-2 F)

It was developed by Biggs et al. (2001). It examines deep and surface learning approaches using only 20 questions; each subscale contains 10 questions [ 22 ]. On a 5-point Likert scale ranging from 0 (never or only rarely true of me) to 4 (always or almost always accurate of me). The total score ranged from 0 to 80, with a higher score reflecting more deep or surface learning approaches. The cut-off points of levels of revised study process questionnaire according to score percentage were low < 33%, moderate 33–66%, and high more than 66%. Biggs et al. (2001) found that Cronbach alpha value was 0.73 for deep learning approach and 0.64 for the surface learning approach, which was considered acceptable. Two translators fluent in English and Arabic initially translated a scale from English to Arabic. To ensure the accuracy of the translation, they translated it back into English. The translated version’s appropriateness was evaluated using a confirmatory factor analysis (CFA). The CFA produced several goodness-of-fit indices, including a Comparative Fit Index (CFI) of 0.790, a Tucker-Lewis Index (TLI) of 0.912, and a Root Mean Square Error of Approximation (RMSEA) of 0.100. Comparative Fit Index (CFI) of 0.790, a Tucker-Lewis Index (TLI) of 0.912, and a Root Mean Square Error of Approximation (RMSEA) of 0.100.

Ethical considerations

The Alexandria University College of Nursing’s Research Ethics Committee provided ethical permission before the study’s implementation. Furthermore, pertinent authorities acquired ethical approval at participating nursing institutions. The vice deans of the participating institutions provided written informed consent attesting to institutional support and authority. By giving written informed consent, participants confirmed they were taking part voluntarily. Strict protocols were followed to protect participants’ privacy during the whole investigation. The obtained personal data was kept private and available only to the study team. Ensuring participants’ privacy and anonymity was of utmost importance.

Tools validity

The researchers created tool one after reviewing pertinent literature. Two bilingual translators independently translated the English version into Arabic to evaluate the applicability of the academic stress and learning approach tools for Arabic-speaking populations. To assure accuracy, two additional impartial translators back-translated the translation into English. They were also assessed by a five-person jury of professionals from the education and psychiatric nursing departments. The scales were found to have sufficiently evaluated the intended structures by the jury.

Pilot study

A preliminary investigation involved 100 nursing student applicants, distinct from the final sample, to gauge the efficacy, clarity, and potential obstacles in utilizing the research instruments. The pilot findings indicated that the instruments were accurate, comprehensible, and suitable for the target demographic. Additionally, Cronbach’s Alpha was utilized to further assess the instruments’ reliability, demonstrating internal solid consistency for both the learning approaches and academic stress tools, with values of 0.91 and 0.85, respectively.

Data collection

The researchers convened with each qualified student in a relaxed, unoccupied classroom in their respective college settings. Following a briefing on the study’s objectives, the students filled out the datasheet. The interviews typically lasted 15 to 20 min.

Data analysis

The data collected were analyzed using IBM SPSS software version 26.0. Following data entry, a thorough examination and verification were undertaken to ensure accuracy. The normality of quantitative data distributions was assessed using Kolmogorov-Smirnov tests. Cronbach’s Alpha was employed to evaluate the reliability and internal consistency of the study instruments. Descriptive statistics, including means (M), standard deviations (SD), and frequencies/percentages, were computed to summarize academic stress and learning approaches for categorical data. Student’s t-tests compared scores between two groups for normally distributed variables, while One-way ANOVA compared scores across more than two categories of a categorical variable. Pearson’s correlation coefficient determined the strength and direction of associations between customarily distributed quantitative variables. Hierarchical regression analysis identified the primary independent factors influencing learning approaches. Statistical significance was determined at the 5% (p < 0.05).

