field of study nursing research

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• v.6(3); 2019 Jul

Nursing research: A marriage of theoretical influences

Kari toverud jensen.

1 Oslo Metropolitan University, Oslo, Norway

Associated Data

The aim is to examine PhD theses in nursing science, their purpose or aim and the theoretical approaches and methods employed. The study seeks to examine how such theses may be categorized, what they study, what theoretical approaches they employ and, in particular, to what degree nursing theory is employed as a current theoretical approach.

This study has a descriptive qualitative design.

This study complied with the Standard for Reporting Qualitative Research (SRQR). Data were collected from 61 PhD theses in nursing science published from 1994–2015, at University of Edinburgh.

Twenty of the PhD theses used theoretical approaches with a sociological perspective and 12 used a psychological perspective. Eighteen of the PhD theses were based on theoretical approaches from philosophy, ethics, pedagogy, medicine or biology as a primary perspective. Nursing theories, in their conventional definition, have a limited presence in the theses examined.

1. INTRODUCTION

Nursing as a profession is changing as other health professions work with and alongside nurses in practice, and patients' knowledge levels have improved. The number of nursing scientists has increased, and research knowledge and skills have improved. Nursing research happens in an increasingly diverse research community with colleagues from other disciplines, often in an international context. In an interdisciplinary environment, the theoretical basis of nursing, as opposed to other disciplines, may be obscured. Nursing research plays a role in developing the theoretical basis of nursing, but this may not be explicit in the way nursing research is conducted.

2. BACKGROUND

As described by Alligood ( 2013 ), a result of the recognition of nursing as an academic field of study is that nursing theories have become more important in nursing science. However, what is the prevalence of nursing theories in nursing science? A literature study by Bond et al. ( 2011 ), looking at articles from seven leading nursing journals, found that 21% of the articles used nursing theory. In her review of US doctoral dissertation abstracts in nursing (2000–2004), Spear ( 2007 ) found that less than one‐third referred to nursing theories or theory development in their abstracts. About 45% referred to non‐nursing theory, with psychosocial theories the most prevalent. Lundgren, Valmari, and Skott ( 2009 ) found that dissertations in Nordic countries completed in 2003 were more likely to have nursing practice as their core, while “nursing concepts and theories” (p. 413) received less attention.

However, beyond the studies mentioned, few have been preoccupied with the theoretical approaches in nursing science. Heyman ( 1995 ) has conducted a study of Swedish nursing and caring research across 65 doctoral theses written by nurses from 1974–1991. She found that the researchers had been inspired by different sciences, belonging to at least one of the two divergent traditions, either biomedical research or the social sciences. The study indicates heterogeneity in theoretical conditions, methodologies, rationales and structures across the PhD theses studied. Yarcheski, Mahon, and Yarcheski ( 2012 ) concluded, in a study of research published in scientific nursing journals, that there was a trend towards less theoretically oriented research and that “the study of psychological variables has dominated the last 20 years (1990–2010) of nursing research” (p. 1,120). In addition, Yarcheski and Mahon ( 2013 ) concluded, in a study of characteristics of quantitative nursing research between 1990–2010, that while quantitative nursing research in general could be defined as multidisciplinary, the discipline of psychology dominated throughout the research literature. Larsen and Adamsen ( 2009 ) studied the emergence of Nordic nursing research. They found three distinct positions operating in nursing research: a clinical and applied position closely connected to clinical contexts or practices, a profession and knowledge position focused on frameworks of knowledge and its dissemination and a theoretical and concept position. The theoretical and conceptual positions were used to describe, explain and interpret practice.

After the 1980s, the number of PhD graduates in nursing has increased worldwide. Doctoral theses are an important source in the interpretation of the development in most sciences. Accordingly, the production of PhD dissertations is crucial for nursing science, as well as the building of a body of knowledge important for education, clinical practice and patient outcomes. In this study of nursing science, I have selected data from doctoral theses in nursing from the University of Edinburgh because this university is of special interest for European nursing as it was one of Europe's first universities to introduce nursing science as an academic discipline in their academic body. The university has a long history and decades of influence on nursing research both in the UK and in Europe. It has been educating doctoral candidates in nursing science since 1959 and established, in 1972, the first professorship in nursing studies in Europe (Anderson, Lynch, & Phillipson, 2003 ). Nursing studies at the University of Edinburgh are, as of 2002, located in the School of Health in Social Science; until 2002, the studies were located in the Faculty of Social Sciences (ibid), which may account for the close relationship with the social sciences. An interesting distinction in theoretical approaches is the one between the social sciences and the biomedical sciences (Heyman, 1995 ) and how the different PhD theses shape the field of nursing, through nursing research and theoretical approaches.

In order to understand the implementation of a scientific approach to nursing, PhD theses have in small‐scale been studied and we lack this type of empirical study also from the UK. The aim of this paper is to examine PhD theses in nursing science, their purpose or aim and the theoretical approaches and methods employed. The study seeks to examine how such theses may be categorized, what they study, what theoretical approaches they employ and, in particular, to what degree nursing theory is employed as a current theoretical approach. Nursing theory has been a contested concept. Meleis ( 2012 ) emphasizes that the “multiple use of concepts to describe the same set of relationships has resulted in more confusion” (p. 29). To meet this challenge, the present study will examine the use of the concept “nursing theory” as what the PhD researchers define as content.

This study has a descriptive qualitative design, with PhD theses in nursing science as data sources. The data underwent analysis, inspired by Braun and Clarke ( 2006 ), Hsieh and Shannon ( 2005 ) and Heyman ( 1995 ).

3.1. Method

Data were collected from 61 PhD theses in nursing science published from 1994–2015. The number of PhD theses represents the total number completed during the period in nursing studies at University of Edinburgh. A total of 101 doctoral theses have been submitted from 1959–2015. The decision to include PhD theses from 1994–2015 resulted in a convenience sample reflecting the field of nursing research following the British “Project 2000: a new preparation for practice” (Fawcett, Waugh, & Smith, 2016 ). This study complied with the Standard for Reporting Qualitative Research (SRQR; O'Brien, Harris, Beckman, Reed, & Cook, 2014 ; File S1 ).

3.2. Data analysis

The coding of texts is inspired by Braun and Clarke's ( 2006 ) thematic analysis involving identifying, analysing and reporting patterns in data. While such an analysis may be inductive or deductive, in this study the analysis is deductive in nature. In the first phase, the PhD theses' abstracts were read, followed by a reading of sections of the thesis, such as summary, background and the theory chapter. In the second phase, the PhD theses were systematically analysed by applying three categories to the collected data: the field of study, the aim/purpose of the study and the research methodology. The summative content analysis, inspired by Hsieh and Shannon ( 2005 ), was used to identify and quantify the concept “nursing theory(ies)”.

The third phase involved the coding, inspired by Heyman's ( 1995 ) characteristics of the affiliation to different disciplines' perspectives, in the theoretical approaches or the field of study of the theses. Heyman identified how nursing researchers have studied the human being from many perspectives, including biological and medical, psychological, sociological, organizational and ethical (as a cultural perspective), in addition to pedagogical perspectives. To identify the theoretical perspective or field of study, information from PhD theses, such as use of concepts, models, theories and references to theorists, was collated in a data matrix and structured. The matrix also recorded author, year, title, aims, research questions, findings and type of PhD thesis (monograph or articles). The data, related to theory, models and concepts, as well as references to theorists, were compiled and classified. In the fourth phase, the collected data were reviewed multiple times in order to define the theoretical approaches of the dissertations. Most of the theses' theoretical approaches were obvious and some used multiple approaches. As an example, McGrath's ( 2006 ) PhD thesis, using both sociological theories of identity and psychology, is described in Table ​ Table1, 1 , whereas the main approach is identified as sociological in accordance with the phases described above. Data collection took place through the Centre of Research Collection, University of Edinburgh, from October 2015–April 2016.

PhD theses: aim, theoretical approach, method and use of nursing theory

Use of NT (how many times the concept nursing theory is used in the PhD text not included reference lists), — refer to “not access” on internet databases.

3.3. Ethical approval

Investigating one's peers' research work is important and requires curiosity, interest and respect for other perspectives. I have not changed the candidates' names but have presented them as official literature sources. All readers may therefore check the PhD theses used in this study to assess how they have been treated, analysed and interpreted. This study is approved by the Norwegian Centre for Research Data, project number 51425.

All 61 PhD theses examined were written as monographs, which is an atypical form compared with the Nordic countries (Larsen & Adamsen, 2009 ), where article‐based PhD theses make up the vast majority. Twenty of the PhD theses used theoretical approaches with a sociological perspective and 12 used a psychological perspective. Eighteen of the PhD theses were based on theoretical approaches from philosophy, ethics, pedagogy, medicine or biology as a primary perspective. Two PhD theses used a theoretical approach with a cultural or linguistic perspective, and the organizational perspective was used by seven PhD theses. An “other” category was created to accommodate the theses that did not fit into any established category. “Others” represented just two PhD theses, one using nursing theories of spiritual care and another exploring historical sources. The PhD theses thematically described, investigated, explored, uncovered, examined, compared, identified, determined, provided, created, developed, generated, extended, measured or contributed to advanced understanding of the challenges faced by patients, the changes associated with illness as disease, sickness and experience and how nurses can help, intervene and alleviate; what nurses and nurse students do when they are nursing and preparing for nursing; and the interaction between patients and nurses.

The Internet and the search function were helpful in examining the use of the concept «nursing theory» in the PhD theses. Of the 61 PhD theses examined, 54 were available on the Internet and were included in this concept search (7 March 2018; https://www.era.lib.ed.ac.uk/ ). In the 54 accessible PhD theses, the concept “nursing theory/theories” was referred to by 13 authors. Five theses referred to the concept more than once. In addition, one thesis used “theory of caring” as one of the theoretical approaches and mentioned it 11 times (Frei, 2005 ). Most of the theses used theoretical approaches based on non‐nursing disciplines (Table ​ (Table1). 1 ). Post‐2005, nursing theory is referred to in only two of 26 theses accessible online (Table ​ (Table2 2 ).

Summarizing through the years; field of study, methods and references to nursing theory

Qualitative research methods were the most commonly used methodologies (43 of 61 PhD theses used qualitative methods; Table ​ Table2). 2 ). Prior to 2000, the dissertations were inspired more by organizational and psychological theoretical approaches and showed more diversity in the use of methods compared with after 2000, when the use of sociological and philosophical approaches increased, as did the extensive use of qualitative methods. The 5‐year period preceding 2015 shows a trend of a greater use of mixed methods.

5. DISCUSSION

This study reveals that different scientific disciplines, traditions and abstraction levels informed the PhD theses we examined. Only a few of the PhD theses referred to nursing theory and even fewer used it as their theoretical approach, or as part of the theoretical approach (Table ​ (Table1; 1 ; Everingham, 2012 ; Frei, 2005 ; Grosvenor, 2005 ; Hogg, 2002 ; Rukholm, 1999 ). Most authors used theories based in disciplines other than nursing as theoretical approaches for studying their topic. Risjord ( 2011 ) claims that “it is a mistake to suppose that a theory is either a nursing theory or a non‐theory; disciplines do not own theories” (p. 517). McEven and Wills ( 2014 ) discuss the use of shared or borrowed theories used by nurse researchers and tried to identify what the application of different theories means for nursing. They argue that use of theory offers structure and organization to nursing knowledge and promotes rational and systematic practice and make nursing practice more purposeful, coordinated and less fragmented. Meleis ( 2012 ) brings in another point of view when she states that “all theories used in nursing to understand, explain, predict, or change nursing phenomena are nursing theories” (p. 35), wherever they may have originated.

This study confirms the limited references to nursing theories and shows that after 2005, such references are only rarely present. Why is this? Most nursing theories were developed in the USA, with roots tracing back to the 1980s and earlier. The nursing education systems in the USA differ from those in the UK and Europe in general, and these differences might also have affected the type of theoretical approaches used. Another reason might be that methods and theories from related sciences frame some nursing research questions better. The limited use of, or references to, nursing theories might also reflect a perception that using such theories does not aid the study of nursing practice or the nursing context. As explained by Risjord ( 2010 ), this might historically relate to the relevance gap between the professional nurses' need of knowledge and the nursing theorists' knowledge production. Critical voices have also claimed that nursing theories have no relevance as tools in nursing practice and that clinically based nurses find nursing theory to be of no practical value, useful only as an academic abstraction separating theory from everyday practice (Doane & Varcoe, 2005 ). According to Alligood ( 2014 ), these assumptions undermine a rationale for developing nursing theories as a means of facing challenges in nursing practice and patient care more confidently. These perspectives will have consequences for education and leadership in nursing.

