nursing interventions in qualitative research

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• v.7(5); 2020 Sep

Qualitative evaluation in nursing interventions—A review of the literature

Kristine rørtveit.

1 Department of Research, Nursing and Healthcare Research Group, Stavanger University Hospital, Stavanger Norway

Britt Saetre Hansen

Kirsten lode, elisabeth severinsson, associated data.

To identify and synthesize qualitative evaluation methods used in nursing interventions.

A systematic qualitative review with a content analysis. Four databases were used: MEDLINE, PsycINFO, Embase and CINAHL using pre‐defined terms. The included papers were published from 2014–2018.

We followed the guidelines of Dixon‐Woods et al., Sandelowski and Barroso, the Critical Appraisal Skills Programme qualitative checklist and The Confidence in the Evidence from Reviews of Qualitative Research Approach.

Of 103 papers, 15 were eligible for inclusion. The main theme Challenging complexity by evaluating qualitatively described processes and characteristics of qualitative evaluation. Two analytic themes emerged: Evaluating the implementation process and Evaluating improvements brought about by the programme.

Different qualitative evaluation methods in nursing are a way of documenting knowledge that is difficult to illuminate in natural settings and make an important contribution when determining the pros and cons of an intervention.

1. INTRODUCTION

During the last decade, there has been an ongoing discussion on the topic of developing and evaluating complex nursing interventions. Nursing interventions can be evaluated qualitatively, as this method enhances the significance of clinical trials and emphasizes the distinctive work and outcomes of nursing care (Sandelowski,  1996 ). However, there are few examples of detailed methodological strategies for doing so (Schumacher et al.,  2005 ). Evaluation is a positive pursuit as it provides an organization with knowledge of how to improve or verify the value of services and how to determine which elements are strong and which are in need of improvement (Stufflebeam & Shinkfield,  2007 ). Nurses should therefore develop and implement strategies aimed at creating professional practice, and furthermore, such strategies should include designing and implementing performance measurement systems (McDavid & Huse,  2006 ). Morse, Penrod, and Hupcey ( 2000 ) describes Qualitative Outcome Analysis (QOA) as a method for qualitatively identifying intervention strategies and evaluating the implementation outcomes of patient‐oriented interventions.

1.1. Background

Clinical nursing is complex, and nurses need to understand the complexity of evaluation to improve their practice. The term “complex intervention” is widely used in the academic health literature to describe both health service and public health interventions. Complex interventions are defined as consisting of several components, which can act either independently or interdependently (Campbell et al.,  2007 ; Mohler, Bartoszek, Kopke, & Meyer,  2012 , p. 455). A complex intervention is characterized by several interacting components in several dimensions such as the behaviour required by the persons involved, the number of groups or levels in the organization, variability of outcomes and/or the degree of intervention flexibility (Craig et al.,  2008 ).

The choice of evaluation method must be determined by its appropriateness for the purpose and intended use (Patton,  2015 ). Qualitative methods provide those who make decisions about the follow‐up of an intervention with access to a deeper understanding of the participants' experiences and perceptions of the intervention that goes beyond numbers and statistics (Patton,  2015 ). There are few studies about nursing intervention evaluation methods that describe the formal documentation of the content and delivery of a specific intervention in greater detail (Michie, Fixsen, Grimshaw, & Eccles,  2009 ) or factors that influence improvement in clinical nursing. Michie et al. ( 2009 , p. 3) describe eight aspects that are essential in healthcare implementation: the content of the intervention, characteristics of those delivering the intervention, characteristics of the recipients, characteristics of the setting, the mode of delivery, the intensity (e.g. contact time), the duration (e.g. number of sessions over a given period) and adherence to delivery protocols. This is in accordance with Craig et al. ( 2008 ), who argue for several aspects necessary of development and evaluation: a good theoretical understanding, implementation problems, level processes, the range of measures and strict fidelity. Thus, we expand on the existing knowledge of complex interventions by searching for studies using qualitative evaluation methods to demonstrate a variety of methods used in relation to nursing evaluation and in the following we identify and synthesize the qualitative evidence of which research methods are applied when nursing interventions are evaluated.

2. THE REVIEW

To identify and synthesize qualitative evaluation methods used in nursing interventions. The review question addressed was: What characterizes the qualitative methods applied in evaluating the implementation of nursing interventions and improvements?

2.2. Design

A systematic literature review was conducted (Dixon‐Woods, Agarwal, Jones, Young, & Sutton,  2005 ; Hansen et al.,  2012 ) on qualitative studies providing knowledge methods used in qualitative evaluation in the clinical nursing field. The qualitative review guidelines for assessing the quality of evidence presented by Sandelowski and Barroso (Sandelowski & Barroso,  2007 ) were adhered to.

2.3. Search method

A systematic search was carried out in MEDLINE, PsycINFO and Embase in October 2018. An additional search was performed in CINAHL to identify articles with nursing perspectives. Articles published in the previous 5 years (from January 2014) were included. The following search terms were used: qualitative evaluation, method* or tool* or model* or process* or strateg* or criteria or plan*, nurs* and implement* or improve* or intervention* or practice* or programme, patient*.

2.4. Search outcomes

The initial search revealed 103 articles, of which 40 were excluded due to being duplicates, 13 for not using a qualitative research method and 12 for other reasons such as not being performed by nurses, not involving nursing in the intervention or not involving patients. Appendix I shows the details and describes the identification process in accordance with PRISMA (Moher, Liberati, Tetzlaff, & Altman,  2009 ).

2.5. Inclusion and exclusion criteria

The searches were limited to peer‐reviewed journal articles in the English language on qualitative research methods applied in the evaluation of nursing interventions for adult patients (<18+ years) published within the previous 5 years. The narrow inclusion criteria stipulated articles focusing on nursing interventions in the clinical context and were from different hospital settings and community care. Articles on the family perspective, students' perspective and those employing mixed methods were excluded.

A total of 15 articles fulfilled the narrow inclusion criteria and were deemed appropriate for the review in addition to being relevant for illuminating the topics addressed by the review question. The Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (Moher et al.,  2009 ; PRISMA,  2018 ) and the Critical Appraisal Skills Programme (CASP,  2018 ) were used to structure the review process. The PRISMA flow diagram shows the selection process ( Appendix I ).

2.6. Quality appraisal and data extraction

Each article was initially critically appraised by two reviewers independently followed by a discussion among all five nurse researchers who finally reached consensus. All the included articles were quality checked in accordance with the checklist (CASP,  2018 ), see Appendix II and were sorted by study aim, intervention and context, method, results, qualitative evaluation and why it was performed as shown in Table  1 .

Overview of included papers

Abbreviations: AVERT, A Very Early Rehabilitation Trial; CCM, chronic care model; CMNs, certified nurse midwives; COPD, chronic obstructive pulmonary disease; DD, dementia disease; GP, general practitioner; ICU, intensive care unit; PN, practice nurses; RCT, randomized controlled trials; RN, Registered Nurses; SAM, Systematic Activation Method; VM, validation method.

2.7. Review

The qualitative review adhered to (Sandelowski & Barroso,  2007 ). The analysis was performed by a thorough reading and rereading of the articles (Dixon‐Woods et al.,  2006 ). The data were analysed stepwise following a manifest content analysis technique (Graneheim & Lundman,  2004 ). After each article had been thoroughly assessed, they were sorted and summarized. In the analysis process, the text describing the evaluation method was considered to constitute the meaning units (Graneheim & Lundman,  2004 ). The meaning units were then coded and thematized as groups of content that shared a similar meaning. The qualitative evaluation method was reflected on, discussed and finally formulated into one theme and three sub‐themes. The sub‐themes helped to describe the identified factors. The main theme and sub‐themes were created by abstraction of the categorized meaning units in a process involving all the authors. Various alternatives were discussed by the authors to reach consensus on the sorting and labelling. Research Ethics Committee approval was not required.

3.1. Characteristic of the studies

Of 103 papers, 15 were eligible for inclusion (Baron et al.,  2018 ; Bolmsjo, Edberg, & Andersson,  2014 ; Clignet, van Meijel, van Straten, & Cuijpers,  2017 ; Davisson & Swanson,  2018 ; Furler et al., 2014 ; Graves, Garrett, Amiel, Ismail, & Winkley,  2016 ; Hahne, Lundstrom, Levealahti, Winnhed, & Ohlen,  2017 ; Halcomb et al.,  2015 ; Hanifa, Glaeemose, & Laursen,  2018 ; Helmle, Edwards, Kushniruk, & Borycki,  2018 ; Hill et al.,  2016 ; Iyer, Koziel, & Langhan,  2015 ; Kang, Moyle, Cooke, & O'Dwyer,  2017 ; Luker et al.,  2016 ; Soderlund, Cronqvist, Norberg, Ternestedt, & Hansebo,  2016 ) and the PRISMA flow diagram shows the selection process ( Appendix I I). The 15 included articles are presented in Table 1 , and there is an example of the questions, while Appendix II contains the criteria from the CASP checklist. Overall, we found that the included articles had a high score, although adequate consideration of the relationship between the researcher and participants was lacking in several articles. The most common methodology was interviews, either individual or in focus groups. Educational programmes were the most frequently used intervention, and thematic analysis was the methodology most often employed. Two analytic themes emerged: Evaluating the implementation process and Evaluating improvements brought about by the programme (Table 2 ). One main theme was developed from this process: Challenging complexity by evaluating qualitatively . The main theme outlined how the design of an evaluation of the intervention was influenced by the inherent complexity.