Table  1 presents socio-demographic data for a group of 1010 nursing students. The age distribution shows that 38.8% of the students were between 18 and 21 years old, 32.9% were between 21 and 24 years old, and 28.3% were between 24 and 28 years old, with an average age of approximately 22.79. Regarding gender, most of the students were female (77%), while 23% were male. The students were distributed across different educational years, a majority of 34.4% in the second year, followed by 29.4% in the fourth year. The students’ hours spent studying were found to be approximately two-thirds (67%) of the students who studied between 3 and 6 h. Similarly, sleep patterns differ among the students; more than three-quarters (77.3%) of students sleep between 5- to more than 7 h, and only 2.4% sleep less than 2 h per night. Finally, the student’s Grade Point Average (GPA) from the previous semester was also provided. 21% of the students had a GPA between 2 and 2.5, 40.9% had a GPA between 2.5 and 3, and 38.1% had a GPA between 3 and 3.5.

Figure  1 provides the learning approach level among nursing students. In terms of learning approach, most students (55.0%) exhibited a moderate level of deep learning approach, followed by 25.9% with a high level and 19.1% with a low level. The surface learning approach was more prevalent, with 47.8% of students showing a moderate level, 41.7% showing a low level, and only 10.5% exhibiting a high level.

Nursing students? levels of learning approach (N=1010)

Figure  2 provides the types of academic stress levels among nursing students. Among nursing students, various stressors significantly impact their academic experiences. Foremost among these stressors are the pressure and demands associated with academic assignments and workload, with 30.8% of students attributing their high stress levels to these factors. Challenges within the clinical environment are closely behind, contributing significantly to high stress levels among 25.7% of nursing students. Interactions with peers and daily life stressors also weigh heavily on students, ranking third among sources of high stress, with 21.5% of students citing this as a significant factor. Similarly, interaction with teachers and nursing staff closely follow, contributing to high-stress levels for 20.3% of nursing students. While still significant, stress from taking care of patients ranks slightly lower, with 16.7% of students reporting it as a significant factor contributing to their academic stress. At the lowest end of the ranking, but still notable, is stress from a perceived lack of professional knowledge and skills, with 15.9% of students experiencing high stress in this area.

Nursing students? levels of academic stress subtypes (N=1010)

Figure  3 provides the total levels of academic stress among nursing students. The majority of students experienced moderate academic stress (56.3%), followed by those experiencing low academic stress (29.9%), and a minority experienced high academic stress (13.8%).

Nursing students? levels of total academic stress (N=1010)

Table  2 displays the correlation between academic stress subscales and deep and surface learning approaches among 1010 nursing students. All stress subscales exhibited a negative correlation regarding the deep learning approach, indicating that the inclination toward deep learning decreases with increasing stress levels. The most significant negative correlation was observed with stress stemming from the lack of professional knowledge and skills (r=-0.392, p < 0.001), followed by stress from the clinical environment (r=-0.109, p = 0.001), stress from assignments and workload (r=-0.103, p = 0.001), stress from peers and daily life (r=-0.095, p = 0.002), and stress from patient care responsibilities (r=-0.093, p = 0.003). The weakest negative correlation was found with stress from interactions with teachers and nursing staff (r=-0.083, p = 0.009). Conversely, concerning the surface learning approach, all stress subscales displayed a positive correlation, indicating that heightened stress levels corresponded with an increased tendency toward superficial learning. The most substantial positive correlation was observed with stress related to the lack of professional knowledge and skills (r = 0.365, p < 0.001), followed by stress from patient care responsibilities (r = 0.334, p < 0.001), overall stress (r = 0.355, p < 0.001), stress from interactions with teachers and nursing staff (r = 0.262, p < 0.001), stress from assignments and workload (r = 0.262, p < 0.001), and stress from the clinical environment (r = 0.254, p < 0.001). The weakest positive correlation was noted with stress stemming from peers and daily life (r = 0.186, p < 0.001).