The use of sociological theories represents 20 of the theses. This is perhaps not surprising, considering that nursing studies at the University of Edinburgh are affiliated with the social sciences. More importantly though, the sociological approach emphasizes the interaction between human society and individuals, which is valuable for the subject of nursing and its impact on individuals, families, groups and societal health and well‐being. According to Laiho ( 2010 ), nursing science is clearly a social discipline, motivated to develop itself through the influence of social interests and goals. Nursing research with a sociological approach is crucial in order to consider social factors and issues that prevent, constrain and promote societal health behaviours (Laiho, 2010 ). An example is Muangman ( 2014 ), who studied the nature of “emotion work” in the context of care among adult stroke survivors aged 18–59 and their carers, situated in Thailand. This helped advance knowledge and understanding of the interaction between stroke survivors and their carers, the sociology of family, helping nurses to better facilitate and optimize their nursing and family care.

The use of psychological theory represents 12 of the studied doctoral theses. This is not surprising. Psychology or behavioural science theories are often used by nurse researchers, especially the theories surrounding stress and/or coping. An example here is Kilbride's ( 2006 ) PhD thesis. This study explored changes in neurological function and the emotional challenges experienced by patients with malignant glioma and their families, during the time period between surgery and radiotherapy. In addition to measuring changes in neurological functional status, the researcher used a coping framework to examine practical and emotional issues. This is relevant knowledge for nursing practice to anticipate and predict the physical and emotional responses of patients and their carers and to contribute to optimal quality of life for both patients and relatives.

Philosophical/ethical theory defined nine theses, with most of them leaning more towards the philosophical. Philosophy is defined by Teichman and Evans ( 1999 ) as “… a study of problems that are ultimate, abstract and general. These problems are concerned with the nature of existence, knowledge, morality, reason and human purpose” (p. 1). Adamson's ( 2015 ) study explored the shared experiences of one woman's experience with ovarian cancer from diagnosis to death, using philosophical theories. Adamson used the insights from German idealism (18th century) as a framework for understanding the aesthetics of how to live and die. In this context, philosophy brings to light knowledge on how to identify what is valuable and essential for this woman and her partner. Nurses need such knowledge to better understand, be prepared for and better care for both patients and their families during the disease trajectory.

Organizational theories were employed by seven PhD theses that looked at different applications of management and administration. One example is Miller ( 2004 ), who studied the processes of Trust managers and how they handle incidents involving qualified nurses, as well as how the outcomes of these processes are used to inform the organization and to develop new models of management. Leading an organization, which many nurses do, requires knowledge of, for instance, theories of error as employed by Miller ( 2004 ). Such theories allow nurses to be better prepared and develop strategies to improve leadership, change, decision‐making and motivation in the repertoire of practice among advanced nursing practitioners (McEven & Wills, 2014 ).

Fields of study in culture and linguistics were represented by two PhD theses. One of them, Quickfall ( 2009 ), studied cross‐cultural promotion of health, investigating issues underlying culturally competent nursing for asylum seekers. Knowledge from such theses has implications for all healthcare professions, including nurses, in providing culturally sensitive and evidence‐based nursing, regardless of geographic location (McEven & Wills, 2014 ).

Important aspects of nursing, including promoting health, advising patients and clients how to live with their illness and teaching nurse students, were addressed by four PhD theses. In the investigation of such phenomena, pedagogy and learning theories contribute to a scientific understanding of nurses in their teaching endeavours. Examples of the use of learning theory include the thesis by Msiska ( 2012 ), who explored the clinical learning experiences of undergraduate student nurses in Malawi and Nugent ( 2014 ), who studied the interactive effects of the construction of a special learning theory in relation to predicting health behaviour when supporting patients with type 2 diabetes mellitus in Scotland.

The last field of study is medicine and biology, used by five PhD theses. An example is Bailey ( 1998 ), who developed a description of the acute exacerbation event of Chronic Obstructive Pulmonary Disease to assist nurses in their work with the patient and their families. Bailey used a theoretical model of managing a medical crisis. The development of knowledge in this field has implications for clinical practice. Nurses need deep knowledge about how to manage crises to ensure the best care for patients and their families in acute situations.

As indicated, the nursing programme at the University of Edinburgh is affiliated with the social sciences, owing to its inclusion in the School of Health in Social Science. This affiliation may have influenced the choice of theoretical approaches in the examined PhD theses' nursing research. This might represent a distinctiveness associated with the location of the PhD programmes in nursing science, either in independent faculties or as a part of other disciplines' PhD programmes. In this study, most of the PhD theses were included in the collective term social sciences and only a few in medicine or biology. With regard to this, the findings in this study diverge from the results of Heyman ( 1995 ), who found that the theoretical approaches fell within either biomedical research or the social sciences.

According to Silverman ( 2011 ), “the facts that we find in ‘the field' never speak for themselves but are impregnated by our own assumptions” (p. 38). The facts remain the challenges faced by patients, the changes associated with illness as disease, sickness and experience and how nurses can help, in their research focus, which the present study has shown.

Complex tasks often require a heterogeneous knowledge base. They require that a professional practitioner in the actual action situation is able to coordinate and merge various forms of disciplinary and practice‐based knowledge. Professional occupation can therefore not be reduced to a question of the relationship between “theory” and “practice”. It is actually not just about applying theoretical knowledge in practical situations. Describing theories used exclusively in nursing research as nursing theory (Meleis, 2012 ) is not seen as a fruitful way to discuss the theoretical challenges in nursing science. The use of different theoretical approaches in nursing research, as the results of this study show, reveals the different theoretical approaches' importance for the development of advanced nursing knowledge as a support for nursing practice. Nursing science originates in a heterogeneous and fragmented body of knowledge, which this study of PhD theses also reflects. According to Risjord ( 2010 ), nursing knowledge will be strengthened when theory is shared with other disciplines, not weakened.

Nursing research is an amalgamation, inspired by a broad range of theories and methodological approaches. This status is what brought nursing to its present academic level: scientific nursing journals, PhD programmes, professors, nursing institutes and faculties. Risjord ( 2011 ) asks “does nursing science need a distinct kind of theory?” (p. 489). It is interesting that nursing research does not seem to rest on one distinct kind of theory. Most of the theses in this study do not refer to or use nursing theory as a theoretical approach. There is quite simply a gradual reduction in direct reference to nursing theory over time.

Professions, such as nursing, are characterized by heterogeneous and fragmented bodies of knowledge and there is no one theory used, but nursing is rather enacted in the application of multiple theories (Grimen, 2008 ). In general, PhD theses represent the scientification of nursing, understood as a scientific contribution to the improvement of nursing knowledge and nursing practice, through an increase in research‐based knowledge. A seemingly natural extension is that increased research activities, given their importance to nursing practice, will boost the nursing reputation and its position in the health research landscape.

6. CONCLUSION

This study concludes that most PhD theses have aims and research questions connected to nursing contexts and practices and are thus nursing related. All the theses studied can be seen as appropriate contributions to improving a general body of knowledge, driven by nursing research.

A relevant question generating from this study is whether the failure to relate research to nursing theory has meant that the traditional nursing theories are obsolete and outdated? It might look that way. However, we need more research to investigate this very question, both empirically and theoretically. The present study investigated all PhD theses on nursing‐related issues, all most likely increasing the knowledge base in nursing practice. Nursing research and nursing science offer a different perspective on health through examining nursing phenomena and posing research questions from a nursing perspective. The PhD theses examined in this study applied a wide variety of theories from other disciplines. The core principle of developing the theoretical basis for nursing and nursing knowledge remains, however, to advance and support nursing practice.

7. LIMITATIONS

The strength of this study is the access to all of the PhD theses from the University of Edinburgh and the Centre of Research Collection. The systematic descriptions in Table ​ Table1 1 strengthen the transparency of this study. The weakness of this study lies, however, also in this interpretive table, as some of the PhD theses combined different fields of study, such as Robertson ( 2007 ), who used both sociological and psychological theories. I chose to include Robertson's study in the field of sociology based on its thematic issues, a subjective decision that is open for discussion.

The selection of only one university for examination may also be considered a weakness. However, the University of Edinburgh has contributed pioneering work in building nursing science in Europe. It therefore represents an important and interesting institution for the investigation of nursing studies. Further research is, however, required to present a more complete picture of nursing researchers' use of theoretical approaches in their research.

CONFLICT OF INTEREST

There were no conflicts of interest associated with this study.

Supporting information

Acknowledgement.

I want to thank Professor Tonks Fawcett, University of Edinburgh, and Professor Kristian Larsen, Aalborg University, for their important comments and inspiration.

Jensen KT. Nursing research: A marriage of theoretical influences . Nursing Open . 2019; 6 :1205–1217. 10.1002/nop2.320 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]

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

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Research Training in the Biomedical, Behavioral, and Clinical Research Sciences (2011)

Chapter: 7 nursing research, 7 nursing research.

Research training in nursing prepares investigators to create new scientific knowledge to guide nursing practice, assess the health care environment, improve patient, family, and community outcomes, and influence health policy.

The science of nursing is focused on the development of knowledge to: (1) build the scientific base for clinical practice; (2) prevent disease and disability; (3) manage and eliminate symptoms caused by illness; and (4) enhance end-of-life and palliative care. 1 As described by Donaldson and Crowley, such research is characterized by three themes of inquiry that relate to human well-being: (1) principles and laws that govern life processes and offer maximum optimum function during illness and health; (2) patterns of human behavior in interaction with the environment in critical life situations; and (3) processes by which positive changes in health status are affected. 2 Thus, nursing studies serve to integrate the full range of biobehavioral responses of human beings.

As in many health care disciplines, much of nursing practice is not currently based on high-quality evidence. The major objective of modern nursing science is to develop the knowledge base on which to plan the most effective health care. Such research may range from fundamental basic laboratory research to community-based and translational research to improve care of groups highly susceptible to a range of different diseases.

The prevention of disease or disability is a major focus of nursing research along with a strong focus on health promotion and risk reduction across a wide spectrum of individuals and disease conditions. This approach is well exemplified by the following example of a school-based program adopted by most North Carolina schools. It is a health promotion program in exercise and diet for young children at risk for cardiovascular disease. The research results from this prevention-based program are impressive; the young people’s total cholesterol levels and measurements of body fat were significantly reduced following the education and exercise interventions, and their fitness levels, physical activity, and knowledge about cardiovascular disease risk factors improved. 3

Preventing the complications of chronic disease is also a major area for research in nursing. Some of this work develops ways to help individuals and families cope with long-term chronic disease. For example, a program targeting better self-management of Type 1 diabetes examined the effectiveness of specific coping skills; the results of the study showed both improved metabolic control and higher quality of life in adolescents who used the skills. The program has been adopted in more than 100 clinical programs. 4

Nursing care and research have traditionally addressed strategies for the management of symptoms associated with illnesses or their treatment. For example, in a study that focused on developing a longer-acting pain medication, investigators found that gender is a major factor in whether drugs are effective. Women responded well to seldom-used kappa-opioid drugs, but men had little benefit from those drugs. 5

Influencing, redesigning, and shaping the environment for patients, families, and communities is another major area of study in nursing. Many studies have shown the influence of nursing surveillance and presence on positive patient outcomes. A shortage of nurses, a critical factor in the current health care environment, has been demonstrated to increase patient mortality and morbidity. Other studies show the benefit of home visits by advanced practice nurses in improving the health and quality of life of elders being discharged from the hospital. 6

Research in nursing is often referred to as “nursing science” or “nursing research,” which has led some to confuse it with the nursing profession. This terminology exists at the National

Institutes of Health (NIH) in the name of the National Institute for Nursing Research (NINR); however, the funding from NINR supports scientific research relevant to the science of nursing, and the investigators may be nurses or non-nurses.

The conditions needed for training in nursing research described in the 2005 NRC report hold true today:

Research training for nurses, as for other biomedical and behavioral researchers, needs to occur within strong research-intensive environments that typically will be in universities and schools of nursing. Important characteristics of these training environments include an interdisciplinary cadre of researchers and a strong group of nursing research colleagues who are senior scientists with consistent extramural review and funding of their investigative programs and obvious productivity in terms of publications and presentations. These elements are essential to the environment required for excellence in research training. (NRC, 2005, p. 73)

To encourage the development of research training in nursing, NINR devotes at least 7 percent of its funds to research training—about double what is found in other Institutes. The committee supports this priority as critical to the future of nursing research.