3.2. Theme 1: Evaluating the implementation process

This theme described the different types of evaluation design used in the implementation processes, data characteristics and context as well as types and models of analysis.

3.2.1. Different types of designs

The theme different types of design was based on the sub‐category aims and types of data , where we found a great variation in the descriptions employed. Some of the studies aimed to report and evaluate the intervention from the staff perspectives , while others described and evaluated the patients' perspectives or reported both perspectives (Baron et al.,  2018 ). Changes associated with the interventions were examined by some, while others explored experiences of care or evaluated experiences and perceptions of an intervention. Several of the aims concerned contributing to a deeper knowledge in staff members' daily practice; to better understand their experiences and explore perceptions and perspectives of an intervention (Graves et al.,  2016 ; Iyer et al.,  2015 ; Luker et al.,  2016 ). Other examples from staff members' perspectives aimed at exploring the use of drama as a tool (Bolmsjo et al.,  2014 ) or developing a model of care (Furler et al.,  2014 ).

Examples of more detailed formulations of the aims were: to improve a programme (Davisson & Swanson,  2018 ), evaluate a programme's impact on staff's knowledge and attitude (Kang et al.,  2017 ) or to evaluate effect on practice (Helmle et al.,  2018 ). Some studies aimed to evaluate the effect of workflow and practice and to examine the strength and weaknesses of a programme (Helmle et al.,  2018 ; Kang et al.,  2017 ). The various aims demonstrated ways of detecting the knowledge sought by the evaluation, and all of them were grounded in a design with a qualitative tradition.

The types of data pointed to a variety of different data collection methods in qualitative evaluations. They all included some form of in‐depth interviews, and semi‐structured interviews were common (Baron et al.,  2018 ; Graves et al.,  2016 ; Halcomb et al.,  2015 ; Hanifa et al.,  2018 ; Helmle et al.,  2018 ; Luker et al.,  2016 ). Several studies employed one or several focus group interviews (Baron et al.,  2018 ; Bolmsjo et al.,  2014 ; Furler et al.,  2014 ; Hahne et al.,  2017 ; Hill et al.,  2016 ), and there were several examples of combined methods, such as evaluation interviews, focus group and telephone interviews (Furler et al.,  2014 ), telephone interviews, voice Internet or face to face (Luker et al.,  2016 ), observations and tape recordings during sessions, focus group interview and written reflections (Bolmsjo et al.,  2014 ). Other examples of data collection were related to the time the data were collected: for instance, a process evaluation conducted by means of qualitative data collected 3 and 12 months postintervention (Furler et al.,  2014 ).

We found no explicit explanations of or reflections on why the specific design was chosen in any of the articles, although an implicit understanding was present.

3.2.2. Data characteristics and context

The different data and context of problems pertaining to the evaluations varied, illuminating the range of fields where qualitative evaluation methods can be valuable in an implementation process. This category describes the types of setting, problem and diagnosis. The data represent a variety of clinical settings and were collected in natural healthcare contexts. Several evaluations were performed in a typical somatic hospital setting such as acute stroke, paediatric, surgical ICU or obstetric departments (Baron et al.,  2018 ; Hahne et al.,  2017 ; Hanifa et al.,  2018 ; Iyer et al.,  2015 ; Luker et al.,  2016 ). In addition, community settings such as elder and dementia care (Bolmsjo et al.,  2014 ) and diabetes care (Furler et al.,  2014 ) were evaluated. The settings of the various studies represented different clinical contexts; acute and emergency care, long‐term care and general practice, community settings and hospital units, all of which were representative of a complex intervention .

3.2.3. Types and models of analysis

All the reviewed articles presented established models of analysis in the methodological section, which provided a detailed description of how the analysis was performed. In addition to traditional qualitative analysis, the articles described more advanced models of analysis such as thematic content analysis, the hermeneutic phenomenological approach, grounded theory, conventional inductive content analysis (Clignet et al.,  2017 ; Hanifa et al.,  2018 ; Iyer et al.,  2015 ) and several forms of content analysis. This summary shows the variety of methods that can be chosen.

The question of whether the evaluation of the detailed intervention was performed inductively or deductively was addressed in some of the articles (Bolmsjo et al.,  2014 ; Furler et al.,  2014 ; Iyer et al.,  2015 ; Luker et al.,  2016 ) but only when explicitly stating that an inductive approach was used. In several of the studies, it seemed as if the reason for choosing a qualitative design was to capture the complexity.

3.3. Theme 2: Evaluating improvements brought about by the programme

This theme analyses the improvements as they were described in the studies that is, the intervention process; types of intervention and characteristics of those who deliver the intervention. The implementation processes were complex, but the qualitative analysis and highlights of the articles made the outcome of the interventions visible.

3.3.1. Clinical benefits

The outcomes were connected to the clinical benefits . For instance, important themes that provided more insight into clinical implementation in complex care settings were described (Luker et al.,  2016 ). These included the fact that the implementation required extra work but was rewarding; that team practices changed; that challenges such as the lack of established interdisciplinary teamwork and inadequate staffing levels arose at some sites; that there were various organizational barriers, the impact of staff attitudes and beliefs and patient‐related barriers; and that enthusiastic team leadership was crucial for success. Another example was described by Clignet et al. ( 2017 ), who studied the implementation process to find which implementation factors are most relevant to this population and to identify facilitators and barriers relating to the characteristics and contextual factors of patients and nurses (Clignet et al.,  2017 ).

One study revealed that although the participants considered the intervention safe, they did not use it (Iyer et al.,  2015 ). Another result revealed that the intervention could be a means to enhance reflection on daily caring practice among nursing staff (Bolmsjo et al.,  2014 ), while one found that the RN led model increased patient satisfaction and gave RNs greater autonomy (Baron et al.,  2018 ). Positive changes in palliative care were described, such as working methods, team collaboration, collegial support, discussions about diagnosis, symptoms at the end of life and the patient's family members (Hahne et al.,  2017 ). Involving relatives was found to be essential in the rehabilitation of former intensive care patients (Hanifa et al.,  2018 ). A study on fall prevention described that an education programme created a positive culture whereby patients and staff worked together to address falls prevention and gained awareness about creating a safe ward environment (Hill et al.,  2016 ).

The study on a 1‐year training programme on validation communication for nurses described the reactions of patients with dementia and found that actions such as not treating the patient as an adult constitute a barrier to communication or talking more freely about what is on one's mind (Soderlund et al.,  2016 ). In one study on a care model for insulin initiation, a long‐standing relationship with and knowledge of patients was described as essential for providing information, education and addressing concerns in a timely manner that suited patients (Furler et al.,  2014 ). In a study on psychological skill training to support patients with diabetes‐2, nurses described a sense of overstepping their professional role when dealing with emotive consultations as they did not feel qualified and had to adjust their role to facilitate the use of the new skills (Graves et al.,  2016 ).

One article described how important the chronic disease management programme was despite a lack of commitment to it. There was an overreliance on coordinators to manage all aspects of the programme and that more efficient communication was necessary when identifying appropriate patients to refer to the programme (Davisson & Swanson,  2018 ). We found that the outcome in all articles was of benefit to clinical practice, despite the fact that no numerical or statistical data were presented.

3.3.2. Types of intervention

As we did not limit the type of clinical implementation when selecting the articles, the types of intervention included in this review were broad. The models and programmes implemented were thoroughly described in the articles. Most of the interventions comprised programmes involving models or guidelines such as drama as a tool (Bolmsjo et al.,  2014 ) and the care model for insulin initiation (Furler et al.,  2014 ). Few of the studies described procedures in detail, with the exception of one study on sedation during the capnography procedure (Iyer et al.,  2015 ). The patient nurse perspective and the intensity and duration of the intervention were thoroughly described in each article. The utility of the intervention and why such interventions were necessary were also outlined.

3.3.3. Characteristics of those who deliver the intervention

In the articles, several professional categories were involved in the implementation process and described in accordance with the mode of delivery and the organizational level of the intervention. Some articles involved only nursing staff, either with one specified nursing specialty or with different types of nursing specialty . Other articles described a multidisciplinary combination of nurses and other professionals, for instance physiotherapists, personal trainer assistants and speech pathologists, paediatric emergency medicine professionals, general practitioners (GPs) and endocrinologists (Furler et al.,  2014 ; Iyer et al.,  2015 ; Luker et al.,  2016 ).