Table  3 outlines the association between the socio-demographic characteristics of nursing students and their deep and surface learning approaches. Concerning age, statistically significant differences were observed in deep and surface learning approaches (F = 3.661, p = 0.003 and F = 7.983, p < 0.001, respectively). Gender also demonstrated significant differences in deep and surface learning approaches (t = 3.290, p = 0.001 and t = 8.638, p < 0.001, respectively). Female students exhibited higher scores in the deep learning approach (31.59 ± 8.28) compared to male students (29.59 ± 7.73), while male students had higher scores in the surface learning approach (29.97 ± 7.36) compared to female students (24.90 ± 7.97). Educational level exhibited statistically significant differences in deep and surface learning approaches (F = 5.599, p = 0.001 and F = 17.284, p < 0.001, respectively). Both deep and surface learning approach scores increased with higher educational levels. The duration of study hours demonstrated significant differences only in the surface learning approach (F = 3.550, p = 0.014), with scores increasing as study hours increased. However, no significant difference was observed in the deep learning approach (F = 0.861, p = 0.461). Hours of sleep per night and GPA from the previous semester did not exhibit statistically significant differences in deep or surface learning approaches.

Table  4 presents a multivariate linear regression analysis examining the factors influencing the learning approach among 1110 nursing students. The deep learning approach was positively influenced by age, gender (being female), educational year level, and stress from teachers and nursing staff, as indicated by their positive coefficients and significant p-values (p < 0.05). However, it was negatively influenced by stress from a lack of professional knowledge and skills. The other factors do not significantly influence the deep learning approach. On the other hand, the surface learning approach was positively influenced by gender (being female), educational year level, stress from lack of professional knowledge and skills, stress from assignments and workload, and stress from taking care of patients, as indicated by their positive coefficients and significant p-values (p < 0.05). However, it was negatively influenced by gender (being male). The other factors do not significantly influence the surface learning approach. The adjusted R-squared values indicated that the variables in the model explain 17.8% of the variance in the deep learning approach and 25.5% in the surface learning approach. Both models were statistically significant (p < 0.001).

Nursing students’ academic stress and learning approaches are essential to planning for effective and efficient learning. Nursing education also aims to develop knowledgeable and competent students with problem-solving and critical-thinking skills.

The study’s findings highlight the significant presence of stress among nursing students, with a majority experiencing moderate to severe levels of academic stress. This aligns with previous research indicating that academic stress is prevalent among nursing students. For instance, Zheng et al. (2022) observed moderated stress levels in nursing students during clinical placements [ 23 ], while El-Ashry et al. (2022) found that nearly all first-year nursing students in Egypt experienced severe academic stress [ 21 ]. Conversely, Ali and El-Sherbini (2018) reported that over three-quarters of nursing students faced high academic stress. The complexity of the nursing program likely contributes to these stress levels [ 24 ].

The current study revealed that nursing students identified the highest sources of academic stress as workload from assignments and the stress of caring for patients. This aligns with Banu et al.‘s (2015) findings, where academic demands, assignments, examinations, high workload, and combining clinical work with patient interaction were cited as everyday stressors [ 25 ]. Additionally, Anaman-Torgbor et al. (2021) identified lectures, assignments, and examinations as predictors of academic stress through logistic regression analysis. These stressors may stem from nursing programs emphasizing the development of highly qualified graduates who acquire knowledge, values, and skills through classroom and clinical experiences [ 26 ].

The results regarding learning approaches indicate that most nursing students predominantly employed the deep learning approach. Despite acknowledging a surface learning approach among the participants in the present study, the prevalence of deep learning was higher. This inclination toward the deep learning approach is anticipated in nursing students due to their engagement with advanced courses, requiring retention, integration, and transfer of information at elevated levels. The deep learning approach correlates with a gratifying learning experience and contributes to higher academic achievements [ 3 ]. Moreover, the nursing program’s emphasis on active learning strategies fosters critical thinking, problem-solving, and decision-making skills. These findings align with Mahmoud et al.‘s (2019) study, reporting a significant presence (83.31%) of the deep learning approach among undergraduate nursing students at King Khalid University’s Faculty of Nursing [ 27 ]. Additionally, Mohamed &Morsi (2019) found that most nursing students at Benha University’s Faculty of Nursing embraced the deep learning approach (65.4%) compared to the surface learning approach [ 28 ].