CHANGING THE CAREER TRAJECTORY FOR NURSE-SCIENTISTS

Changing the career trajectory for nurse-researchers involves three major efforts: (1) enhancing sustained productivity for nurse-scientists to promote an earlier and more rapid progression through the educational programs to doctoral and postdoctoral study; (2) responding to the shortage of nurse-investigators by increasing the number of individuals seeking doctoral education and faculty roles; and (3) emphasizing research-intensive training environments, including increased postdoctoral and career development opportunities.

ENHANCING SUSTAINED PRODUCTITY FOR NURSE-SCIENTISTS

Nurse-scientists play a critical role in the conduct of research and the generation of new knowledge that can serve as the evidence base for practice and the improvement of patient health outcomes. However, nurses enter Ph.D. programs mostly at a substantially later age than in any other biomedical or clinical science, limiting their years of potential scientific productivity. Faculty in many scientific fields starting their careers in their mid-30s may well have a research career of 30 to 40 years (to age 65-75). The average age of doctorally prepared nurse faculty, however, is 55.6 years [AACN data online] 7 , and the average age of retirement is 62.5 years—clearly limiting the productive years for nursing science and health practice in general. Nurse-investigators tend to have a shorter career span, thus limiting the development of nursing science and its application to nursing practice. Clearly a major driver in the short career span is the late stage at which nurse-scientists receive the Ph.D.

The fact that Ph.D. training for nurse-scientists occurs at such an advanced age (current assistant professors in nursing schools received the Ph.D. when they were 42.9 years) is a direct consequence of the traditional model for nurse-scientist training. The current path from the R.N. to the Ph.D. can be remarkably tortuous. After receiving the B.S.N. degree, nurses are encouraged to work in clinical practice, and indeed a subsequent application for admission to an M.S.N. program often requires several years of work experience. Again, after receipt of the M.S.N. degree, a period of additional clinical exposure is customary before entering a Ph.D. program. In addition, 65 percent of such doctoral students are unfunded (or only partly funded), and it is likely that these students work to cover their expenses. As a result, graduate students in nursing spend 8.3 to 15.9 years earning their doctorate after entering a master’s program, 8 and the committee sees no sign that this trend is being reversed.

One way to help address this problem is to reduce the number of interruptions that nursing doctoral students experience. Once students enter undergraduate programs in nursing, students with interests in science should be identified early and encouraged to consider doctoral education and research. They should also have a chance to interact with nurse-scientists early in their undergraduate years. Several such programs have already been created.

In order to move undergraduates directly into doctoral education, nursing programs need to dispel the myth that students need clinical practice before entering graduate school. In fact, students interested in a research career may be best served by not earning a master’s degree first, as is the case in many scientific fields. In addition, certification requirements for advanced practice may add two years to master’s programs, further postponing entry into doctoral education. Funding that supports concurrent clinical and research training (similar to the MSTP) may facilitate movement into and through doctoral education.

The origins of the current educational structure in nursing and the hurdles it creates are summarized in the 2005 report:

Nursing developed both its Ph.D. and its D.N.Sc. 9 programs to build on the master’s degree in nursing as well as to accommodate breaks between degrees for clinical practice. Early

reliance on the master’s degree is understandable in that it was nursing’s highest degree for many years before the establishment of a significant number of research doctoral programs. As doctoral programs were developed, they built on the master’s content, which at the time was predominantly research and theory focused. Over time the master’s programs have changed to become primarily preparation for advanced clinical practice, yet nursing continues to require the master’s degree for entry into doctoral study in most programs. Currently, very few doctoral programs in nursing admit baccalaureate graduates directly into the program, and for those that do, the master’s degree is usually required as a progression step. This requirement for entry into the Ph.D. program makes the group of advanced nurse-practitioners, rather than baccalaureate students, the major pool from which applicants are recruited into research. This is problematic in that this practitioner pool has the same demographic characteristics as the profession and thus is older in average age and more limited in diversity compared to applicants for science Ph.D. programs in general. Incorporation of the clinical/professional content from the master’s degree as foundational to the Ph.D. in nursing also encourages faculty to recruit and teach only nurses. Currently there are only a few doctorate programs in nursing that admit non-nurses.

Even though there are other fields that require a master’s degree as a requirement for earning the professional research doctorate, such as the M.P.H. for the Dr.P.H., the master’s degree has a completely different meaning relative to the science Ph.D. degree. The master’s degree is usually awarded as a “consolation prize” for students who are unable to complete the requirements for the science Ph.D. By making the master’s degree a requirement for its Ph.D. program, nursing has created confusion as to the meaning of the degree outside the nursing profession. (NRC, 2005, p. 74)

Nursing is both a practice profession that requires practitioners with clinical expertise and an academic discipline and science that requires independent researchers and scientists to build the body of knowledge. Each has a separate set of educational needs and goals. To improve the productivity and research focus of the Ph.D. in nursing, doctoral programs need to be structured to admit students directly from baccalaureate programs, to admit non-nurses, to decrease the number of years from high school to Ph.D. graduation, and to expand the interdisciplinary scope of their programs and research topics.

As outlined above, there is no consistent research career trajectory evident among practicing scientists in nursing today. The common thread is that they entered their doctoral programs later than most other scientists, and the majority have not benefited from postdoctoral education. As such, they bring with them rich clinical experiences that may help shape the focus of their inquiry. In addition, when nurses complete their doctoral education, most move directly into an academic career. There they frequently encounter a setting in which the demands for teaching and lack of pervasive research programs, socialization, and further mentoring make continuing progress as a scientist difficult.

RESPONDING TO THE SHORTAGE OF NURSE-INVESTIGATORS

It has been well established that not only is there both a current shortage but also there is a projected continued shortage of nursing faculty, especially those who are scientists and researchers. At this time, approximately 50 percent of the faculty teaching in nursing baccalaureate programs are doctorally prepared [AACN]. 10 This represents a marked increase from the 15 percent in the late 1970s. This 50 percent level was reached by 1999, but it has not increased since then despite a large increase in the number of doctoral degree programs available to nurses during the same time period. This is a reflection of two factors: (1) other than a modest increase in the number of doctoral degrees earned in 2007 and 2008, the yield of Ph.D. degrees has been largely static (even though the number of programs has increased, as shown in Table 7-1 ), and (2) the older age of graduates. The combination of these two factors suggests that an increasing number of doctorally prepared faculty will retire in the next few years, but there will not be an adequate number of new Ph.D.s to replace them. Nursing programs will be left with too few faculty members to conduct research and educate the next generation of scientists.

A 2009-2010 Special Survey of Vacant Faculty Positions conducted by the American Association of Colleges of Nursing (AACN) indicated that 90.6 percent of the vacancies require an earned doctoral degree [AACN], 11 yet graduation rates from nursing doctoral programs are relatively flat. If there is any hope of filling a significant number of these faculty positions, both the NIH and nursing schools will need to provide incentives to increase the number of nurses who select a research career, and to do so early in their professional development.

CHARACTERISTICS OF NURSING PROGRAM FROM THE RESEARCH-DOCTORATE STUDY

The data in this section come from the NRC Research-Doctorate Study. The data from the study are valuable, because they provide unique information on program, faculty, and student characteristics. Although not time series data, they do provide a snapshot of nursing programs in 2006. Data were collected from 55 of the 85 programs that awarded Ph.D.s in nursing in 2006. Not all Ph.D.-granting institutions agreed to participate in the study, and only programs that averaged one Ph.D. or more per year submitted data. But these 55 programs educate a large proportion of the Ph.D.s in nursing, and their characteristics are generally representative of nursing programs. The data support the

TABLE 7-1 Nursing Doctorates from U.S. Institutions, 1997-2008

finding elsewhere in this chapter concerning the aging of the faculty, the late age at which students receive a doctorate, and the need for additional training support at the doctoral and postdoctoral levels.

The Faculty

There are 1,471 faculty members in these 55 programs and the average size is 26, varying from a minimum of 8 to a maximum of 110. As is true of the profession in general, the faculty members are primarily female (7 percent male), and 14 of the programs have an all female faculty. Only 10 of the faculty with known citizenship were temporary residents. Most of the nursing faculty (88 percent) had an appointment in the nursing department or school, and only 12 percent were neither tenured nor on the tenure track (see Table 7-2 ). The percentage of assistant professors in other sciences ranges from 15 percent to 21 percent, and in nursing 31 percent of the tenure-track faculty are in that rank. This would suggest that either assistant professors in nursing are staying longer in this rank than in other sciences, or they tend to move out of the assistant professor faculty role into clinical positions at a significant rate, to be replaced by new Ph.D.s. A final possibility is that in 2006 the number of assistant professors of nursing increased rapidly by absorbing many of the newly minted Ph.D.s, although viewed historically this seems unlikely.

The average age of the faculty is 54, and 26 percent of the faculty are 60 years old or older. The age at time of degree for new assistant professors is 42.9 years, and for associate professors it is 39.9 years. The professors who received their degree even earlier were on average 35.9 years old when they completed their doctorate. Again this is consistent with the trend noted earlier in this chapter. Of the faculty who provided information about postdoctoral training, 30.1 percent had at least one postdoctoral appointment and 7.4 percent had more than one appointment. As would be expected, faculty members with more recent doctorates were more likely to have

TABLE 7-2 Tenure and Rank Status of Nursing Faculty

postdoctoral training with 31 percent receiving their degree in the period 1997 to 2006. This also is likely contributing to the increasing age of assistant professors on nursing faculties.

A majority, 64 percent or 801 of the nursing faculty, have extramural funding, and these grants support 810 students either totally or partially. The average number of publications per faculty per year during the period 2000 to 2006 was about 0.5 in nursing, which is much lower than seen in other fields in the biomedical sciences, where the range is between 1.3 and 1.9.

The Trainees

In the fall of 2005, 2,176 students were enrolled in 55 doctoral programs, and the first-year enrollment was 442 students. As is the case with the profession, 94 percent of the doctoral students were female. In addition 12 percent were underrepresented minorities, and 10 percent were temporary residents. The enrollment status of the students is very different from other fields, with 1,294 (59 percent) full-time and 882 part-time. For full time-students the time to degree was 3.8 years. One of the 55 programs had an M.D./Ph.D. program with an enrollment of 3 students.

The level of full financial support for nursing students in 2006 was only 35 percent, and 27 percent of the students received no support. Presumably many of these graduate students worked to offset all, or part, of the cost of their education. A total of 37 of the 55 programs had externally funded training grants, and 17 percent of the students were supported on these grants. A small percentage, 9 percent and 7 percent, respectively, were supported on research assistant-ships and teaching assistantships. In addition to predoctoral training activities, 24 of the 55 nursing programs in the fall of 2005 supported 99 postdoctoral trainees.

Emphasizing Research Intensive Training Environments

Typically funded by the NINR, research training for nurse scientists has uses a variety of National Research Service Awards (NRSAs) and Career Development K awards. Individual predoctoral awards (F31) have been slowly increasing, but there are very limited numbers of individual postdoctoral awards (F32). In contrast, the institutional NRSAs (T32) initially grew considerably over time, but since 2003 there have been no steady increases in the number of slots supported (see Figure 7-1 ). There were 245 trainees supported in 2009 (156 predoctorates and 62 postdoctorates), which represents a decline from 2003.

The institutional and individual research training awards under the NRSA program both serve an extremely valuable purpose in nursing research and should continue to be funded. Individual awards build scientific capability, and T32 institutional awards build a cadre of strong senior researchers. The individual predoctoral awards (F31), if allocated for up to 5 years per award, will support full-time, consistent progression for research training.

FIGURE 7-1 Training positions at the postdoctoral and predoctoral levels.

SOURCE: National Institutes of Health.

As outlined in the 2005 report, several changes to the T32 awards would strengthen them:

T32 awards should be placed only in research-intensive universities with strong interdisciplinary opportunities and research funding, and interdisciplinary activities should be a critical aspect of the initial NRSA application and annual reports.

T32 awards should be allocated only to schools with research-intensive environments including a cadre of senior investigators with extramurally funded research and research infrastructures that support research and research training.

The application process for T32 positions as predoctoral trainees or postdoctoral fellows should be more formalized, with specific proposals submitted in relationship to their research and the match with faculty at the institution made explicit.