The organizational level did not vary as much as the professional categories. However, some of the articles combined more than one unit, for instance several clinical units for old age psychiatry, adult care facilities or different medical wards in a regional hospital (Clignet et al.,  2017 ; Helmle et al.,  2018 ; Kang et al.,  2017 ). The evaluation studies were performed in their natural setting, and the mode and description of the delivery and the organizational level of the intervention provided important information that illuminated the complexity of the actual clinical setting.

4. DISCUSSION

The aim of this review was to identify and synthesize qualitative evaluation methods used in nursing interventions, and the review question was What characterizes the qualitative methods applied in evaluating the implementation of nursing interventions and improvements? This review illuminates how evaluating the implementation of nursing interventions and improvements i s challenging because of the complexity involved, which is described by the variety of different methods included in the qualitative evaluation of interventions. The review states that different perspectives of the qualitative evaluation designs highlight the variation and benefits of such evaluation.

The implementation process perspective illuminates the obvious reasons for performing the actual evaluation based on the design, the problems revealed, and the analysis methods employed. The evaluation perspective demonstrates how improvements based on concrete benefits are crucial. The actual evaluation of the intervention shows the importance of thorough descriptions of the implementation strategies, those who deliver the intervention and the level of the activity.

From the methodological perspective, we were surprised to detect such different modes and creative ways of handling the need to evaluate complex situations in clinical practice. Although several of the included articles aim to explore , we hold that the concept exploring experiences is continuous and needs to be considered a little further. According to van Manen, qualitative methods explore a variety of issues such as empirical questions or perceptions (p. 811). Qualitative methodology focuses on individuals, and the clinical evaluations as unique examples are under the spotlight in the current review. Therefore, What ‐questions are crucial as they provide insight. However, only a few articles explicitly aimed to gain insight. The concept explore is typically used in phenomenological approaches, but only one article in the present review claims to adopt a hermeneutic phenomenological approach; as the authors study the patients' perspective they combine observations, interviews and a hermeneutic phenomenological approach to analyse the data (Hanifa et al.,  2018 ). The original meaning of a phenomenon is captured by phenomenology; to bring experience we lived through to our awareness retrospectively; and to be able to reflect on the lived meaning of the experience (van Manen,  2017 ). While these approaches may be of benefit, they are more commonly used in studies at a theoretical level than the empirical studies included in the present review. It is obvious that the data collection method is guided by the research question. However, our review also reveals that the clinical field influences how the data are collected and analysed and that the method may lead to new methods for evaluating clinics.

In the qualitative evaluation checklist guidelines, Patton ( 2015 ) emphasizes the importance of the evaluator's knowledge of methodological issues and preparedness to argue for the credibility of the findings. Qualitative evaluations are most often performed in accordance with established methodological guidelines. According to Patton ( 2015 ), the quality of qualitative data and analysis depends on skilful interviews, systematic and rigorous observations as well as the sensitivity and integrity of the evaluator (Patton,  2015 ).

Our review detected that content analysis is common. According to Graneheim, Lindgren, and Lundman ( 2017 ), qualitative content analysis typically focuses on subject and context. It emphasizes variation and offers opportunities to perform a manifest descriptive and latent interpretative content analysis (Graneheim & Lundman,  2004 ). Research using qualitative content analysis is grounded in ontological assumptions, epistemology and methodology. It is important to be aware that the ontological assumptions are open and may vary according to the researchers' standpoint. Another explicit issue is that the epistemological basis of qualitative content analysis should guide the way that data are interpreted: as cocreations of the interviewee and the interviewer. Furthermore, the interpretation method is viewed as a cocreation of the researchers and the text. Graneheim et al. ( 2017 ) state that one methodological issue is the difficulties involved in keeping the levels of abstraction and degree of interpretation logical and congruent throughout the analysis and presentation (Graneheim et al.,  2017 ).

In the 1990s, Sandelowski ( 1996 ) viewed qualitative methods as the antithesis of clinical research and “far removed from the immediate practical aims of intervention studies and nursing practice” (Sandelowski,  1996 , p. 359). However, today we see that such methods not only benefit clinical studies, but are needed to explore, illuminate and describe the variation in the phenomenon to evaluate nursing interventions in their real‐life contexts. Therefore, we believe that the vast number of different methods in the selected articles needs to be outlined and further developed so that such methods will become more common when evaluating in different clinical contexts.

From the intervention perspective , the included articles are based on complex interventions (Mohler et al.,  2012 ). Qualitative evaluations seem appropriate when knowledge about the process of testing tools or information about established programmes is needed. It appears to be correct to evaluate any type of intervention qualitatively if the aim is the above‐mentioned knowledge. This supports arguments that the type of evaluative approach is decided by the research question, not the type of intervention.

Another important aspect is whether the intervention is designed ahead of the actual project or whether existing methods or models are to be evaluated. The former adheres to an inductive approach—when the evaluation looks for knowledge derived from the actual practice. According to Graneheim et al. ( 2017 ), such an approach is data‐ or text‐driven and characterized by a search for patterns through similarities and differences. This type of analysis is described in categories and/or themes, and the levels of abstraction and interpretation vary. Using the inductive approach, the researcher moves “from the data to a theoretical understanding—from the concrete and specific to the abstract and general” (Graneheim et al.,  2017 ). One important issue that must be addressed when employing an inductive approach is the researchers' pre‐understanding. The question that arises is whether the inductive approach is merely a result of the researchers' pre‐understanding of the studied phenomena. The challenge, according to Graneheim et al. ( 2017 ), is to avoid surface descriptions and general summaries when using an inductive approach. A deductive model is employed when data are interpreted through concepts, a model or a theory, and implications about the studied phenomenon are tested against the collected data. In these designs, the researchers move explicitly from theory to data. The challenge, according to Graneheim et al. ( 2017 ), is to avoid formulating categories that are exclusively based on established theory or models and the handling of left‐over data. The latter occurs when data are found that do not fit the explanatory model (Graneheim et al.,  2017 ).

The articles included in the present review provide a detailed description of the intervention they evaluated. According to Michie et al. ( 2009 ), formal documentation describing the content and delivery of an intervention will help to inform about what to teach new practitioners, how to transform or reorganize healthcare processes and what to include in the assessment of practitioner performance. These are all key features of successful implementation (Michie et al.,  2009 ).

Characteristics of those who deliver the intervention and characteristics that make interventions complex are the different professional categories or varying organizational levels targeted by the intervention (context of the intervention) and/or a need to tailor the intervention to specific settings (flexibility of the intervention) (Mohler et al.,  2012 ). Despite that one narrow inclusion criterion focuses on nursing interventions in a clinical context, we typically find a combination of multiple professional categories delivering nursing interventions in the included articles. Michie et al. ( 2009 ) state that description of the characteristics of the setting and of those who deliver an intervention is essential for replicating an implementation strategy.

Intervention level activity is presented as high‐level activity with multiple phases and settings. The need to tailor the intervention to specific settings seems to be the most complex component in the included articles as the evaluations were performed in a natural setting and developed by an actual need in the clinics.

Central questions in the field of evaluating complex interventions are how these interventions work in clinical practice? What are their active components? And are they effective? The answers to such questions will enable new and more effective interventions across multidisciplinary teams in live practice (Michie & Abraham,  2004 ). The Criteria for Reporting the Development and Evaluation of Complex Interventions in healthcare (CReDECI) may be of use for addressing evaluation (Craig et al.,  2008 ). In contrast to most reporting guidelines, the CReDECI does not offer criteria for a specific study design, but on the process of developing, piloting and evaluating complex interventions (Craig et al.,  2008 ).

Planning is crucial for the implementation of an intervention. According to Morse (Morse et al.,  2000 ), by examining current practice by means of QOA, researchers can contribute to generating increased clinical knowledge. This kind of evaluation can provide a detailed description of local processes in an intervention programme. Morse et al. ( 2000 ) claims that QOA may bridge the gap between research and practice. The same could probably be said about the qualitative evaluation method, as it may bring nursing research and practice closer together, and qualitative research methods more accurately describe complex nursing practice. Furthermore, Morse et al. ( 2000 ) emphasizes that as nursing is a practice‐based discipline, the development of QOA methodology is critical. We genuinely believe that the same applies to the qualitative evaluation method, which often highlights experiences of a process. As nursing practice is comprehensive and individual, these important characteristics should be emphasized when evaluating it.

The implementation method requires thorough planning, and we assume that such planning is common in clinical nursing. However, the planning of the evaluation seems to be less important compared with the planning of the actual implementation. This may be a result of a dynamic, real‐life situation, which is very much dependent on resources. However, if a new intervention is not evaluated, how will we know what effect it has? We assume that qualitative evaluation is performed at a clinical level—those who receive the intervention are observed and asked at an open level: what was your experience of this intervention? We suggest that these evaluations should be systemized; the responses to open‐ended questions can be collected and analysed with the aim of improving practice. Continuous evaluation during the implementation process is crucial for success.