The study observed a negative correlation between the deep learning approach and the overall mean stress score, contrasting with a positive correlation between surface learning approaches and overall stress levels. Elevated academic stress levels may diminish motivation and engagement in the learning process, potentially leading students to feel overwhelmed, disinterested, or burned out, prompting a shift toward a surface learning approach. This finding resonates with previous research indicating that nursing students who actively seek positive academic support strategies during academic stress have better prospects for success than those who do not [ 29 ]. Nebhinani et al. (2020) identified interface concerns and academic workload as significant stress-related factors. Notably, only an interest in nursing demonstrated a significant association with stress levels, with participants interested in nursing primarily employing adaptive coping strategies compared to non-interested students.

The current research reveals a statistically significant inverse relationship between different dimensions of academic stress and adopting the deep learning approach. The most substantial negative correlation was observed with stress arising from a lack of professional knowledge and skills, succeeded by stress associated with the clinical environment, assignments, and workload. Nursing students encounter diverse stressors, including delivering patient care, handling assignments and workloads, navigating challenging interactions with staff and faculty, perceived inadequacies in clinical proficiency, and facing examinations [ 30 ].

In the current study, the multivariate linear regression analysis reveals that various factors positively influence the deep learning approach, including age, female gender, educational year level, and stress from teachers and nursing staff. In contrast, stress from a lack of professional knowledge and skills exert a negative influence. Conversely, the surface learning approach is positively influenced by female gender, educational year level, stress from lack of professional knowledge and skills, stress from assignments and workload, and stress from taking care of patients, but negatively affected by male gender. The models explain 17.8% and 25.5% of the variance in the deep and surface learning approaches, respectively, and both are statistically significant. These findings underscore the intricate interplay of demographic and stress-related factors in shaping nursing students’ learning approaches. High workloads and patient care responsibilities may compel students to prioritize completing tasks over deep comprehension. This pressure could lead to a surface learning approach as students focus on meeting immediate demands rather than engaging deeply with course material. This observation aligns with the findings of Alsayed et al. (2021), who identified age, gender, and study year as significant factors influencing students’ learning approaches.

Deep learners often demonstrate better self-regulation skills, such as effective time management, goal setting, and seeking support when needed. These skills can help manage academic stress and maintain a balanced learning approach. These are supported by studies that studied the effect of coping strategies on stress levels [ 6 , 31 , 32 ]. On the contrary, Pacheco-Castillo et al. study (2021) found a strong significant relationship between academic stressors and students’ level of performance. That study also proved that the more academic stress a student faces, the lower their academic achievement.

Strengths and limitations of the study

This study has lots of advantages. It provides insightful information about the educational experiences of Egyptian nursing students, a demographic that has yet to receive much research. The study’s limited generalizability to other people or nations stems from its concentration on this particular group. This might be addressed in future studies by using a more varied sample. Another drawback is the dependence on self-reported metrics, which may contain biases and mistakes. Although the cross-sectional design offers a moment-in-time view of the problem, it cannot determine causation or evaluate changes over time. To address this, longitudinal research may be carried out.

Notwithstanding these drawbacks, the study substantially contributes to the expanding knowledge of academic stress and nursing students’ learning styles. Additional research is needed to determine teaching strategies that improve deep-learning approaches among nursing students. A qualitative study is required to analyze learning approaches and factors that may influence nursing students’ selection of learning approaches.

According to the present study’s findings, nursing students encounter considerable academic stress, primarily stemming from heavy assignments and workload, as well as interactions with teachers and nursing staff. Additionally, it was observed that students who experience lower levels of academic stress typically adopt a deep learning approach, whereas those facing higher stress levels tend to resort to a surface learning approach. Demographic factors such as age, gender, and educational level influence nursing students’ choice of learning approach. Specifically, female students are more inclined towards deep learning, whereas male students prefer surface learning. Moreover, deep and surface learning approach scores show an upward trend with increasing educational levels and study hours. Academic stress emerges as a significant determinant shaping the adoption of learning approaches among nursing students.