Criteria for selection of T32 fellows and trainees should be based on a consistent, full-time plan for research training and long-term potential for contribution to science and nursing.

The monitoring and tracking of trainees and fellows should be formalized with changes in research plans or mentor(s) filed as part of the annual report.

A growing number of nurse-investigators are receiving K awards from NINR through the following mechanisms: K01 Mentored Research Scientist Development Award; Minority K01, Mentored Research Scientist Development Award for Minority Investigators; K22, Career Transition Award and K23, Mentored Patient Oriented-Research Career Development Award; and K24, Mid-Career Investigator Award in Patient Oriented Research. In addition, other NIH institutes and centers support nursing research through the K mechanisms, because elements of nursing research are intrinsic to other fields.

Recently, NINR staff have been advising potential K awardees to apply instead for small R-series awards. To compete in an era of limited research dollars, the availability of these early and mid-career awards needs to be increased and encouraged. There is little systematic information on the outcomes of these awards, e.g., successful research grants and publications by awardees. Based on the success in other fields, however, and the need for strongly research-prepared faculty to concentrate on the science necessary for practice, the committee believes that expanding such awards would benefit the field.

RECOMMENDATIONS

In addition to the recommendations which cross disciplines, the committee recognizes that the graying of the professoriate and need for nurse-scientists is particularly acute in nursing.

Recommendation 7–1: T32 programs in nursing should emphasize the rapid progression into research careers. Criteria should include identification of predoctoral trainees who are within 8 years of high school graduation, streamlining the master’s degree in passing to the Ph.D., and postdoctoral training within 2 years of completion of the Ph.D.

Recommendation 7–2: T32 awards should focus on pro grams where students and fellows have the opportunity to work with senior scientists, and applications to slots should require applicants a specific research and mentor ing plan.

Recommendation 7–3: NINR should increase the num ber of mid- and senior career awards to enhance the number of scientists capable of sustaining programs of research and should increase the length of support for K awards to 5 years to be consistent with other institutes and centers.

Recommendation 7–4: Given the size of the NINR budget and the acute need for nursing faculty, the NIH should consider an infusion of support to allow NINR to more closely meet the needs.

Recommendation 7–5: To enhance the rapid progres sion for clinical scientist training, NINR should develop and pilot-test an MSTP-like program to support clinical training at the M.S.N. or D.N.P. level for those wishing to be clinician-scientists.

Comprehensive research and a highly-trained workforce are essential for the improvement of health and health care both nationally and internationally. During the past 40 years the National Research Services Award (NRSA) Program has played a large role in training the workforce responsible for dramatic advances in the understanding of various diseases and new insights that have led to more effective and targeted therapies. In spite of this program, the difficulty obtaining jobs after the postdoc period has discouraged many domestic students from pursuing graduate postdoc training. In the United States, more than 50 percent of the postdoc workforce is made up of individuals who obtained their Ph.D.s from other countries. Indeed, one can make a strong argument that the influx of highly trained and creative foreigners has contributed greatly to U.S. science over the past 70 years.

Research Training in the Biomedical, Behavioral, and Clinical Research Sciences discusses a number of important issues, including: the job prospects for postdocs completing their training; questions about the continued supply of international postdocs in an increasingly competitive world; the need for equal, excellent training for all graduate students who receive NIH funding; and the need to increase the diversity of trainees. The book recommends improvements in minority recruiting, more rigorous and extensive training in the responsible conduct of research and ethics, increased emphasis on career development, more attention to outcomes, and the requirement for incorporating more quantitative thinking in the biomedical curriculum.

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Home » Degrees » RN to BSN » Why Do Nurses Need Research?

Why Do Nurses Need Research?

• Published On: September 12, 2017

Research helps nurses determine effective best practices and improve patient care. Nurses in an online RN to BSN program learn to retrieve, read, critique and apply nursing research. Because new information is always coming to light, it is crucial that BSN-prepared nurses know the importance of research. The findings from peer-reviewed studies can correct old misunderstandings, pave the way for new treatment protocols and create new methodology — all of which improve patient outcomes.

Research also helps nursing respond to changes in the healthcare environment, patient populations and government regulations. As researchers make discoveries, the practice of nursing continues to change. The information students learn can become quickly outdated, so being able to keep up with new developments in nursing helps graduates in their careers.

Every nurse can benefit from knowing why nursing research is important, how research is conducted and how research informs patient care. Bachelor of Science in Nursing (BSN) programs teach nurses to appreciate and use research in their everyday careers, compare findings and read published research.

Information Literacy and Nursing

Information literacy is not the same as the ability to read, use the computer effectively or use search engines. This skill goes beyond comprehending the basics of finding resources. Understanding information transforms it from knowledge you have into knowledge you can actually use. As a nurse, you need knowledge that makes a difference in your practice and helps you stay current in your field.

Nurses learning to effectively process and use information from published research can improve their information literacy. Simply reading study results is of little help if you do not comprehend what you read. Nursing schools teach nurses how to interpret data, compare different studies, process information, critique results and think critically. Information literacy empowers nurses to use research in their careers so they can make meaningful clinical decisions.

Teaching Information Literacy

BSN programs teach nurses to refer to research in response to problems and questions. To this end, many nursing schools collaborate with research librarians to help students become more competent at using information. Problem-based learning allows students to use available information resources when they experience clinical challenges. Practicing these skills in an academic environment prepares nurses to use information resources in their own clinical practice.

Evidence-Based Practice

Evidence-based practice requires using research outcomes to drive clinical decisions and care. Nurses must base their work on the results of research. Peer-reviewed, published data that is accepted by the nursing profession as a whole provides guidance and establishes best practices in the field. Following the evidence, wherever it leads, is key to evidence-based practice. Results must be free of bias, verifiable and reproducible under the same research conditions. The standards for good research are high because published research results are likely to substantially influence the practice of nursing.

When you evaluate published research, consider these four important areas:

• Validity : Is the study legitimate, sound and accurate?
• Reliability : Is the measurement’s result consistent?
• Relevance : Is there a logical connection between two occurrences, concepts or tasks?
• Outcome : What conclusions did the researchers reach?

Not every study may be meaningful for your patient, question, topic or concern. You need to carefully evaluate every research paper you consider — look for weaknesses, inconsistencies, biases and other problems. Evidence-based practice requires you to become proficient at performing these evaluations and reaching your own conclusions about the information you use.

Types of Research

Research used in evidence-based practice can be quantitative, qualitative or both. From there, these two types can be divided into multiple categories. Understanding how nursing research can be categorized can help you understand and interpret research results.

• Quantitative research : Numbers, percentages and variables are used to communicate results.
• Qualitative research : Findings take the form of thoughts, perceptions and experiences.

Three Types of Quantitative Research:

• Descriptive research expresses the characteristics or traits of a specific group, situation or individual. This type of research looks for new conclusions and connections that can be made based on observed traits.
• Quasi-experimental research looks at cause-and-effect relationships between different variables.
• Correlational research considers the relationships among variables, but does not draw a cause-and-effect relationship.

Five Types of Qualitative Research:

• Ethnography observes or provides analysis about cultural and social customs and practices and how particular cultures understand disease and health.
• Grounded theory is all about building theories in response to questions, problems and observations.
• Symbolic interactionism studies personal interaction, communication patterns, interpretations and reactions. These factors can influence how people change their health practices over time.
• Historical research systematically reviews a topic, culture or group and the subject’s history.
• Phenomenology uses personal experiences and insights to inform the author’s conclusion.

No particular type of research is necessarily better than the others, but each type has certain uses and limitations. It is important for nurses to know the different types of research and how to use them.

Nurses need research because it helps them advance their field, stay updated and offer better patient care. Information literacy skills can help nurses use information more effectively to develop their own conclusions. Evidence-based practice is important for nurses. Nurses need to understand, evaluate and use research in their careers. Nursing schools teach these skills to help nurses advance in their careers.

Learn more about Northeastern State’s online RN to BSN program .

The Online Journal of Issues in Nursing: Information Resources: Information Literacy: The Benefits of Partnership

Wolters Kluwer Health: Evidence-Based Practice Network

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• Research article
• Open access
• Published: 14 June 2021

Nurses in the lead: a qualitative study on the development of distinct nursing roles in daily nursing practice

• Jannine van Schothorst–van Roekel 1 ,
• Anne Marie J.W.M. Weggelaar-Jansen 1 ,
• Carina C.G.J.M. Hilders 1 ,
• Antoinette A. De Bont 1 &
• Iris Wallenburg 1  

BMC Nursing volume  20 , Article number:  97 ( 2021 ) Cite this article

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Transitions in healthcare delivery, such as the rapidly growing numbers of older people and increasing social and healthcare needs, combined with nursing shortages has sparked renewed interest in differentiations in nursing staff and skill mix. Policy attempts to implement new competency frameworks and job profiles often fails for not serving existing nursing practices. This study is aimed to understand how licensed vocational nurses (VNs) and nurses with a Bachelor of Science degree (BNs) shape distinct nursing roles in daily practice.

A qualitative study was conducted in four wards (neurology, oncology, pneumatology and surgery) of a Dutch teaching hospital. Various ethnographic methods were used: shadowing nurses in daily practice (65h), observations and participation in relevant meetings (n=56), informal conversations (up to 15 h), 22 semi-structured interviews and member-checking with four focus groups (19 nurses in total). Data was analyzed using thematic analysis.

Hospital nurses developed new role distinctions in a series of small-change experiments, based on action and appraisal. Our findings show that: (1) this developmental approach incorporated the nurses’ invisible work; (2) nurses’ roles evolved through the accumulation of small changes that included embedding the new routines in organizational structures; (3) the experimental approach supported the professionalization of nurses, enabling them to translate national legislation into hospital policies and supporting the nurses’ (bottom-up) evolution of practices. The new roles required the special knowledge and skills of Bachelor-trained nurses to support healthcare quality improvement and connect the patients’ needs to organizational capacity.

Conclusions

Conducting small-change experiments, anchored by action and appraisal rather than by design , clarified the distinctions between vocational and Bachelor-trained nurses. The process stimulated personal leadership and boosted the responsibility nurses feel for their own development and the nursing profession in general. This study indicates that experimental nursing role development provides opportunities for nursing professionalization and gives nurses, managers and policymakers the opportunity of a ‘two-way-window’ in nursing role development, aligning policy initiatives with daily nursing practices.

Peer Review reports

The aging population and mounting social and healthcare needs are challenging both healthcare delivery and the financial sustainability of healthcare systems [ 1 , 2 ]. Nurses play an important role in facing these contemporary challenges [ 3 , 4 ]. However, nursing shortages increase the workload which, in turn, boosts resignation numbers of nurses [ 5 , 6 ]. Research shows that nurses resign because they feel undervalued and have insufficient control over their professional practice and organization [ 7 , 8 ]. This issue has sparked renewed interest in nursing role development [ 9 , 10 , 11 ]. A role can be defined by the activities assumed by one person, based on knowledge, modulated by professional norms, a legislative framework, the scope of practice and a social system [ 12 , 9 ].

New nursing roles usually arise through task specialization [ 13 , 14 ] and the development of advanced nursing roles [ 15 , 16 ]. Increasing attention is drawn to role distinction within nursing teams by differentiating the staff and skill mix to meet the challenges of nursing shortages, quality of care and low job satisfaction [ 17 , 18 ]. The staff and skill mix include the roles of enrolled nurses, registered nurses, and nurse assistants [ 19 , 20 ]. Studies on differentiation in staff and skill mix reveal that several countries struggle with the composition of nursing teams [ 21 , 22 , 23 ].

Role distinctions between licensed vocational-trained nurses (VNs) and Bachelor of Science-trained nurses (BNs) has been heavily debated since the introduction of the higher nurse education in the early 1970s, not only in the Netherlands [ 24 , 25 ] but also in Australia [ 26 , 27 ], Singapore [ 20 ] and the United States of America [ 28 , 29 ]. Current debates have focused on the difficulty of designing distinct nursing roles. For example, Gardner et al., revealed that registered nursing roles are not well defined and that job profiles focus on direct patient care [ 30 ]. Even when distinct nursing roles are described, there are no proper guidelines on how these roles should be differentiated and integrated into daily practice. Although the value of differentiating nursing roles has been recognized, it is still not clear how this should be done or how new nursing roles should be embedded in daily nursing practice. Furthermore, the consequences of these roles on nursing work has been insufficiently investigated [ 31 ].