4.1. Strengths and limitations

The strengths and limitations were assessed by the Confidence in the Evidence from Reviews of Qualitative Research Approach (CERQual) (Lewin et al.,  2015 ), which helps assess the confidence in qualitative reviews. CERQual comprises four components, which contribute to assessment of confidence: methodological considerations, relevance, coherence and adequacy of data. We believe that we have thoroughly described the relevance, coherence and adequacy of the data by documenting the review process, the body of evidence and outlining the primary studies. The methodological considerations are the extent to which potential problems in the design are reflected on. The five nurse researchers who conducted the/present review worked in different areas at a University hospital on the West coast of Norway and represent different clinical nursing contexts. We consider this a strength, as we based the analysis and discussion section on rich and deep reflection resulting in the understanding of the review question.

Despite that mixed method evaluations are available, the present review only included qualitative studies. Such a design would illuminate other aspects of evaluation than/that were not a part of the present study.

5. CONCLUSION

This review presents a summary of different ways to perform qualitative evaluation in a range of clinical nursing areas and illuminates the complexity involved in evaluation of interventions in naturalistic settings. To the best of our knowledge, no previous review has focused on qualitative evaluation of the implementation of nursing interventions.

The review highlights the fact that to be able to say anything about the needs of nursing in the health field, we must evaluate how nursing functions and nurses act. When caring for the individual patient, qualitative methods are a natural choice for revealing the unique and specific qualities of the experiences of the individual nursing context.

CONFLICT OF INTEREST

All authors declare that there are no conflicts of interest with regard to this study.

AUTHOR CONTRIBUTIONS

KR was responsible for writing the manuscript. All authors contributed to the critical revision of the intellectual content, provided feedback on the draft manuscript and approved the final version. They all adhered to the criteria pertaining to roles and responsibilities in the research process recommended by the International Committee of Medical Journal Editors (ICMJE) ( http://www.icmje.org/recommendations ).

Overview of identified factors

Supporting information

Appendix I: Flow diagram

Appendix II: CASP checklist

ACKNOWLEDGEMENT

The authors would like to thank Monique Federsel for proofreading the English language and the specialized librarian at Stavanger University Hospital, Norway, for valuable help with the electronic search for articles.

Rørtveit K, Saetre Hansen B, Joa I, Lode K, Severinsson E. Qualitative evaluation in nursing interventions—A review of the literature . Nursing Open . 2020; 7 :1285–1298. 10.1002/nop2.519 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]

We acknowledge that the study was supported by grants from Stavanger University Hospital, Stavanger, Norway.

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• Volume 22, Issue 1
• How to appraise qualitative research
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• Calvin Moorley 1 ,
• Xabi Cathala 2
• 1 Nursing Research and Diversity in Care, School of Health and Social Care , London South Bank University , London , UK
• 2 Institute of Vocational Learning , School of Health and Social Care, London South Bank University , London , UK
• Correspondence to Dr Calvin Moorley, Nursing Research and Diversity in Care, School of Health and Social Care, London South Bank University, London SE1 0AA, UK; Moorleyc{at}lsbu.ac.uk

https://doi.org/10.1136/ebnurs-2018-103044

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Introduction

In order to make a decision about implementing evidence into practice, nurses need to be able to critically appraise research. Nurses also have a professional responsibility to maintain up-to-date practice. 1 This paper provides a guide on how to critically appraise a qualitative research paper.

What is qualitative research?

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Useful terms

Some of the qualitative approaches used in nursing research include grounded theory, phenomenology, ethnography, case study (can lend itself to mixed methods) and narrative analysis. The data collection methods used in qualitative research include in depth interviews, focus groups, observations and stories in the form of diaries or other documents. 3

Authenticity

Title, keywords, authors and abstract.

In a previous paper, we discussed how the title, keywords, authors’ positions and affiliations and abstract can influence the authenticity and readability of quantitative research papers, 4 the same applies to qualitative research. However, other areas such as the purpose of the study and the research question, theoretical and conceptual frameworks, sampling and methodology also need consideration when appraising a qualitative paper.

Purpose and question

The topic under investigation in the study should be guided by a clear research question or a statement of the problem or purpose. An example of a statement can be seen in table 2 . Unlike most quantitative studies, qualitative research does not seek to test a hypothesis. The research statement should be specific to the problem and should be reflected in the design. This will inform the reader of what will be studied and justify the purpose of the study. 5

Example of research question and problem statement

An appropriate literature review should have been conducted and summarised in the paper. It should be linked to the subject, using peer-reviewed primary research which is up to date. We suggest papers with a age limit of 5–8 years excluding original work. The literature review should give the reader a balanced view on what has been written on the subject. It is worth noting that for some qualitative approaches some literature reviews are conducted after the data collection to minimise bias, for example, in grounded theory studies. In phenomenological studies, the review sometimes occurs after the data analysis. If this is the case, the author(s) should make this clear.

Theoretical and conceptual frameworks

Most authors use the terms theoretical and conceptual frameworks interchangeably. Usually, a theoretical framework is used when research is underpinned by one theory that aims to help predict, explain and understand the topic investigated. A theoretical framework is the blueprint that can hold or scaffold a study’s theory. Conceptual frameworks are based on concepts from various theories and findings which help to guide the research. 6 It is the researcher’s understanding of how different variables are connected in the study, for example, the literature review and research question. Theoretical and conceptual frameworks connect the researcher to existing knowledge and these are used in a study to help to explain and understand what is being investigated. A framework is the design or map for a study. When you are appraising a qualitative paper, you should be able to see how the framework helped with (1) providing a rationale and (2) the development of research questions or statements. 7 You should be able to identify how the framework, research question, purpose and literature review all complement each other.

There remains an ongoing debate in relation to what an appropriate sample size should be for a qualitative study. We hold the view that qualitative research does not seek to power and a sample size can be as small as one (eg, a single case study) or any number above one (a grounded theory study) providing that it is appropriate and answers the research problem. Shorten and Moorley 8 explain that three main types of sampling exist in qualitative research: (1) convenience (2) judgement or (3) theoretical. In the paper , the sample size should be stated and a rationale for how it was decided should be clear.

Methodology

Qualitative research encompasses a variety of methods and designs. Based on the chosen method or design, the findings may be reported in a variety of different formats. Table 3 provides the main qualitative approaches used in nursing with a short description.

Different qualitative approaches

The authors should make it clear why they are using a qualitative methodology and the chosen theoretical approach or framework. The paper should provide details of participant inclusion and exclusion criteria as well as recruitment sites where the sample was drawn from, for example, urban, rural, hospital inpatient or community. Methods of data collection should be identified and be appropriate for the research statement/question.

Data collection

Overall there should be a clear trail of data collection. The paper should explain when and how the study was advertised, participants were recruited and consented. it should also state when and where the data collection took place. Data collection methods include interviews, this can be structured or unstructured and in depth one to one or group. 9 Group interviews are often referred to as focus group interviews these are often voice recorded and transcribed verbatim. It should be clear if these were conducted face to face, telephone or any other type of media used. Table 3 includes some data collection methods. Other collection methods not included in table 3 examples are observation, diaries, video recording, photographs, documents or objects (artefacts). The schedule of questions for interview or the protocol for non-interview data collection should be provided, available or discussed in the paper. Some authors may use the term ‘recruitment ended once data saturation was reached’. This simply mean that the researchers were not gaining any new information at subsequent interviews, so they stopped data collection.

The data collection section should include details of the ethical approval gained to carry out the study. For example, the strategies used to gain participants’ consent to take part in the study. The authors should make clear if any ethical issues arose and how these were resolved or managed.

The approach to data analysis (see ref  10 ) needs to be clearly articulated, for example, was there more than one person responsible for analysing the data? How were any discrepancies in findings resolved? An audit trail of how the data were analysed including its management should be documented. If member checking was used this should also be reported. This level of transparency contributes to the trustworthiness and credibility of qualitative research. Some researchers provide a diagram of how they approached data analysis to demonstrate the rigour applied ( figure 1 ).

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Example of data analysis diagram.

Validity and rigour

The study’s validity is reliant on the statement of the question/problem, theoretical/conceptual framework, design, method, sample and data analysis. When critiquing qualitative research, these elements will help you to determine the study’s reliability. Noble and Smith 11 explain that validity is the integrity of data methods applied and that findings should accurately reflect the data. Rigour should acknowledge the researcher’s role and involvement as well as any biases. Essentially it should focus on truth value, consistency and neutrality and applicability. 11 The authors should discuss if they used triangulation (see table 2 ) to develop the best possible understanding of the phenomena.

Themes and interpretations and implications for practice

In qualitative research no hypothesis is tested, therefore, there is no specific result. Instead, qualitative findings are often reported in themes based on the data analysed. The findings should be clearly linked to, and reflect, the data. This contributes to the soundness of the research. 11 The researchers should make it clear how they arrived at the interpretations of the findings. The theoretical or conceptual framework used should be discussed aiding the rigour of the study. The implications of the findings need to be made clear and where appropriate their applicability or transferability should be identified. 12

Discussions, recommendations and conclusions

The discussion should relate to the research findings as the authors seek to make connections with the literature reviewed earlier in the paper to contextualise their work. A strong discussion will connect the research aims and objectives to the findings and will be supported with literature if possible. A paper that seeks to influence nursing practice will have a recommendations section for clinical practice and research. A good conclusion will focus on the findings and discussion of the phenomena investigated.