Implications in nursing practice

Nursing programs should consider integrating stress management techniques into their curriculum. Providing students with resources and skills to cope with academic stress can improve their well-being and academic performance. Educators can incorporate teaching strategies that promote deep learning approaches, such as problem-based learning, critical thinking exercises, and active learning methods. These approaches help students engage more deeply with course material and reduce reliance on surface learning techniques. Recognizing the gender differences in learning approaches, nursing programs can offer gender-specific support services and resources. For example, providing targeted workshops or counseling services that address male and female nursing students’ unique stressors and learning needs. Implementing mentorship programs and peer support groups can create a supportive environment where students can share experiences, seek advice, and receive encouragement from their peers and faculty members. Encouraging students to reflect on their learning processes and identify effective study strategies can help them develop metacognitive skills and become more self-directed learners. Faculty members can facilitate this process by incorporating reflective exercises into the curriculum. Nursing faculty and staff should receive training on recognizing signs of academic stress among students and providing appropriate support and resources. Additionally, professional development opportunities can help educators stay updated on evidence-based teaching strategies and practical interventions for addressing student stress.

Data availability

The datasets generated and/or analysed during the current study are not publicly available due to restrictions imposed by the institutional review board to protect participant confidentiality, but are available from the corresponding author on reasonable request.

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Acknowledgements

Our sincere thanks go to all the nursing students in the study. We also want to thank Dr/ Rasha Badry for their statistical analysis help and contribution to this study.

The research was not funded by public, commercial, or non-profit organizations.

Open access funding provided by The Science, Technology & Innovation Funding Authority (STDF) in cooperation with The Egyptian Knowledge Bank (EKB).

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Critical Care & Emergency Nursing, Faculty of Nursing, Alexandria University, Alexandria, Egypt

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Obstetrics and Gynecology Nursing, Faculty of Nursing, Alexandria University, Alexandria, Egypt

Asmaa Saber Ghaly

Faculty of Nursing, Beni-Suef University, Beni-Suef, Egypt

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Psychiatric and Mental Health Nursing, Faculty of Nursing, Alexandria University, Alexandria, Egypt

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Ayman M. El-Ashry & Rawhia S. Dogham: conceptualization, preparation, and data collection; methodology; investigation; formal analysis; data analysis; writing-original draft; writing-manuscript; and editing. Heba F. Mansy Ali & Asmaa S. Ghaly: conceptualization, preparation, methodology, investigation, writing-original draft, writing-review, and editing. Nermine M. Elcokany & Mohamed M. Seweid: Methodology, investigation, formal analysis, data collection, writing-manuscript & editing. All authors reviewed the manuscript and accept for publication.

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Correspondence to Ayman Mohamed El-Ashry .

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The research adhered to the guidelines and regulations outlined in the Declaration of Helsinki (DoH-Oct2008). The Faculty of Nursing’s Research Ethical Committee (REC) at Alexandria University approved data collection in this study (IRB00013620/95/9/2022). Participants were required to sign an informed written consent form, which included an explanation of the research and an assessment of their understanding.

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Dogham, R.S., Ali, H.F.M., Ghaly, A.S. et al. Deciphering the influence: academic stress and its role in shaping learning approaches among nursing students: a cross-sectional study. BMC Nurs 23 , 249 (2024). https://doi.org/10.1186/s12912-024-01885-1

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Received : 31 January 2024

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Published : 17 April 2024

DOI : https://doi.org/10.1186/s12912-024-01885-1

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A warm welcome to the School of Nursing & Midwifery, Trinity College Dublin. As the leading school of nursing and midwifery in Ireland, we are committed to the provision of a first rate educational experience for the high quality students that we serve. The School is ranked 26th in the world in the QS World University Subject Rankings 2024. We are proud to offer a wide range of programmes at undergraduate and postgraduate level.

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