This study reports on a study of nursing teams developing new roles in daily nursing hospital practice. In 2010, the Dutch Ministry of Health announced a law amendment (the Individual Health Care Professions Act) to formalize the distinction between VNs and BNs. The law amendment made a distinction in responsibilities regarding complexity of care, coordination of care, and quality improvement. Professional roles are usually developed top-down at policy level, through competency frameworks and job profiles that are subsequently implemented in nursing practice. In the Dutch case, a national expert committee made two distinct job profiles [ 32 ]. Instead of prescribing role implementation, however, healthcare organizations were granted the opportunity to develop these new nursing roles in practice, aiming for a more practice-based approach to reforming the nursing workforce. This study investigates a Dutch teaching hospital that used an experimental development process in which the nurses developed role distinctions by ‘doing and appraising’. This iterative process evolved in small changes [ 33 , 34 , 35 , 36 ], based on nurses’ thorough knowledge of professional practices [ 37 ] and leadership role [ 38 , 39 , 40 ].

According to Abbott, the constitution of a new role is a competitive action, as it always leads to negotiation of new openings for one profession and/or degradation of adjacent professions [ 41 ]. Additionally, role differentiation requires negotiation between different professionals, which always takes place in the background of historical professionalization processes and vested interests resulting in power-related issues [ 42 , 43 , 44 ]. Recent studies have described the differentiation of nursing roles to other professionals, such as nurse practitioners and nurse assistants, but have focused on evaluating shifts in nursing tasks and roles [ 31 ]. Limited research has been conducted on differentiating between the different roles of registered nurses and the involvement of nurses themselves in developing new nursing roles. An ethnographic study was conducted to shed light on the nurses’ work of seeking openings and negotiating roles and responsibilities and the consequences of role distinctions, against a background of historically shaped relationships and patterns.

The study aimed to understand the formulation of nursing role distinctions between different educational levels in a development process involving experimental action (doing) and appraisal.

We conducted an ethnographic case study. This design was commonly used in nursing studies in researching changing professional practices [ 45 , 46 ]. The researchers gained detailed insights into the nurses’ actions and into the finetuning of their new roles in daily practice, including the meanings, beliefs and values nurses give to their roles [ 47 , 48 ]. This study complied with the consolidated criteria for reporting qualitative research (COREQ) checklist.

Setting and participants

Our study took place in a purposefully selected Dutch teaching hospital (481 beds, 2,600 employees including 800 nurses). Historically, nurses in Dutch hospitals have vocational training. The introduction of higher nursing education in 1972 prompted debates about distinguishing between vocational-trained nurses (VNs) and bachelor-trained nurses (BNs). For a long time, VNs resisted a role distinction, arguing that their work experience rendered them equally capable to take care of patients and deal with complex needs. As a result, VNs and BNs carry out the same duties and bear equal responsibility. To experiment with role distinctions in daily practice, the hospital management and project team selected a convenience but representative sample of wards. Two general (neurology and surgery) and two specific care (oncology and pneumatology) wards were selected as they represent the different compositions of nursing educational levels (VN, BN and additional specialized training). The demographic profile for the nursing teams is shown in Table  1 . The project team, comprising nursing policy staff, coaches and HR staff ( N  = 7), supported the four (nursing) teams of the wards in their experimental development process (131 nurses; 32 % BNs and 68 % VNs, including seven senior nurses with an organizational role). We also studied the interactions between nurses and team managers ( N  = 4), and the CEO ( N  = 1) in the meetings.

Data collection

Data was collected between July 2017 and January 2019. A broad selection of respondents was made based on the different roles they performed. Respondents were personally approached by the first author, after close consultation with the team managers. Four qualitative research methods were used iteratively combining collection and analysis, as is common in ethnographic studies [ 45 ] (see Table  2 ).

Shadowing nurses (i.e. observations and questioning nurses about their work) on shift (65 h in total) was conducted to observe behavior in detail in the nurses’ organizational and social setting [ 49 , 50 ], both in existing practices and in the messy fragmented process of developing distinct nursing roles. The notes taken during shadowing were worked up in thick descriptions [ 46 ].

Observation and participation in four types of meetings. The first and second authors attended: (1) kick-off meetings for the nursing teams ( n  = 2); (2) bi-monthly meetings ( n  = 10) between BNs and the project team to share experiences and reflect on the challenges, successes and failures; and (3) project group meetings at which the nursing role developmental processes was discussed ( n  = 20). Additionally, the first author observed nurses in ward meetings discussing the nursing role distinctions in daily practice ( n  = 15). Minutes and detailed notes also produced thick descriptions [ 51 ]. This fieldwork provided a clear understanding of the experimental development process and how the respondents made sense of the challenges/problems, the chosen solutions and the changes to their work routines and organizational structures. During the fieldwork, informal conversations took place with nurses, nursing managers, project group members and the CEO (app. 15 h), which enabled us to reflect on the daily experiences and thus gain in-depth insights into practices and their meanings. The notes taken during the conversations were also written up in the thick description reports, shortly after, to ensure data validity [ 52 ]. These were completed with organizational documents, such as policy documents, activity plans, communication bulletins, formal minutes and in-house presentations.

Semi-structured interviews lasting 60–90 min were held by the first author with 22 respondents: the CEO ( n  = 1), middle managers ( n  = 4), VNs ( n  = 6), BNs ( n  = 9, including four senior nurses), paramedics ( n  = 2) using a predefined topic list based on the shadowing, observations and informal conversations findings. In the interviews, questions were asked about task distinctions, different stakeholder roles (i.e., nurses, managers, project group), experimental approach, and added value of the different roles and how they influence other roles. General open questions were asked, including: “How do you distinguish between tasks in daily practice?”. As the conversation proceeded, the researcher asked more specific questions about what role differentiation meant to the respondent and their opinions and feelings. For example: “what does differentiation mean for you as a professional?”, and “what does it mean for you daily work?”, and “what does role distinction mean for collaboration in your team?” The interviews were tape-recorded (with permission), transcribed verbatim and anonymized.

The fieldwork period ended with four focus groups held by the first author on each of the four nursing wards ( N  = 19 nurses in total: nine BNs, eight VNs, and two senior nurses). The groups discussed the findings, such as (nurses’ perceptions on) the emergence of role distinctions, the consequences of these role distinctions for nursing, experimenting as a strategy, the elements of a supportive environment and leadership. Questions were discussed like: “which distinctions are made between VN and BN roles?”, and “what does it mean for VNs, BNs and senior nurses?”. During these meetings, statements were also used to provoke opinions and discussion, e.g., “The role of the manager in developing distinct nursing roles is…”. With permission, all focus groups were audio recorded and the recordings were transcribed verbatim. The focus groups also served for member-checking and enriched data collection, together with the reflection meetings, in which the researchers reflected with the leader and a member of the project group members on program, progress, roles of actors and project outcomes. Finally, the researchers shared a report of the findings with all participants to check the credibility of the analysis.

Data analysis

Data collection and inductive thematic analysis took place iteratively [ 45 , 53 ]. The first author coded the data (i.e. observation reports, interview and focus group transcripts), basing the codes on the research question and theoretical notions on nursing role development and distinctions. In the next step, the research team discussed the codes until consensus was reached. Next, the first author did the thematic coding, based on actions and interactions in the nursing teams, the organizational consequences of their experimental development process, and relevant opinions that steered the development of nurse role distinctions (see Additional file ). Iteratively, the research team developed preliminary findings, which were fed back to the respondents to validate our analysis and deepen our insights [ 54 ]. After the analysis of the additional data gained in these validating discussions, codes were organized and re-organized until we had a coherent view.

Ethnography acknowledges the influence of the researcher, whose own (expert) knowledge, beliefs and values form part of the research process [ 48 ]. The first author was involved in the teams and meetings as an observer-as-participant, to gain in-depth insight, but remained research-oriented [ 55 ]. The focus was on the study of nursing actions, routines and accounts, asking questions to obtain insights into underlying assumptions, which the whole research group discussed to prevent ‘going native’ [ 56 , 57 ]. Rigor was further ensured by triangulating the various data resources (i.e. participants and research methods), purposefully gathered over time to secure consistency of findings and until saturation on a specific topic was reached [ 54 ]. The meetings in which the researchers shared the preliminary findings enabled nurses to make explicit their understanding of what works and why, how they perceived the nursing role distinctions and their views on experimental development processes.

Ethical considerations

All participants received verbal and written information, ensuring that they understood the study goals and role of the researcher [ 48 ]. Participants were informed about their voluntary participation and their right to end their contribution to the study. All gave informed consent. The study was performed in accordance with the Declaration of Helsinki and was approved by the Erasmus Medical Ethical Assessment Committee in Rotterdam (MEC-2019-0215), which also assessed the compliance with GDPR.

Our findings reveal how nurses gradually shaped new nursing role distinctions in an experimental process of action and appraisal and how the new BN nursing roles became embedded in new nursing routines, organizational routines and structures. Three empirical appeared from the systematic coding: (1) distinction based on complexity of care; (2) organizing hospital care; and (3) evidence-based practices (EBP) in quality improvement work.

Distinction based on complexity of care

Initially, nurses distinguished the VN and BN roles based on the complexity of patient care, as stated in national job profiles [ 32 ]. BNs were supposed to take care of clinically complex patients, rather than VNs, although both VNs and BNs had been equally taking care of every patient category. To distinguish between highly and less complex patient care, nurses developed a complexity measurement tool. This tool enabled classification of the predictability of care, patient’s degree of self-reliance, care intensity, technical nursing procedures and involvement of other disciplines. However, in practice, BNs questioned the validity of assessing a patient’s care complexity, because the assessments of different nurses often led to different outcomes. Furthermore, allocating complex patient care to BNs impacted negatively on the nurses’ job satisfaction, organizational routines and ultimately the quality of care. VNs experienced the shift of complex patient care to BNs as a diminution of their professional expertise. They continuously stressed their competencies and questioned the assigned levels of complexity, aiming to prevent losses to their professional tasks:

‘Now we’re only allowed to take care of COPD patients and people with pneumonia, so no more young boys with a pneumothorax drain. Suddenly we are not allowed to do that. (…) So, your [professional] world is getting smaller. We don’t like that at all. So, we said: We used to be competent, so why aren’t we anymore?’ (Interview VN1, in-service trained nurse).

In discussing complexity of care, both VNs and BNs (re)discovered the competencies VNs possess in providing complex daily care. BNs acknowledged the contestability of the distinction between VN and BN roles related to patient care complexity, as the next quote shows:

‘Complexity, they always make such a fuss about it. (…) At a given moment you’re an expert in just one certain area; try then to stand out on your ward. (…) When I go to GE [gastroenterology] I think how complex care is in here! (…) But it’s also the other way around, when I’m the expert and know what to expect after an angioplasty, or a bypass, or a laparoscopic cholecystectomy (…) When I’ve mastered it, then I no longer think it’s complex, because I know what to expect!’ (Interview BN1, 19-07-2017).

This quote illustrates how complexity was shaped through clinical experience. What complex care is , is influenced by the years of doing nursing work and hence is individual and remains invisible. It is not formally valued [ 58 ] because it is not included in the BN-VN competency model. This caused dissatisfaction and feelings of demotion among VNs. The distinction in complexities of care was also problematic for BNs. Following the complexity tool, recently graduated BNs were supposed to look after highly complex patients. However, they often felt insecure and needed the support of more experienced (VN) colleagues – which the VNs perceived as a recognition of their added value and evidence of the failure of the complexity tool to guide division of tasks. Also, mundane issues like holidays, sickness or pregnancy leave further complicated the use of the complexity tool as a way of allocating patients, as it decreased flexibility in taking over and swapping shifts, causing dissatisfaction with the work schedule and leading to problems in the continuity of care during evening, night and weekend shifts. Hence, the complexity tool disturbed the flexibility in organizing the ward and held possible consequences for the quality and safety of care (e.g. inexperienced BNs providing complex care), Ultimately, the complexity tool upset traditional teamwork, in which nurses more implicitly complemented each other’s competencies and ability to ‘get the work done’ [ 59 ]. As a result, role distinction based on ‘quantifiable’ complexity of care was abolished. Attention shifted to the development of an organizational and quality-enhancing role, seeking to highlight the added value of BNs – which we will elaborate on in the next section.