Qualitative research has much to offer nursing and healthcare, in terms of understanding patients’ experience of illness, treatment and recovery, it can also help to understand better areas of healthcare practice. However, it must be done with rigour and this paper provides some guidance for appraising such research. To help you critique a qualitative research paper some guidance is provided in table 4 .

Some guidance for critiquing qualitative research

• ↵ Nursing and Midwifery Council . The code: Standard of conduct, performance and ethics for nurses and midwives . 2015 https://www.nmc.org.uk/globalassets/sitedocuments/nmc-publications/nmc-code.pdf ( accessed 21 Aug 18 ).
• Barrett D ,
• Cathala X ,
• Shorten A ,

Patient consent for publication Not required.

Competing interests None declared.

Provenance and peer review Commissioned; internally peer reviewed.

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Nursing Interventions for Drug Users: Qualitative Meta-Synthesis

Selene Cordeiro Vasconcelos, Iracema da Silva Frazão, Estela Maria Leite Meirelles Monteiro, Murilo Duarte da Costa Lima, José Francisco de Albuquerque, Vânia Pinheiro Ramos

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1 Neuropsychiatry of Universidade Federal de Pernambuco-UFPE, Psychosocial care center for alcohol and other drugs

2 Social Service, Universidade Federal de Pernambuco

3 Nursing, Universidade Federal de Pernambuco

4 Psychiatry, Universidade Federal de Pernambuco

5 Neuropsychiatry, Universidade Federal de Pernambuco

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1. Introduction

4. discussion, 5. conclusion.

Objective: To identify the Brazilians nurses’ interventions in the drug users care. Methods: Research on the databases LILACS, PubMed, Scopus, CINHAL, and Cochrane, indexed from 2003 to 2012, using the keywords ‘health education’ and ‘substance-related disorders’. Obtained 8 articles as sample that resulted in a thematic and two sub themes. Results: Demonstrated that Brazilian nurses’ interventions in the drug users care are grounded in health education. Conclusion: Health education actions are relevant to the process of rehabilitation and social reintegration of drug user, can promote improvement in self-care and in the quality of life of this clientele, in addition to strengthening the nursing professional identity in this setting of care.

Keywords: nursing, health education, substance-related disorders, drug users, mental health

American Journal of Nursing Research , 2013 1 (1), pp 24-27. DOI: 10.12691/ajnr-1-1-4

Received July 31, 2013; Revised November 06, 2013; Accepted November 08, 2013

Cite this article:

• Chicago Style
• Vasconcelos, Selene Cordeiro, et al. "Nursing Interventions for Drug Users: Qualitative Meta-Synthesis." American Journal of Nursing Research 1.1 (2013): 24-27.
• Vasconcelos, S. C. , Frazão, I. D. S. , Monteiro, E. M. L. M. , Lima, M. D. D. C. , Albuquerque, J. F. D. , & Ramos, V. P. (2013). Nursing Interventions for Drug Users: Qualitative Meta-Synthesis. American Journal of Nursing Research , 1 (1), 24-27.
• Vasconcelos, Selene Cordeiro, Iracema da Silva Frazão, Estela Maria Leite Meirelles Monteiro, Murilo Duarte da Costa Lima, José Francisco de Albuquerque, and Vânia Pinheiro Ramos. "Nursing Interventions for Drug Users: Qualitative Meta-Synthesis." American Journal of Nursing Research 1, no. 1 (2013): 24-27.

The performance of nursing experiences influences of social context, historical and cultural diversity of its clientele, constituting new demands on the health care that need to be inserted and adapted to different scenarios of care.

Particularly in the field of mental health, in recent decades, there has been a progressive restructuring in care, resulting from the redefinition of mental illness and its sufferers. Drug users, inserted in this context, also undergo a process of deconstruction and reconstruction of their representation in society, initially discriminated against and marginalized until the current understanding of patients.

These patients have peculiarities related to changes in behavior, changes in critical thinking and judgment, which results in functional disorders individual, family and social [ 1 ] . Therefore the patient becomes vulnerable to health problems, puts himself in risk situations and has a commitment to self-care.

Thus, the logic of the expanded clinical care, offers a support for drug users grounded in the knowledge of professionals with different backgrounds [ 2 ] , encouraging co-responsibility, autonomy and citizenship of this clientele. It is noted that each professional exerts its interventions according to their area of expertise.

In this context, the nurse needs to seek the knowledge necessary to effective practice, evidence-based, that provides the security needed to work within an interdisciplinary team without losing their specificity.

From these considerations, emerged the following research question: "What are the interventions of Brazilian nurses in the drug users’ care?" Therefore, this research aims to identify interventions used by Brazilian nurses in the care of drug users.

It was decided to conduct a meta-synthesis of the literature [ 3 , 4 ] . This methodology aims to strengthen the role of qualitative research in the health sciences, improving the applicability of the results in clinical practice, support the theory, practice, research and health policies [ 3 ] .

To contemplate the methodological rigor, followed the steps: 1. identify the purpose of the research and intellectual interests; 2. establish criteria for inclusion and exclusion of studies, conduct data collection and evaluation of individual research; 3. analyze the research; 4. relate studies by the juxtaposition of results; 5. prepare new statements; 6. develop a new explanation [ 5 ] .

To find the articles were performed the choice of Descriptors in Health Sciences (MeSH): 'Health Education' and 'Substance-related Disorders'. The search was conducted by online access, in January 2013.

To select the articles we used the following databases: LILACS (Latin American and Caribbean Health Sciences), PubMed (Public/Publish Medline), CINHAL (Cumulative Index to Nursing and Allied Health Literature), Scopus and Cochrane. Adjustments were made in the strategies used to find the articles, but was preserved as guiding the question and the inclusion criteria previously established, to maintain consistency in the search for articles and avoid possible biases. The databases PubMed, Scopus, and CINAHL allowed perform an advanced search, justifying a lower number of items rescued.

The inclusion criteria adopted to guide the search and selection of articles were: research in Portuguese language, English and Spanish, full articles published in national and international journals in the period 2003-2012, indexed in the databases used, qualitative studies, portraying the nursing interventions care to drug users with, at least, one Brazilian nurse in the board of authors.

Exclusion criteria were: publications relating to conference abstracts, annals, editorials, reviews and opinions, review articles without systematic literature review, theses, dissertations and research projects.

After obtaining the sample, articles selected were submitted to the reading for the collection of relevant information [ 6 ] and assessment of methodological rigor [ 7 ] through the application of instruments [ 6 , 7 ] . Both the analysis and synthesis of data extracted from the articles were made descriptively to observe, describe and classify the data in order to gather the knowledge produced on the theme explored in the meta-synthesis. Therefore, the meta-synthesis is capable of producing a new concept through synthesis of the content of the studies surveyed in order to transform several qualitative studies in a new study and contribute to the socialization of scientific knowledge [ 8 ] .

From the digital search, 189 articles were found in the databases consulted, 181 were excluded for not meeting the inclusion criteria. Among the articles excluded, it was observed that the majority addressed the prevention of drug misuse and the epidemiological profile and/or characteristics of drug users. Other approached the conceptions of families about the use of drugs and treatment, the pattern of drug use, factors associated with drug use; characterization of chemically-dependent; medical comorbidities and drug use by students and nursing professionals.

The search was performed by online access, in January 2013, being the final sample of this integrative review constituted by 8 articles ( Table 1 ).

Table 1. Selection of research articles in the databases LILACS, PubMed, CINAHL, Scopus e Cochrane, according to the inclusion criteria

All selected articles were published in Brazilians journals. Eight articles were identified in LILACS. In relation the type of journal in which they were published, two belonged to the Journal Interface - Comunicação, Saúde, Educação, the others were published in the Anna Nery School Journal of Nursing.

The 8 articles selected and analyzed showed a level of evidence VI, because they are evidence derived from a single descriptive or qualitative study [ 7 ] . These articles were identified by letters of the alphabet as follows:

A. Youth and drug use: workshops instrumentalization of workers in social institutions, in view of health/2009.

B. The nurses’ role in primary health care approach drug addict in João Pessoa, PB, Brazil/2010.

C. Alcoholic beverage in adolescence: the care-education as action strategy of nursing/2010.

D. Alcoholism in women: support for the professional practice of nursing/2008.

E. Nurse's role in caring for the user of alcohol and other drugs in outpatient services/2007.

F. Reflections on drug abuse and violence in youth/2010.

G. Health education in nursing work with drug users/2003.

H. The harm reduction approach in non-formal educational spaces: a qualitative study in the state of Rio de Janeiro, Brazil/2011.

The theme "Learning to care" was built as a new assertion of this meta-synthesis because the eight articles discussed the importance of the nurse know the reality of the person who needs their care, whether it be the user, their family or the own healthcare team. Therefore, the intervention of nurses has been: individual care, therapeutic workshops, therapeutic groups, individual semi-structured interviews, and semi-structured interviews with collective application.

By knowing your clientele, nurses take subsidies to plan your tour. From this perspective, the analysis of items B, C, E, F and G originated the themed - 1 "The nurse performs actions of health education for drug users” . The articles described interventions of Brazilian nurses in the drug users’ care. These actions were executed through advices, referral and therapeutic listening and aimed to promote integrated care, disease prevention, health promotion, furthermore, consider the user context in which he lives.

As a result of these nursing interventions, users demystified their ideas about alcohol consumption and developed critical reflection on protective strategies, drug dependence, consequences of consumption and harm reduction.

Analysis of articles A and D originated the themed - 2 " The nurse plays educational actions for professionals who care for drug users" where the clientele was composed by health professionals. These interventions were developed through therapeutic workshops and semi-structured interviews with collective application.

Thus, professionals appropriated concepts and develop critical analysis of reality; learned about the origin of harmful drug consumption; undid myths, prejudices and stereotypes about the user, the power and effects of drugs; understood the female alcoholism; were made reflections in relation to public policy and the reality of nursing practice through health education.

As result of the interpretation of the research found in the selected studies and demonstrated in this meta-synthesis, knowledge for improved care, implies the understanding of the socio-historical context [ 9 ] and the knowledge of the other as an assumption of therapeutic care, which must be built from a supportive relationship, looking for alternatives and possibilities facing the problems, noting the complexity of the subject and the world in which he lives [ 10 ] . Knowledge about the family history provides care for it in an integral way, with opportunity to interact with people, strengthening the bond and favoring communication, being able to share the care to be performed [ 11 ] .

Moreover, the family has an important role to perform a control on the use of psychoactive substances among its members, with socialize according to idealized community values [ 12 ] .

To know about the users and their families contributes to the elaboration of strategies most appropriate to this clientele reality with the aim to employ a harm reduction approach based on the social determinants of health that supports evidence-informed choice among programme participants [ 13 ] .

Beyond this, a program’s health educators provide a space for conversation between the members. In these calls, the parents reported full involvement with the treatments and benefitted from each. They also understand the importance of communicating with their members and the relationship between participating parents and the health educators appears to have contributed to the program’s successful implementation [ 14 ] .

However, just knowing this reality is not enough to perform nursing interventions appropriate to the logic of the expanded clinical care. As an example, some nurses reported that even working on Psychosocial Care Center for Alcohol and other Drugs (CAPSad) feel unprepared to care for drug users, hindering their integration into health treatment [ 12 ] .

An academic deficit about drug use, generates a lack of knowledge about the complexity of this phenomenon and the nurse's role in the scenery [ 15 ] . Faced with the limited experience with this theme, nurses tend to seek other sources of knowledge, such as discussion with the team, internet, reading books and articles [ 16 ] .

Due to the work process, the nurses remain more time with your clientele and build a broad experience in interpersonal relationships, which contributes to their interventions with drug users, developing educational and therapeutic health promotion, prevention, monitoring of comorbidities, rehabilitation and social reintegration within health institutions and in the community [ 17 ] .

This situation reinforces the importance of nurses conduct health education with other health professionals team in the workplace itself, about the use of drugs [ 16 ] . At this moment, it is necessary linkage between the service management and public policy for this educational support. The theoretical knowledge acquired during the graduate is appointed as a facilitator to overcome difficulties during labor insertion of newly graduated nurses [ 18 ] . To improve this formal education, courses are offered on the drug phenomenon, which has been a successful experience in the political, academic and social [ 19 ] .

This insight is important in providing a foundation for the development of educational approaches aimed at challenging what appear to be negative attitudes to illicit drug users within nursing. Student nurses enter training with a wide range of personal experiences relating to illicit drug use. The influences of society's, negative views and the image of drug use presented in the press appeared to be significant factors in developing their attitudes on the subject. In the absence of effective approaches to education, and given that many professionals in the practice environment appear to view illicit substance users in a negative way, it is likely that interventions with identified drug users will be influenced by negative attitudes [ 20 ] .

Strategies to increase knowledge involving this phenomenon may extend the work of professionals in relation to the process of working with the chemically dependent and exercise care emancipatory able to help in the construction of the autonomy of the subject and put them in touch with reality contributing to an understanding about themselves [ 21 ] . Health education contributes to the user's awareness about his problem with drug use and the difficulties to achieve their rehabilitation [ 22 ] . From this understanding, professionals may also expand its interventions for family members, building more space to care during treatment in CAPSad [ 23 ] .

Therefore, health education becomes a strategy for nurses to contribute to the maintenance of individual and collective health [ 24 ] . It also enables one nurse's role in the different scenarios of care, such as: individual consultation, group waiting room, therapeutic groups and home visits [ 25 ] .

This study demonstrated that the speeches of Brazilian nurses in the care of drug users have been guided in health education as a strategy that values the knowledge of drug user, being an effective therapeutic approach that stimulates and co-responsibility in their treatment, contributing to the improvement of the general health of these clients.

In addition, the Brazilian Nurse also intervenes through educational actions to professionals who care for drug users. Therefore, strategies were used to work in groups, enabling the exchange of experiences and sharing of challenges and overcoming searches. The studies showed an increase in the capabilities of professionals involved in educational activities, resulting in improved service to these clients, through a more appropriate management and safe this problem.

This meta-synthesis also led to reflection on the gap in the scientific reality of professional nurses, considering the overhead of duties and requirements regarding scientific rigor. Highlights the need to expand the links between the university and nursing care, aiming at the strengthening of the category and the construction of a theoretical knowledge with practical visibility as to the impact on care; well as in public policy. Thus emerges the meaning of foster better links between education, research, outreach and assistance for the socialization of scientific knowledge, thus strengthening the professional identity of the nurse in different settings of care.

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A Toolkit for Delirium Identification and Promoting Partnerships Between Carers and Nurses: A Pilot Pre–Post Feasibility Study

• Original Research
• Open access
• Published: 22 April 2024

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• Christina Aggar PhD   ORCID: orcid.org/0000-0002-0137-7796 1 , 6 ,
• Alison Craswell PhD   ORCID: orcid.org/0000-0001-8603-3134 2 ,
• Kasia Bail PhD   ORCID: orcid.org/0000-0002-4797-0042 4 ,
• Roslyn M. Compton PhD   ORCID: orcid.org/0000-0002-2069-2767 3 ,
• Mark Hughes PhD   ORCID: orcid.org/0000-0002-1158-5214 1 ,
• Golam Sorwar PhD   ORCID: orcid.org/0000-0002-5294-1895 5 ,
• James Baker PhD   ORCID: orcid.org/0000-0002-8290-3996 1 ,
• Jennene Greenhill PhD   ORCID: orcid.org/0000-0001-8325-2139 1 ,
• Lucy Shinners PhD   ORCID: orcid.org/0000-0002-7160-5838 1 ,
• Belinda Nichols MCN 1 , 6 ,
• Rachel Langheim MSc 6 ,
• Allison Wallis MRes 6 ,
• Karen Bowen MBA   ORCID: orcid.org/0000-0001-5840-3820 6 &
• Hazel Bridgett DTPH 6  

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Delirium is frightening for people experiencing it and their carers, and it is the most common hospital-acquired complication worldwide. Delirium is associated with higher rates of morbidity, mortality, residential care home admission, dementia, and carer stress and burden, yet strategies to embed the prevention and management of delirium as part of standard hospital care remain challenging. Carers are well placed to recognize subtle changes indicative of delirium, and partner with nurses in the prevention and management of delirium.

To evaluate a Pr evention & E arly Delirium I dentification C arer T oolkit (PREDICT), to support partnerships between carers and nurses to prevent and manage delirium.

A pre–post-test intervention and observation study.

Main Measures

Changes in carer knowledge of delirium; beliefs about their role in partnering with nurses and intended and actual use of PREDICT; carer burden and psychological distress. Secondary measures were rates of delirium.

Participants

Participants were carers of Indigenous patients aged 45 years and older and non-Indigenous patients aged 65 years and older.

Intervention

Nurses implemented PREDICT, with a view to provide carers with information about delirium and strategies to address caregiving stress and burden.

Key Results

Participants included 25 carers (43% response rate) ( n  = 17, 68% female) aged 29–88 ( M  = 65, SD  = 17.7 years). Carer delirium knowledge increased significantly from pre-to-post intervention ( p  =  < .001; CI 2.07–4.73). Carers’ intent and actual use of PREDICT was ( n  = 18, 72%; and n  = 17, 68%). Carer burden and psychological distress did not significantly change. The incidence of delirium in the intervention ward although not significant, decreased, indicating opportunity for scaling up.

The prevention and management of delirium are imperative for safe and quality care for patients, carers, and staff. Further comprehensive and in-depth research is required to better understand underlying mechanisms of change and explore facets of nursing practice influenced by this innovative approach.