Organizing hospital care

Nurses increasingly fulfill a coordinating role in healthcare, making connections across occupational, departmental and organizational boundaries, and ‘mediating’ individual patient needs, which Allen describes as organizing work [ 49 ]. Attempting to make a valuable distinction between nursing roles, BNs adopted coordinating management tasks at the ward level, taking over this task from senior nurses and team managers. BNs sought to connect the coordinating management tasks with their clinical role and expertise. An example is bed management, which involves comparing a ward’s bed capacity with nursing staff capacity [ 1 , 60 ]. At first, BNs accompanied middle managers to the hospital bed review meeting to discuss and assess patient transfers. On the wards where this coordination task used to be assigned to senior nurses, the process of transferring this task to BNs was complicated. Senior nurses were reluctant to hand over coordinating tasks as this might undermine their position in the near future. Initially, BNs were hesitant to take over this task, but found a strategy to overcome their uncertainty. This is reflected in the next excerpt from fieldnotes:

Senior nurse: ‘First we have to figure out if it will work, don’t we? I mean, all three of us [middle manager, senior nurse, BN] can’t just turn up at the bed review meeting, can we? The BN has to know what to do first, otherwise she won’t be able to coordinate properly. We can’t just do it.’ BN: ‘I think we should keep things small, just start doing it, step by step. (…) If we don’t try it out, we don’t know if it works.’ (Field notes, 24-05-2018).

This excerpt shows that nurses gradually developed new roles as a series of matching tasks. Trying out and evaluating each step of development in the process overcame the uncertainty and discomfort all parties held [ 61 ]. Moreover, carrying out the new tasks made the role distinctions become apparent. The coordinating role in bed management, for instance, became increasingly embedded in the new BN nursing role. Experimenting with coordination allowed BNs prove their added value [ 62 ] and contributed to overall hospital performance as it combined daily working routines with their ability to manage bed occupancy, patient flow, staffing issues and workload. This was not an easy task. The next quote shows the complexity of creating room for this organizing role:

The BNs decide to let the VNs help coordinate the daily care, as some VNs want to do this task. One BN explains: ‘It’s very hard to say, you’re not allowed.’ The middle manager looks surprised and says that daily coordination is a chance to draw a clear distinction and further shape the role of BNs. The project group leader replies: ‘Being a BN means that you dare to make a difference [in distinctive roles]. We’re all newbies in this field, but we can use our shared knowledge. You can derive support from this task for your new role.’ (Field notes, 09-01-2018).

This excerpt reveals the BNs’ thinking on crafting their organizational role, turning down the VNs wishes to bear equal responsibility for coordinating tasks. Taking up this role touched on nurse identity as BNs had to overcome the delicate issue of equity [ 63 ], which has long been a core element of the Dutch nursing profession. Taking over an organization role caused discomfort among BNs, but at the same time provided legitimation for a role distinction.

Legitimation for this task was also gained from external sources, as the law amendment and the expert committee’s job descriptions both mentioned coordinating tasks. However, taking over coordinating tasks and having an organizing role in hospital care was not done as an ‘implementation’; rather it required a process of actively crafting and carving out this new role. We observed BNs choosing not to disclose that they were experimenting with taking over the coordinating tasks as they anticipated a lack of support from VNs:

BN: ‘We shouldn’t tell the VNs everything. We just need this time to give shape to our new role. And we all know who [of the colleagues] won’t agree with it. In my opinion, we’d be better off hinting at it at lunchtime, for example, to figure out what colleagues think about it. And then go on as usual.’ (Field notes, 12-06-2018).

BNs stayed ‘under the radar’, not talking explicitly about their fragile new role to protect the small coordination tasks they had already gained. By deliberately keeping the evaluation of their new task to themselves, they protected the transition they had set into motion. Thus, nurses collected small changes in their daily routines, developing a new role distinction step by step. Changes to single tasks accumulated in a new role distinction between BNs, VNs and senior nurses, and gave BNs a more hybrid nursing management role.

Evidence-based practices in quality improvement work

Quality improvement appeared to be another key concern in the development of the new BN role. Quality improvement work used to be carried out by groups of senior nurses, middle managers and quality advisory staff. Not involved in daily routines, the working group focused on nursing procedures (e.g. changing infusion system and wound treatment protocols). In taking on this new role BNs tried different ways of incorporating EBP in their routines, an aspect that had long been neglected in the Netherlands. As a first step, BNs rearranged the routines of the working group. For example, a team of BNs conducted a quality improvement investigation of a patient’s formal’s complaint:

Twenty-two patients registered a pain score of seven or higher and were still discharged. The question for BNs was: how and why did this bad care happen? The BNs used electronic patient record to study data on the relations between pain, medication and treatment. Their investigation concluded: nurses do not always follow the protocols for high pain scores. Their improvement plan covered standard medication policy, clinical lessons on pain management and revisions to the patient information folder. One BN said: ‘I really loved investigating this improvement.’ (Field notes, 28-05-2018).

This fieldnote shows the joy quality improvement work can bring. During interviews, nurses said that it had given them a better grip on the outcome of nursing work. BNs felt the need to enhance their quality improvement tasks with their EBP skills, e.g. using clinical reasoning in bedside teaching, formulating and answering research questions in clinical lessons and in multi-disciplinary patient rounds to render nursing work more evidence based. The BNs blended EBP-related education into shift handovers and ward meetings, to show VNs the value of doing EBP [ 64 ]. In doing so, they integrated and fostered an EBP infrastructure of care provision, reflecting a new sense of professionalism and responsibility for quality of care.

However, learning how to blend EPB quality work in daily routines – ‘learning in practice’ –requires attention and steering. Although the BNs had a Bachelor’s degree, they had no experience of a quality-enhancing role in hospital practice [ 65 ]. In our case, the interplay between team members’ previous education and experienced shortcomings in knowledge and skills uncovered the need for further EBP training. This training established the BNs’ role as quality improvers in daily work and at the same time supported the further professionalization of both BNs and VNs. Although introducing the EBP approach was initially restricted to the BNs, it was soon realized that VNs should be involved as well, as nursing is a collaborative endeavor [ 1 ], as one team member (the trainer) put it:

‘I think that collaboration between BNs and VNs would add lots of value, because both add something different to quality work. I’d suggest that BNs could introduce the process-oriented, theoretical scope, while VNs could maybe focus on the patients’ interest.’ (Fieldnote, informal conversation, 11-06-2018).

During reflection sessions on the ward level and in the project team meetings BNs, informed by their previous experience with the complexity tool, revealed that they found it a struggle to do justice to everyone’s competencies. They wanted to use everyone’s expertise to improve the quality of patient care. They were for VNs being involved in the quality work, e.g. in preparing a clinical lesson, conducting small surveys, asking VNs to pose EBP questions and encourage VNs to write down their thoughts on flip over charts as means of engaging all team members.

These findings show that applying EPB in quality improvement is a relational practice driven by mutual recognition of one another’s competencies. This relational practice blended the BNs’ theoretical competence in EBP [ 66 ] with the VNs’ practical approach to the improvement work they did together. As a result, the blend enhanced the quality of daily nursing work and thus improved the quality of patient care and the further professionalization of the whole nursing team.

This study aimed to understand how an experimental approach enables differently educated nurses to develop new, distinct professional roles. Our findings show that roles cannot be distinguished by complexity of care; VNs and BNs are both able to provide care to patients with complex healthcare needs based on their knowledge and experience. However, role distinctions can be made on organizing care and quality improvement. BNs have an important role organizing care, for example arranging the patient flow on and across wards at bed management meetings, while VNs contribute more to organizing at the individual patient level. BNs play a key role in starting and steering quality improvement work, especially blending EBP in with daily nursing tasks, while VNs are involved but not in the lead. Working together on quality improvement boosts nursing professionalization and team development.

Our findings also show that the role development process is greatly supported by a series of small-change experiments, based on action and appraisal. This experimental approach supported role development in three ways. First, it incorporates both formal tasks and the invisible, unconscious elements of nursing work [ 49 ]. Usually, invisible work gets no formal recognition, for example in policy documents [ 55 ], whereas it is crucial in daily routines and organizational structures [ 49 , 60 ]. Second, experimenting triggers an accumulation of small changes [ 33 , 35 ] leading to the embeddedness of role distinctions in new nursing routines, allowing nurses to influence the organization of care. This finding confirms the observations of Reay et al. that nurses can create small changes in daily activities to craft a new nursing role, based on their thorough knowledge of their own practice and that of the other involved professional groups [ 37 ]. Although these changes are accompanied by tension and uncertainty, the process of developing roles generates a certain joy. Third, experimenting stimulated nursing professionalization, enabling the nurses to translate national legislation into hospital policy and supporting the nurses’ own (bottom-up) evolution of practices. Historically, nursing professionalization is strongly influenced by gender and education level [ 43 ] resulting in a subordinate position, power inequity and lack of autonomy [ 44 ]. Giving nurses the lead in developing distinct roles enables them to ‘engage in acts of power’ and obtain more control over their work. Fourth, experimenting contributes to role definition and clarification. In line with Poitras et al. [ 12 ] we showed that identifying and differentiating daily nursing tasks led to the development of two distinct and complementary roles. We have also shown that the knowledge base of roles and tasks includes both previous and additional education, as well as nursing experience.

Our study contributes to the literature on the development of distinct nursing roles [ 9 , 10 , 11 ] by showing that delineating new roles in formal job descriptions is not enough. Evidence shows that this formal distinction led particularly to the non-recognition, non-use and degradation [ 41 ] of VN competencies and discomforted recently graduated BNs. The workplace-based experimental approach in the hospital includes negotiation between professionals, the adoption process of distinct roles and the way nurses handle formal policy boundaries stipulated by legislation, national job profiles, and hospital documents, leading to clear role distinctions. In addition to Hughes [ 42 ] and Abbott [ 67 ] who showed that the delineation of formal work boundaries does not fit the blurred professional practices or individual differences in the profession, we show how the experimental approach leads to the clarification and shape of distinct professional practices.

Thus, an important implication of our study is that the professionals concerned should be given a key role in creating change [ 37 , 39 , 40 ]. Adding to Mannix et al. [ 38 ], our study showed that BNs fulfill a leadership role, which allows them to build on their professional role and identity. Through the experiments, BNs and VNs filled the gap between what they had learned in formal education, and what they do in daily practice [ 64 , 65 ]. Experimenting integrates learning, appraising and doing much like going on ‘a journey with no fixed routes’ [ 34 , 68 ] and no fixed job description, resulting in the enlargement of their roles.

Our study suggests that role development should involve professionalization at different educational levels, highlighting and valuing specific roles rather than distinguishing higher and lower level skills and competencies. Further research is needed to investigate what experimenting can yield for nurses trained at different educational levels in the context of changing healthcare practices, and which interventions (e.g., in process planning, leadership, or ownership) are needed to keep the development of nursing roles moving ahead. Furthermore, more attention should be paid to how role distinction and role differentiation influence nurse capacity, quality of care (e.g., patient-centered care and patient satisfaction), and nurses’ job satisfaction.

Limitations

Our study was conducted on four wards of one teaching hospital in the Netherlands. This might limit the potential of generalizing our findings to other contexts. However, the ethnographic nature of our study gave us unique understanding and in-depth knowledge of nurses’ role development and distinctions, both of which have broader relevance. As always in ethnographic studies, the chances of ‘going native’ were apparent, and we tried to prevent this with ongoing reflection in the research team. Also, the interpretation of research findings within the Dutch context of nurse professionalization contributed to a more in-depth understanding of how nursing roles develop, as well as the importance of involving nurses themselves in the development of these roles to foster and support professional development.

We focused on role distinctions between VNs and BNs and paid less attention to (the collaboration with) other professionals or management. Further research is needed to investigate how nursing role development takes place in a broader professional and managerial constellation and what the consequences are on role development and healthcare delivery.

This paper described how nurses crafted and shaped new roles with an experimental process. It revealed the implications of developing a distinct VN role and the possibility to enhance the BN role in coordination tasks and in steering and supporting EBP quality improvement work. Embedding the new roles in daily practice occurred through an accumulation of small changes. Anchored by action and appraisal rather than by design , the changes fostered by experiments have led to a distinction between BNs and VNs in the Netherlands. Furthermore, experimenting with nursing role development has also fostered the professionalization of nurses, encouraging nurses to translate knowledge into practice, educating the team and stimulating collaborative quality improvement activities.

This paper addressed the enduring challenge of developing distinct nursing roles at both the vocational and Bachelor’s educational level. It shows the importance of experimental nursing role development as it provides opportunities for the professionalization of nurses at different educational levels, valuing specific roles and tasks rather than distinguishing between higher and lower levels of skills and competencies. Besides, nurses, managers and policymakers can embrace the opportunity of a ‘two-way window’ in (nursing) role development, whereby distinct roles are outlined in general at policy levels, and finetuned in daily practice in a process of small experiments to determine the best way to collaborate in diverse contexts.