Avoid common mistakes on your manuscript.

INTRODUCTION

Delirium, the most common hospital-acquired complication worldwide, is characterized by shifting attention, incoherence, disorientation, and impaired cognition. 1  It is a frightening experience for the person affected, and their sudden change in behavior and/or emotions can impact family carers’ burden and psychological distress. 1 , 2 , 3  The global rise in ageing populations is expected to exacerbate the impact of delirium in healthcare settings, leading to increased rates of hospital-acquired complications (e.g., falls), delayed discharge, re-admissions, dementia, residential aged care admissions, death, and greater caregiving responsibilities for families. 4  Therefore, the prevention, identification, and early management of delirium are imperative in the provision of safe, high-quality care for both the patient and their family.

The healthcare team, including nurses, are responsible for the initial and ongoing assessment, management, and safety of patients at risk of delirium across hospital settings; however, prevention strategies and risk screening are not consistently practiced, and understanding of and recognition of delirium is poor. 5 , 6 , 7  Reasons for undiagnosed delirium include language barriers, fluctuation of symptoms during the day, a lack of routine screening and assessment, lack of resources, competing clinical priorities, and organization culture. 5 , 8 , 9 , 10 , 11 , 12 , 13  These are compounded by a lack of knowledge of the patient’s prior day-to-day level of functioning by the healthcare team. 14

Rapid deterioration due to delirium begins with subtle changes that are best recognized by family or close ones (referred to as carers here on). 15  Carers can provide not only a valuable cognitive anchor point but also comforting reassurance, and if supported by clinicians, implement preventative non-pharmacological interventions. 14 , 16 , 17 , 18 , 19 , 20 , 21  Interventions implemented with carers to address delirium have been found to improve nurse and carer delirium knowledge, 20  reduce carer psychological distress, 18 , 22  and length of hospital stay. 18 , 23 , 24  However, innovative interventions to support partnerships with carers in the prevention and management of delirium in the hospitalized older patient are needed. 25 , 26

The primary aim of this study was to evaluate a Pr evention & E arly D elirium I dentification C arer T oolkit (PREDICT) to support partnerships between carers and nurses to prevent and manage delirium. Specifically, the study aimed to evaluate changes in the carer:

•Knowledge of delirium prevention and management

•Beliefs about their role in partnering in delirium prevention and management

•Actual and intended use of PREDICT

•Levels of burden and psychological distress

A secondary aim of this study was to evaluate changes in the incidence of delirium. We hypothesized that the involvement of nurses would improve their understanding of delirium and lead to changes in nursing practice and delirium incidence rates.

METHOD AND MATERIALS

A pre–post-test intervention study was conducted on a medical ward in an Australian regional hospital with data collected during admission (pre-intervention) and 4–6 weeks post-discharge (post-intervention). A further observational study to address the secondary aim examined the incidence of delirium during the intervention period compared to the same period 12 months prior.

The Intervention (PREDICT)

Acknowledging and valuing the insight and lived experience, a model of care utilizing a Pr evention & E arly D elirium I dentification C arer T oolkit (PREDICT) was codesigned and validated by carers whose family members had been hospitalized and for some had experienced delirium, consumers, and healthcare professionals working in the acute care setting. 27  PREDICT, available on a digital platform and accessed via QR code, included short videos and information on delirium preventive strategies, risk factors, and non-pharmacological interventions to reorientate older adults who experience delirium. To enable carers to express and communicate their concerns about the person being cared for, an interactive psychometrically tested delirium screening questionnaire suitable for informal or untrained carers was also included. 14  To support carer well-being and address burden and psychological distress, PREDICT also includes information and links to carer resources such as counselling and social prescribing programs (social service programs that provide activities to improve health and well-being). 27  PREDICT was also made available in hard copy.

Participants were carers of Indigenous patients aged 45 years and older and non-Indigenous patients aged 65 years and older. The lower age range for Indigenous patients was set because people who identify as Indigenous Australians are more likely to develop serious medical conditions earlier in life and have a lower life expectancy than non-Indigenous Australians 28 (Australian Institute of Health and Welfare, 2023).

Eligibility

The carer was eligible to receive PREDICT if visiting at the patient’s bedside daily during hospitalization for ≥ 2 days and could communicate in English or with an interpreter. The carer was not eligible to participate if the patient’s hospital stay was less than 48 h, and the patient was receiving end-of-life care or had a diagnosis of advanced dementia and was unable to communicate or interact.

Prior to the implementation of PREDICT (September 2022 to February 2023), nurses received a delirium education session and orientation to PREDICT, and during the study nurses received ongoing weekly briefings from the lead ward nurse for dementia and delirium. This regular communication was to ensure the nursing staff were equipped to answer questions the carer may have regarding PREDICT, the delirium screening questionnaire, and the study evaluation. Posters promoting PREDICT and the study evaluation were placed in strategic areas around the ward, with contact information for further enquiries.

The admitting nurse offered eligible carers access to PREDICT. Carers were advised that they were not required to participate in the study evaluation (that is, complete the study survey) to receive and engage with PREDICT.

Nursing staff were encouraged to support all carers to use PREDICT daily, including the delirium screening questionnaire. 14  Carers were not offered incentives to participate.

Data Collection

Participating carers were invited to complete an anonymous survey online using Qualtrics, 29  or in a paper-based format, at admission (pre-intervention) and 4–6 weeks post-discharge (post-intervention). Pre- and post-intervention surveys were matched using an anonymous participant-generated code (the last 4 digits of participants’ phone numbers, and first initial of their mother’s name). For carers completing a paper-based survey, a secure box was placed at the nurses’ station for surveys returned at admission and a reply-paid envelope for surveys returned at 4–6 weeks follow-up. The incidence of delirium (using the standard unit of measurement of utilization—cases per 1000 occupied bed days (OBDs)) during the intervention period (T2) was compared to the same period 12 months prior (T1).

The following measures were combined into the online survey as a continuous tool.

Demographics

Carer demographic items included age, gender, whether they identified as Aboriginal or Torres Strait Islander, length of time as a carer, their relationship with the person they cared for, and whether they lived together, as well as the age and gender of the person they cared for.

Caregiver Delirium Knowledge Questionnaire (CDKQ) 14

The CDKQ is a validated measure of carer knowledge of delirium risk factors, symptoms, and appropriate actions with good internal consistency reliability (Cronbach’s α  = 0.76). 22  Nineteen true/false items across three subscales include Risk (10 items, e.g., dehydration), Symptoms (5 items, e.g., increasing confusion over several days), and Actions (4 items, e.g., immediately calling a doctor). Total and subscale scores comprise the sum of correct items where higher scores indicate greater knowledge.

Beliefs About Carers’ Role in Partnering in Delirium Prevention and Management

A single item question was asked, rated “yes” or “no.”

“Do you think that carers should be incorporated into delirium identification and management?”

Carers’ Intended and Actual use of PREDICT, Including the Delirium Screening Questionnaire

Two questions were asked, rated “yes” or “no.”

“Do you intend to use/ Did you use the Delirium Toolkit?” “Do you intend to use/ Did you use the delirium screening questionnaire?”

Caregiver Delirium Burden Scale (DEL-B-C) 30

The DEL-B-C is a validated 16-item measure of the burden experienced by carers; Cronbach’s α  = 0.82. 31  Total scores range from 0 to 40 with higher scores indicating greater burden.

Kessler Psychological Distress Scale (K10) 32

The K10 is a widely used and validated measure of psychological distress; Cronbach’s α  = 0.93. 32 , 33  Total scores range from 10 to 50 with higher scores indicating greater psychological distress.

Incidence of Delirium

Routinely collected hospital data was accessed to determine delirium incidence. Data was calculated using cases per 1000 OBDs which were compared from September 2021 to February 2022 (T1) and during the intervention period September 2022–February 2023 (T2).

Ethical Conduct

Ethical approval was provided by [ removed for blinding ].

Data were entered using Qualtrics survey software, 29  downloaded and cleaned, checked, and analyzed in SPSS 27 34 and OpenEpi 35 analysis software. Summary and descriptive statistics were produced including frequencies, totals, and means of participant demographics and study outcome variables. Significance level was set at alpha ( α ) = 0.05. Normality was established by visual inspection of histograms, skew and kurtosis, and Shapiro–Wilk (as n  < 50) tests of normality. 36  Cohen’s d effect sizes were calculated as estimates of clinical significance where 0.2 indicates a small effect size, 0.5 moderate, and 0.8 large. 37  Normally distributed data were assessed for change from admission to post-discharge using paired t -tests (CDKQ, DEL-B-C, K10). Non-parametric data were assessed for change using related-samples McNemar change tests for dichotomous dependent variables (beliefs about partnering, satisfaction with care). Relationships between demographics and outcome variables (years as a carer versus intended and actual use of PREDICT) were assessed using independent-samples Mann–Whitney U tests. Missing values were handled as follows: frequency data (demographics, beliefs about partnering and use of PREDICT) were unchanged and were reported in raw form; missing CDKQ items were scored as incorrect; missing DEL-B-C items were scored as though carers had not experienced the relevant burden; and no K10 items were missing. Change in delirium incidence was analyzed by calculating an incidence rate ratio (IRR)—that is, comparing incidence at T1 and T2, wherein an IRR of 1 (or 95% CI that includes 1) indicates equal rates of delirium and thus a non-significant change; Z (standard) scores and p values are also presented for IRRs. 38 , 39

PREDICT was provided to a total of 56 carers, of whom 25 carers (43%) provided pre- and post-intervention data. Carers were primarily females ( n  = 17, 68%) with an average age of 65 years ( SD  = 17.7) providing care for their partner ( n  = 15, 60%). The majority of carers ( n  = 17, 68%) lived with the patient prior to admission. A total of seven carers (28%) reported the patient was diagnosed with delirium; see Table  1 for demographics.