Availability of data and materials

The data generated and analyzed during the current study is not publicly available to ensure data confidentiality but is available from the corresponding author on reasonable request and with the consent of the research participants.

Abbreviations

Bachelor-trained nurse

Vocational-trained nurse

Evidence-based Practices

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

The Reinier de Graaf hospital in Delft, who was central to this study provided financial support for this research.

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Jannine van Schothorst–van Roekel, Anne Marie J.W.M. Weggelaar-Jansen, Carina C.G.J.M. Hilders, Antoinette A. De Bont & Iris Wallenburg

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A.W. and I.W. developed the study design. J.S. and A.W. were responsible for data collection, enhanced by I.W. for data analysis and drafting the manuscript. C.H. and A.B. critically revised the paper. All authors have read and approved the manuscript.

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van Schothorst–van Roekel, J., Weggelaar-Jansen, A.M.J., Hilders, C.C. et al. Nurses in the lead: a qualitative study on the development of distinct nursing roles in daily nursing practice. BMC Nurs 20 , 97 (2021). https://doi.org/10.1186/s12912-021-00613-3

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If you're a nursing student who dreads writing research papers, this article may help ease your anxiety. We'll cover everything you need to know about writing nursing school research papers and the top topics for nursing research.  

Continue reading to make your paper-writing jitters a thing of the past.

A nursing research paper is a work of academic writing composed by a nurse or nursing student. The paper may present information on a specific topic or answer a question.

During LPN/LVN and RN programs, most papers you write focus on learning to use research databases, evaluate appropriate resources, and format your writing with APA style. You'll then synthesize your research information to answer a question or analyze a topic.

BSN , MSN , Ph.D., and DNP programs also write nursing research papers. Students in these programs may also participate in conducting original research studies.

Writing papers during your academic program improves and develops many skills, including the ability to:

• Select nursing topics for research
• Conduct effective research
• Analyze published academic literature
• Format and cite sources
• Synthesize data
• Organize and articulate findings

About Nursing Research Papers

When do nursing students write research papers.

You may need to write a research paper for any of the nursing courses you take. Research papers help develop critical thinking and communication skills. They allow you to learn how to conduct research and critically review publications.

That said, not every class will require in-depth, 10-20-page papers. The more advanced your degree path, the more you can expect to write and conduct research. If you're in an associate or bachelor's program, you'll probably write a few papers each semester or term.

Do Nursing Students Conduct Original Research?

Most of the time, you won't be designing, conducting, and evaluating new research. Instead, your projects will focus on learning the research process and the scientific method. You'll achieve these objectives by evaluating existing nursing literature and sources and defending a thesis.

However, many nursing faculty members do conduct original research. So, you may get opportunities to participate in, and publish, research articles.

Example Research Project Scenario:

In your maternal child nursing class, the professor assigns the class a research paper regarding developmentally appropriate nursing interventions for the pediatric population. While that may sound specific, you have almost endless opportunities to narrow down the focus of your writing. 

You could choose pain intervention measures in toddlers. Conversely, you can research the effects of prolonged hospitalization on adolescents' social-emotional development.

What Does a Nursing Research Paper Include?

Your professor should provide a thorough guideline of the scope of the paper. In general, an undergraduate nursing research paper will consist of:

Introduction : A brief overview of the research question/thesis statement your paper will discuss. You can include why the topic is relevant.

Body : This section presents your research findings and allows you to synthesize the information and data you collected. You'll have a chance to articulate your evaluation and answer your research question. The length of this section depends on your assignment.

Conclusion : A brief review of the information and analysis you presented throughout the body of the paper. This section is a recap of your paper and another chance to reassert your thesis.

The best advice is to follow your instructor's rubric and guidelines. Remember to ask for help whenever needed, and avoid overcomplicating the assignment!

How to Choose a Nursing Research Topic

The sheer volume of prospective nursing research topics can become overwhelming for students. Additionally, you may get the misconception that all the 'good' research ideas are exhausted. However, a personal approach may help you narrow down a research topic and find a unique angle.

Writing your research paper about a topic you value or connect with makes the task easier. Additionally, you should consider the material's breadth. Topics with plenty of existing literature will make developing a research question and thesis smoother.

Finally, feel free to shift gears if necessary, especially if you're still early in the research process. If you start down one path and have trouble finding published information, ask your professor if you can choose another topic.

The Best Research Topics for Nursing Students

You have endless subject choices for nursing research papers. This non-exhaustive list just scratches the surface of some of the best nursing research topics.

1. Clinical Nursing Research Topics

• Analyze the use of telehealth/virtual nursing to reduce inpatient nurse duties.
• Discuss the impact of evidence-based respiratory interventions on patient outcomes in critical care settings.
• Explore the effectiveness of pain management protocols in pediatric patients.

2. Community Health Nursing Research Topics

• Assess the impact of nurse-led diabetes education in Type II Diabetics.
• Analyze the relationship between socioeconomic status and access to healthcare services.

3. Nurse Education Research Topics

• Review the effectiveness of simulation-based learning to improve nursing students' clinical skills.
• Identify methods that best prepare pre-licensure students for clinical practice.
• Investigate factors that influence nurses to pursue advanced degrees.
• Evaluate education methods that enhance cultural competence among nurses.
• Describe the role of mindfulness interventions in reducing stress and burnout among nurses.

4. Mental Health Nursing Research Topics

• Explore patient outcomes related to nurse staffing levels in acute behavioral health settings.
• Assess the effectiveness of mental health education among emergency room nurses .
• Explore de-escalation techniques that result in improved patient outcomes.
• Review the effectiveness of therapeutic communication in improving patient outcomes.

5. Pediatric Nursing Research Topics

• Assess the impact of parental involvement in pediatric asthma treatment adherence.
• Explore challenges related to chronic illness management in pediatric patients.
• Review the role of play therapy and other therapeutic interventions that alleviate anxiety among hospitalized children.

6. The Nursing Profession Research Topics

• Analyze the effects of short staffing on nurse burnout .
• Evaluate factors that facilitate resiliency among nursing professionals.
• Examine predictors of nurse dissatisfaction and burnout.
• Posit how nursing theories influence modern nursing practice.

Tips for Writing a Nursing Research Paper

The best nursing research advice we can provide is to follow your professor's rubric and instructions. However, here are a few study tips for nursing students to make paper writing less painful:

Avoid procrastination: Everyone says it, but few follow this advice. You can significantly lower your stress levels if you avoid procrastinating and start working on your project immediately.

Plan Ahead: Break down the writing process into smaller sections, especially if it seems overwhelming. Give yourself time for each step in the process.

Research: Use your resources and ask for help from the librarian or instructor. The rest should come together quickly once you find high-quality studies to analyze.

Outline: Create an outline to help you organize your thoughts. Then, you can plug in information throughout the research process. 

Clear Language: Use plain language as much as possible to get your point across. Jargon is inevitable when writing academic nursing papers, but keep it to a minimum.

Cite Properly: Accurately cite all sources using the appropriate citation style. Nursing research papers will almost always implement APA style. Check out the resources below for some excellent reference management options.

Revise and Edit: Once you finish your first draft, put it away for one to two hours or, preferably, a whole day. Once you've placed some space between you and your paper, read through and edit for clarity, coherence, and grammatical errors. Reading your essay out loud is an excellent way to check for the 'flow' of the paper.

Helpful Nursing Research Writing Resources:

Purdue OWL (Online writing lab) has a robust APA guide covering everything you need about APA style and rules.

Grammarly helps you edit grammar, spelling, and punctuation. Upgrading to a paid plan will get you plagiarism detection, formatting, and engagement suggestions. This tool is excellent to help you simplify complicated sentences.

Mendeley is a free reference management software. It stores, organizes, and cites references. It has a Microsoft plug-in that inserts and correctly formats APA citations.

Don't let nursing research papers scare you away from starting nursing school or furthering your education. Their purpose is to develop skills you'll need to be an effective nurse: critical thinking, communication, and the ability to review published information critically.

Choose a great topic and follow your teacher's instructions; you'll finish that paper in no time.

Joleen Sams is a certified Family Nurse Practitioner based in the Kansas City metro area. During her 10-year RN career, Joleen worked in NICU, inpatient pediatrics, and regulatory compliance. Since graduating with her MSN-FNP in 2019, she has worked in urgent care and nursing administration. Connect with Joleen on LinkedIn or see more of her writing on her website.

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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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PG Coursework Unit

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Pre-requisites

NURS6001 - Clinical Nursing II

Unit description

Examines a range of research methodologies that can be ethically and responsibly utilised in clinical practice environments. These methodologies are considered within the context of critically appraising the quality and appropriateness of published research findings for translation into nursing knowledge and practice. Students will have an opportunity to apply research and inquiry methods to independently scope, plan and report on an original project proposal. The proposal must address a quality, sustainability or safety improvement initiative related to practice or sustainable development goals.  

Unit content

• Human research ethics
• Clinical research
• Appraising and utilising research
• Research methodologies
• Quality improvement and safety projects
• Integrating evidence in practice

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2025 unit offering information will be available in November 2024

Learning outcomes

Unit Learning Outcomes express learning achievement in terms of what a student should know, understand and be able to do on completion of a unit. These outcomes are aligned with the graduate attributes . The unit learning outcomes and graduate attributes are also the basis of evaluating prior learning.

On completion of this unit, students should be able to:

communicate to others the key human ethics considerations and components of a quality improvement initiative or clinical research utilising appropriate strategies

critically analyse research philosophies, methodologies and principles relevant to nursing practice

develop a research question and problem statement to guide critical examination of an area of interest, located within a health, social, or community care setting

apply research skills to plan, develop and disseminate a project proposal for a quality, sustainability or safety practice initiative related to the discipline of nursing

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Commonwealth Supported courses For information regarding Student Contribution Amounts please visit the Student Contribution Amounts .

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Master of nursing (graduate entry) (2025), master of nursing (graduate entry) (2024), any questions we'd love to help.

WMU nursing students lead hospital study that could change future of pressure-wound monitoring

Students Maddie Bies, Jordyn Swenson and David Le are making an impact at Ascension Borgess Hospital with a project for their nursing leadership and management course.

Dave Neuman prepares WMU student volunteers for their work on the IPUP Survey.

Students walk from Ascension Borgess's Navigation Center to the hospital where they will begin observing patients.

Western's student leaders gathered the largest number of student volunteers to date for the IPUP Survey at Ascension Borgess Hospital.

Maddie Bees helps fellow nursing students enter information into the computer system.

Students learn charting skills and interact with patients while conducting the IPUP Survey.

KALAMAZOO, Mich.—An innovative effort is underway to better detect and prevent pressure wounds at Ascension Borgess Hospital, and Western Michigan University nursing students are leading the charge.

"This is cutting-edge work," says Dave Neuman , wound ostomy coordinator at Ascension Borgess.  

Students Maddie Bies , David Le and Jordyn Swenson are conducting research and compiling data to help the hospital determine if a new pressure ulcer risk assessment scale could lead to better patient care. Neuman emphasized the potential impact of the Western team's work in an email to their professor, Dr. Kelley Pattison .

Currently, the Braden Scale is the industry standard in terms of scoring risk factors for ulcers. But scoring is subjective and can vary depending on who is filling out the chart. The Shieh Score is a new tool developed to be more objective.

"We tell them all the time how important charting and documentation is … but this really gives them examples and will help their skills after graduation," says Jaime Neary, faculty specialist II of nursing.

"What the Western Michigan University students are doing is retrospectively analyzing our internal data utilizing the Shieh scale to see if we could have captured more patients who would have been pressure injury risks who were not labeled as risks," Neuman says.

The students are working with Neuman and his colleague Tammy Austin , a wound nurse and preceptor, through a nursing leadership and management class that all Bronson School of Nursing students take in their final semester before graduation. It pairs students with a nurse leader in the community to do a project related to patient safety and quality.

"The fact that we're last-year nursing students on the forefront of this effort is pretty phenomenal," says Le, of Portage. "I really love research, and this project reflects how much care has evolved—and we're adding to it. I know we're just at the beginning, but it's crazy to think that one day maybe hospitals will be using this Shieh scale."

"Health care is ever-changing; nursing is ever-changing. We're always researching and updating our practices," adds Swenson, of Homer Glen, Illinois. "I like seeing this new scale and seeing how well it's working so far. … I'm really excited to see where this goes and see how it's implemented into this hospital and possibly throughout the country."

The results of the research are being presented to hospital leadership and could potentially lead to the Shieh Score being adopted not just locally but systemwide within Ascension.

"The initial data from the students' research is already so compelling that nursing leadership is excited about the possibilities," says Neuman.

It's also opening up potential future career possibilities for the students, who admit they'd never considered research or community nursing before this project.

"It's really cool because we're getting to step into not just the clinical side of nursing that we've been so used to, we're able to dig into the research and continuing education aspect," says Bies, of Kingsley, Michigan, who plans to start her career as a patient care nurse. "This has opened the doors and shown that this is a part of nursing and this is an option for me."

UNIQUE EXPERIENCE

Bies, Le and Swenson also recently led the annual International Pressure Ulcer/Injury Prevention (IPUP) Survey at Ascension Borgess, which is conducted by more than 1,000 facilities around the globe to assess the number and severity of pressure wounds in health care systems. The Western team coordinated a group of two dozen fellow nursing students to staff the daylong effort.

"To the best of my knowledge, this is the only student-run operation in the nation. 

We've been doing this in collaboration with Western for about five or six years now, and it's been fantastically successful," says Neuman.

Bies, Swenson and Le

Six years ago, a Western nursing student in the same course created the student-led survey as her project, and it has grown every year. This year's student volunteer group was the largest the hospital has seen.

"I've had nothing but excellent students from Western in my entire tenure here," Neuman says. "It says a lot about our student externs and the buy-in from the University. It's just a great partnership."

"Every year it gets better," Austin adds. "This group is the best we've had yet. They're absolutely phenomenal."

It also allows students to gain resume-worthy experience that could give them a leg up when they begin applying for jobs.

"We're really honing in on advancing their assessment skills. When they do these surveys, they're finding that the pressure ulcers are not always properly charted, so it's giving them a lot of practice for assessment skills and communication skills in explaining what they are doing to patients," says Jaime Neary , faculty specialist II of nursing. "We tell them all the time how important charting and documentation is … but this really gives them examples and will help their skills after graduation."

The opportunity to focus on patient care and have a measurable impact at the hospital reinforces the reason the students chose Western to explore this profession in the first place.

"I want something where every day I walk away knowing that I made a difference in someone's life," Bies says. "Nursing truly fulfills that passion for me in caring for others."

For more WMU news, arts and events , visit WMU News online.

Research Transparency in 59 Fields of Medical and Health Sciences: A Meta-Research Study

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Background: Transparency in research is crucial as it allows for the scrutiny and replication of findings, fosters confidence in scientific outcomes, and ultimately contributes to the advancement of knowledge and the betterment of society. Aim: We aimed to assess adherence to five practices promoting transparency in scientific publications (data availability, code availability, protocol registration, conflicts of interest (COI) and funding disclosures) from open-access articles published in medical journals. Methods: We searched and exported all open-access articles from Science Citation Index Expanded (SCIE)-indexed journals through the Europe PubMed Central database published until March 16, 2024. Basic journal- and article-related information was retrieved from the database. We used R to produce descriptive statistics. Results: The analysis included 2,189,542 open-access articles from SCIE-indexed medical journals. Of these, 87.5% (95% CI: 87.4%-87.5%) disclosed COI and 80.1% (95% CI: 80.0%-80.1%) disclosed funding. Protocol registration was present in 6.6% (95% CI: 6.6%-6.6%), data sharing in 7.6% (95% CI: 7.6%-7.6%), and code sharing in 1.4% (95% CI: 1.4%-1.4%) of the articles. More than 76.0% adhered to at least two transparency practices, while full adherence to all five practices was less than 0.02%. The data showed an increasing trend in adherence to transparency practices since the late 2000s. COI and funding were disclosed more often in lower impact factor journals whereas protocol registration and data and code sharing were more prevalent in higher impact factor journals (all had P-values<0.001). Also, articles that did not disclose their COI had higher median citations. Among all fields, Rheumatology (97.2%), Neuroimaging (94.6%), Anesthesiology (32.4%), Genetics & Heredity (36.7%), and Neuroimaging (12.5%) showed the highest level of transparency in COI and funding disclosure, protocol registration, and data and code sharing, respectively. Whereas Medicine, Legal (61.5%), Andrology (59.0%), Materials Science, Biomaterials (0.3%), Surgery (1.5%), and Nursing (<0.01%) showed the lowest adherence. Conclusion: While most articles and fields had a COI disclosure, adherence to other transparent practices was far from acceptable. To increase protocol registration, data, and code sharing, much stronger commitment is needed from all stakeholders.

Competing Interest Statement

The authors have declared no competing interest.

Funding Statement

This study did not receive any funding.

Author Declarations

I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained.

I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals.

I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance).

I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable.

Data Availability

All the code and data associated with the study were shared through both its OSF repository (https://osf.io/zbc6p/) and GitHub (https://github.com/choxos/medical-transparency) when the manuscript was submitted.

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A world-class city filled with art and culture and an incredible campus that offers cutting edge resources–that’s what students receive at Penn Nursing. And that’s just the start. Penn Nursing and the wider university offer something for everyone, as well as a lifelong community.

Penn Nursing is globally known for educating dynamic nurses—because our School values evidence-based science and health equity. That’s where our expertise lies, whether in research, practice, community health, or beyond. Everything we do upholds a through-line of innovation, encouraging our exceptional students, alumni, and faculty share their knowledge and skills to reshape health care.

Penn Nursing students are bold and unafraid, ready to embrace any challenge that comes their way. Whether you are exploring a career in nursing or interested in advancing your nursing career, a Penn Nursing education will help you meet your goals and become an innovative leader, prepared to change the face of health and wellness.

Penn Nursing is the #1-ranked nursing school in the world. Its highly-ranked programs help develop highly-skilled leaders in health care who are prepared to work alongside communities to tackle issues of health equity and social justice to improve health and wellness for everyone.

Penn Nursing’s rigorous academic curricula are taught by world renowned experts, ensuring that students at every level receive an exceptional Ivy League education . From augmented reality classrooms and clinical simulations to coursework that includes experiential global travel to clinical placements in top notch facilities, a Penn Nursing education prepares our graduates to lead.

Nurses Cite Employer Failures as their Top Reason for Leaving

A new study from the University of Pennsylvania School of Nursing ’s Center for Health Outcomes and Policy Research (CHOPR) – published in JAMA Network Open today – showed that, aside from retirements, poor working conditions are the leading reasons nurses leave healthcare employment. These study findings come at a time when hospital executives cite staffing problems as their most pressing concern.

Karen Lasater, PhD, RN , Associate Professor, the Jessie M. Scott Term Chair in Nursing and Health Policy, and Senior Fellow of the Leonard Davis Institute for Health Economics.

“Prior studies evaluate nurses’ intentions to leave their job. Our study is one of the few evaluating why nurses actually left healthcare employment entirely,” said lead author K. Jane Muir, PhD, RN , a CHOPR Postdoctoral Research Fellow, Associate Fellow of the Leonard Davis Institute for Health Economics, and a National Clinician Scholar at the University of Pennsylvania. The study surveyed 7,887 registered nurses in New York and Illinois who left healthcare employment between 2018 and 2021.

Across a variety of healthcare settings including hospitals, long-term care facilities, and ambulatory care, planned retirement was the most cited reason nurses are leaving healthcare employment. Closely behind retirements, insufficient staffing, burnout, and poor work-life balance topped the list. Among retired nurses in the study, only 59% stated their retirement was planned, suggesting nearly half of nurse retirements are premature exits due to poor working conditions.

“Nurses are not principally leaving for personal reasons, like going back to school or because they lack resilience. They are working in chronically poorly staffed conditions which is an ongoing problem that predates the pandemic ,” said senior author Karen Lasater, PhD, RN , Associate Professor, the Jessie M. Scott Term Chair in Nursing and Health Policy, and Senior Fellow of the Leonard Davis Institute for Health Economics.

Study authors say that healthcare employers could also retain more nurses through solutions that enhance nurses’ work-life balance. This includes greater flexibility in work hours such as shorter shift-length options, higher pay-differentials for weekend/holiday shifts, and on-site dependent care.

“Nurses are retiring early and leaving employment in the healthcare sector because of longstanding failures of their employers to improve working conditions that are bad for nurses and unsafe for patients. Until hospitals meaningfully improve the issues driving nurses to leave, everyone loses,” said Muir.

The study was led by researchers at the Center for Health Outcomes and Policy Research, in partnership with the National Council of State Boards of Nursing. Funding for the study was from the National Council of State Boards of Nursing, the National Institute of Nursing Research/NIH (T32NR007104; R01NR014855), and the Agency for Healthcare Research and Quality (R01HS028978).  

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Nevada Today

The university of nevada, reno orvis school of nursing ranks as top nursing program in the country, 2023 national council licensure examination (nclex®) nursing graduate passing rates place the university at the top of the charts in the state and country.

In a recent report from the National Council Licensure Examination (NCLEX®), University of Nevada, Reno Orvis School of Nursing graduates who took the exam ranked number one not only in Nevada, but in the entire United States. The exam is designed to test graduates’ decision-making abilities with clinical judgment problems through an adaptive test that evolves as the student answers questions. The accomplishment is no easy feat – with an average of about 1,400 students taking the exam each quarter, Cameron Duncan, interim dean for the Orvis School of Nursing, is incredibly proud of the University’s graduates, faculty and staff whose hard work led to such a high passing rate.

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• Orvis School of Nursing Degrees and Programs

“This accomplishment is evidence of the dedication of students, faculty and staff to maintaining the highest standards of education and preparing nurses for successful careers in nursing,” Duncan said. “It also reflects the effectiveness of the program in providing a demanding and wide-ranging curriculum that prepares students with the knowledge and skills needed for success in the nursing profession.”

Graduates from the Orvis School of Nursing have steadily and more frequently been passing the exam since 2022, with numbers improving dramatically over even a single year. Their success is thanks to faculty and staff who use student data to identify gaps and areas of improvement in the program and frequently update the curriculum to prepare students for the rapidly evolving medical field.

“The curriculum is frequently updated to reflect the most up-to-date nursing education and compliance with accreditation guidelines,” Duncan said. “We also have wonderful clinical agency partners who provide feedback to prepare the best nurses to care for the sickest patients with ever-increasing expectations and technology.”

Staff and faculty in the Orvis School of Nursing constantly look for ways to elevate and enrich their curriculum, providing opportunities to connect textbook material to the praxis. Programs unique to the University of Nevada, Reno, like the Bachelor of Science in Nursing, or BSN, are instrumental in preparing students for real-world scenarios, and have been the base for increased passing rates for NCLEX®.

“One example is the increased use of simulation at all levels of the BSN Program,” Duncan said.  “Students, under the guidance of experienced simulation faculty, face realistic scenarios with simulation manikins that allow them to clinically reason and safely assume the role of the nurse. Immediately following the simulation, detailed debriefing is provided to support learning and reinforce skills and concepts. Using this technology, students can practice in a safe environment and move confidently and competently into the clinical setting.”

Being ranked the number one nursing program is a multi-faceted accomplishment. Students’ high passing rate for the NCLEX® is the result of staff and faculty coming together to create an unmatched curriculum. This achievement demonstrates the Orvis School of Nursing's dedication to excellence and positions it as a leader in nursing education. With this distinguishment, the University will continue to attract talented students and faculty and continue to produce high-caliber nurses that endlessly continue to represent and inspire the Wolf Pack as leaders in the medical community.

“Being ranked the number one nursing program nationwide is a significant accomplishment for the Orvis School of Nursing,” Duncan said. “These rankings indicate that the program has excelled in various aspects, including curriculum, faculty expertise, clinical training opportunities, and student outcomes. It highlights the school's commitment to providing high-quality education and producing competent and skilled nurses.”

Impact & Student Success

Researchers and students gain new insights and make new connections in Panama

Student participants join researchers to support international conservation efforts

Faces of the Pack: Viktor Cruz-Calderon

A journey filled with happy mistakes and new adventures, Gilman Scholarship recipient Viktor Cruz-Calderon takes on Spain

STEM Sisters in Panamá

Two high school graduates had the research experience of a lifetime

University Professor Deborah Boehm and team contribute to a guide for preparing publicly engaged scholars

“Build Bridges, Not Walls” encourages meaningful community engagement

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Iranian Culture Celebration event

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