Carer Delirium Knowledge

Carer delirium knowledge (CDKQ) 22 increased significantly from admission ( M  = 8.7, SD  = 4.62) to post-discharge ( M  = 12.1, SD  = 5.43). Scores increased by an average of 3.4 ( SE  = 0.65, 95% CI [2.07, 4.73]; paired t (24) = 5.27, p  =  < 0.001, d  = 1.1). This very large effect size (d) indicates a meaningful, clinically significant improvement in delirium knowledge. 37

Beliefs about Partnering in Delirium Prevention and Management

During admission, the majority of carers ( n  = 18, 72%) believed carers should be incorporated into delirium identification and management, which increased to 24 (96%) post-discharge. A related-samples McNemar change test indicated this was a significant increase ( p  < 0.001).

Carers’ Intended and Actual Use of PREDICT

At admission, most carers intended to use PREDICT ( n  = 18, 72%), and at post-discharge nearly all carers with positive intentions reported they had used PREDICT ( n  = 17, 68%). Similarly, at admission, most carers intended to use the delirium screening questionnaire ( n  = 17, 68%) and at post-discharge most reported they had used it ( n  = 15, 60%), reflecting an effective intention-behavior link with minimal gap; 40  see Table  2 .

Intended and actual use of PREDICT was associated with total time as a carer, where participants who had been carers for longer were significantly more likely to report intention to use PREDICT (Mann–Whitney U  = 93.5, p  = 0.003) and the delirium screening questionnaire ( U  = 90.0, p  < 0.001) weekly, and actual weekly use PREDICT ( U  = 69.0, p  = 0.039) and delirium screening questionnaire ( U  = 77.0, p  = 0.011).

Carer Burden and Distress

Carer burden (DEL-B-C) 31 and distress (K10) 32 did not change significantly from admission to post-discharge ( p  > 0.05). K10 scores were consistently high with carers reporting moderate–high levels of psychological distress at both timepoints 41 ; see Table  3 .

The incidence of delirium on the medical ward was 16.6 cases per 1000 OBDs for 2022/2023, compared to 27.1 cases per 1000 OBDs in the 2021/2022 matched period. The incident risk ratio (IRR) for delirium during the period PREDICT was introduced, compared to the same period 12 months prior which was 0.61 [95%CI 0.33, 1.13]. The associated z -value was 1.59 with a p -value of 0.056 approaching significance. Given the impacts of COVID-19 on healthcare utilization, for contextual comparison points data was also pulled for the whole of hospital, the whole of health district, and the state for the same time periods, which can be seen in Table  4 . No other dataset showed any changes in OBD nearing significance, demonstrating promise of association related to the intervention rather than external factors.

There is increasing attention on the importance of the prevention and early management of delirium because of the deleterious effect on older patients’ and carers’ health and well-being. 2 , 3 , 30  This study evaluated the introduction of a model of care utilizing PREDICT, an interactive toolkit designed to support partnerships with carers and nurses in the prevention and management of delirium. The results of this study while only indicative, are promising, highlighting a partnership approach with carers may impact delirium prevention and management.

Several recent systematic reviews and meta-analyses highlight the importance of carer involvement in delirium management 42 and the efficacy of education; 11 , 18  however, many key studies omit the carer perspective. 15  While most carers in this study significantly increased their knowledge of delirium, we were also able to demonstrate that they saw a clear role for their ongoing involvement in preventing and managing delirium, particularly carers who had been caring for a longer time. This is important because it presents opportunities for improved long-term patient outcomes as the carer is likely to continue to monitor delirium risk following discharge. These findings respond directly to the expectations of carer involvement in care decisions and delivery, as demonstrated by delirium guidelines and standards worldwide. 43 , 44 , 45

Despite increases in delirium knowledge and the utilization of acquired learnings, carers’ moderately high levels of psychological distress and burden did not significantly improve, contrasting with other studies. 11 , 22  While this finding could be due to differences in characteristics of sample populations, it is consistent with studies reporting carers were often highly distressed when the person they were caring for experienced delirium or was at risk of delirium. 46 , 47  Perception of burden is multifaceted and changes over time, raising questions as to whether equity measurements, such as social needs and barriers to care, such as transportation, food insecurity, and housing, are more relevant outcome indicators of burden for carers. 48  While the focus on partnering with carers in our study maximizes the opportunity for enhanced communication and collaboration between carers and nurses, further research is required to elicit the impact of psychological distress and burden in the management of delirium. 30 , 49  Where health inequities impact vulnerable groups including LGBTQ + and Indigenous communities, 50  further research is required to enable carers to highlight their well-being and support needs.

Finally, in relation to our secondary aim, our findings indicate the potential of partnering with carers in delirium prevention and the broad promotion of PREDICT for reducing the incidence of delirium. Given change in the incidence of delirium was not seen elsewhere in the hospital, local health district, or state figures, it is reasonable to hypothesize that PREDICT might have had a ripple effect at the ward level and improved nurses’ delirium prevention practice. Combined with the pre–post-intervention results, there appears to be merit in proceeding to a randomized controlled trial to further validate and understand this model of care and PREDICT’s broader impact.

When deploying this toolkit in additional facilities, it would be of benefit to specifically explore changes in nurse delirium knowledge levels and self-rated confidence in detecting delirium. This would enable improved measurement of the program’s impact on nurses’ understanding and competence in managing delirium cases. It would also be of benefit to include qualitative interviews to better understand how consciously or unconsciously the program may have influenced their practice, altered perceptions of patient interactions, and transformed their overall approach to care, providing a deeper understanding of any mechanisms of change. Finally, future studies could examine any changes to the way in which nurses work when acting in the role of partner in care, including if there are any changes in shared vigilance, improved communication with carers, or changes in intervention strategies. Understanding any mechanisms of change would be crucial for refining program design and understanding its impact.

Study Limitations

A limitation of this study lies in the small sample size and its location in a single medical ward in an Australian regional hospital. This study did not calculate average length of stay; however, older persons’ hospital service utilization in Australia is reported to average 7.1 days. 51  A further limitation was that PREDICT was validated with carers in the community 27 but not an inpatient setting. Finally, PREDICT is limited to those patients who have carers visit at the bedside. While carers are not always at the bedside 24/7, the provision of PREDICT to carers upon admission will support any non-face to face communication between healthcare professionals and carers about the cognitive status of the patient. Future rigorous research as to whether partnering with carers in the prevention of delirium using PREDICT can reduce the incidence of delirium will be an important next step.

This study focused on engaging and supporting carers as partners in the prevention and management of delirium. While this study presents encouraging preliminary results, more extensive research is required seeking to better understand underlying mechanisms of change and exploring additional facets of nursing practice influenced by this innovative approach.

Data Availability

The data presented in this study are available on request from the corresponding author (Christina Aggar).

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Acknowledgements

Nursing staff who supported the dissemination of Carer Delirium Toolkit and partnering with carers. Nurse leaders who advocated for the Carer Delirium Toolkit: Brenda Paddon, Princy Albert, and Hannah Graves. Tamsin Thomas and Tina Prassos for supporting the analysis of this study and preparation of the paper for publication and most importantly the study participants for sharing their experiences.

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Aggar, C., Craswell, A., Bail, K. et al. A Toolkit for Delirium Identification and Promoting Partnerships Between Carers and Nurses: A Pilot Pre–Post Feasibility Study. J GEN INTERN MED (2024). https://doi.org/10.1007/s11606-024-08734-6

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

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

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

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

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

Design and Method

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

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

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

Nursing implication

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

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Introduction

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

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

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

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

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

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

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

Study objectives

Assess the levels of academic stress among nursing students.

Assess the learning approaches among nursing students.

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

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

Materials and methods

Research design.

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

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

Participants and sample size calculation

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

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

Tool two: the perceived stress scale (PSS)

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

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

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

Ethical considerations

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

Tools validity

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

Pilot study

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

Data collection

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

Data analysis

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Strengths and limitations of the study

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

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

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

Implications in nursing practice

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

Data availability

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

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Acknowledgements

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

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

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

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

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

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

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Received : 31 January 2024

Accepted : 21 March 2024

Published : 17 April 2024

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

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