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The essentials of nursing leadership: A systematic review of factors and educational interventions influencing nursing leadership

Affiliations.

1 Faculty of Nursing, Edmonton Clinic Health Academy, University of Alberta, 11405 87 Ave NW, Edmonton, AB T6G 1C9, Canada. Electronic address: [email protected].
2 Department of Nutrition, Dietetics and Food, School of Clinical Sciences at Monash Health, Monash University, Level 1, 264 Ferntree Gully Rd, Notting Hill, VIC 3168, Australia.
3 Faculty of Nursing, Edmonton Clinic Health Academy, University of Alberta, 11405 87 Ave NW, Edmonton, AB T6G 1C9, Canada.
4 Faculty of Nursing, Edmonton Clinic Health Academy, University of Alberta, 11405 87 Ave NW, Edmonton, AB T6G 1C9, Canada; Technical High School of Campinas, State University of Campinas (UNICAMP), Barão Geraldo, Campinas - São Paulo 13083-970, Brazil.
PMID: 33383271
DOI: 10.1016/j.ijnurstu.2020.103842

Background: Nursing leadership plays a vital role in shaping outcomes for healthcare organizations, personnel and patients. With much of the leadership workforce set to retire in the near future, identifying factors that positively contribute to the development of leadership in nurses is of utmost importance.

Objectives: To identify determining factors of nursing leadership, and the effectiveness of interventions to enhance leadership in nurses.

Design: We conducted a systematic review, including a total of nine electronic databases.

Data sources: Databases included: Medline, Academic Search Premier, Embase, PsychInfo, Sociological Abstracts, ABI, CINAHL, ERIC, and Cochrane.

Review methods: Studies were included if they quantitatively examined factors contributing to nursing leadership or educational interventions implemented with the intention of developing leadership practices in nurses. Two research team members independently reviewed each article to determine inclusion. All included studies underwent quality assessment, data extraction and content analysis.

Results: 49,502 titles/abstracts were screened resulting in 100 included manuscripts reporting on 93 studies (n=44 correlational studies and n=49 intervention studies). One hundred and five factors examined in correlational studies were categorized into 5 groups experience and education, individuals' traits and characteristics, relationship with work, role in the practice setting, and organizational context. Correlational studies revealed mixed results with some studies finding positive correlations and other non-significant relationships with leadership. Participation in leadership interventions had a positive impact on the development of a variety of leadership styles in 44 of 49 intervention studies, with relational leadership styles being the most common target of interventions.

Conclusions: The findings of this review make it clear that targeted educational interventions are an effective method of leadership development in nurses. However, due to equivocal results reported in many included studies and heterogeneity of leadership measurement tools, few conclusions can be drawn regarding which specific nurse characteristics and organizational factors most effectively contribute to the development of nursing leadership. Contextual and confounding factors that may mediate the relationships between nursing characteristics, development of leadership and enhancement of leadership development programs also require further examination. Targeted development of nursing leadership will help ensure that nurses of the future are well equipped to tackle the challenges of a burdened health-care system.

Keywords: Interventions; Leadership; Nursing workforce; Systematic Review.

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Targeting personalised leadership factors based on the organisational needs of nurses may cultivate and improve their nursing leadership. Singh S, Kapoor S. Singh S, et al. Evid Based Nurs. 2022 Apr;25(2):68. doi: 10.1136/ebnurs-2020-103385. Epub 2021 Aug 18. Evid Based Nurs. 2022. PMID: 34407986 No abstract available.

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Anne Mulhall , MSc, PhD
Independent Training and Research Consultant West Cottage, Hook Hill Lane Woking, Surrey GU22 0PT, UK

https://doi.org/10.1136/ebn.1.1.4

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Why has research-based practice become so important and why is everyone talking about evidence-based health care? But most importantly, how is nursing best placed to maximise the benefits which evidence-based care can bring?

Part of the difficulty is that although nurses perceive research positively, 2 they either cannot access the information, or cannot judge the value of the studies which they find. 3 This journal has evolved as a direct response to the dilemma of practitioners who want to use research, but are thwarted by overwhelming clinical demands, an ever burgeoning research literature, and for many, a lack of skills in critical appraisal. Evidence-Based Nursing should therefore be exceptionally useful, and its target audience of practitioners is a refreshing move in the right direction. The worlds of researchers and practitioners have been separated by seemingly impenetrable barriers for too long. 4

Tiptoeing in the wake of the movement for evidence-based medicine, however, we must ensure that evidence-based nursing attends to what is important for nursing. Part of the difficulty that practitioners face relates to the ambiguity which research, and particularly “scientific” research, has within nursing. Ambiguous, because we need to be clear as to what nursing is, and what nurses do before we can identify the types of evidence needed to improve the effectiveness of patient care. Then we can explore the type of questions which practitioners need answers to and what sort of research …

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Published: 14 June 2021

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

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

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

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

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

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

Conclusions

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

Peer Review reports

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

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

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

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

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

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

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

Setting and participants

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

Data collection

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

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

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

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

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

Data analysis

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

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

Ethical considerations

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

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

Distinction based on complexity of care

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

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

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

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

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

Organizing hospital care

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

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

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

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

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

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

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

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

Evidence-based practices in quality improvement work

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

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

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

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

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

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

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

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

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

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

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

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

Limitations

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

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

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

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

Availability of data and materials

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

Abbreviations

Bachelor-trained nurse

Vocational-trained nurse

Evidence-based Practices

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Acknowledgements

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

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

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

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

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Published: 23 August 2024

Unveiling missed nursing care: a comprehensive examination of neglected responsibilities and practice environment challenges

Somayeh Babaei 1 ,
Kourosh Amini ORCID: orcid.org/0000-0003-2363-894X 2 &
Farhad Ramezani-Badr 3

BMC Health Services Research volume 24 , Article number: 977 ( 2024 ) Cite this article

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Metrics details

The global variable of missed nursing care and practice environment are widely recognized as two crucial contextual factors that significantly impact the quality of nursing care. This study assessed the current status of missed nursing care and the characteristics of the nursing practice environment in Iran. Additionally, this study aimed to explore the relationship between these two variables.

We conducted an across-sectional study from May 2021 to January 2022 in which we investigated 255 nurses. We utilized the Missed Nursing Care Survey, the Nursing Work Index-Practice Environment Scale, and a demographic questionnaire to gather the necessary information. We used the Shapiro‒Wilk test, Pearson correlation coefficient test, and multiple linear regression test in SPSS version 20 for the data analyses.

According to the present study, 41% of nurses regularly or often overlooked certain aspects of care, resulting in an average score of 32.34 ± 7.43 for missed nursing care. It is worth noting that attending patient care conferences, providing patient bathing and skin care, and assisting with toileting needs were all significant factors contributing to the score. The overall practice environment was unfavorable, with a mean score of 2.25 ± 0.51. Interestingly, ‘nursing foundations for quality of care’ was identified as the sole predictor of missed nursing care, with a β value of -0.22 and a p -value of 0.036.

Conclusions

This study identified attending patient care interdisciplinary team meetings and delivering basic care promptly as the most prevalent instances of missed nursing care. Unfortunately, the surveyed hospitals exhibited an undesirable practice environment, which correlated with a higher incidence of missed nursing care. These findings highlight the crucial impact of nurses’ practice environment on care delivery. Addressing the challenges in the practice environment is essential for reducing instances of missed care, improving patient outcomes, and enhancing overall healthcare quality.

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Introduction

Missed Nursing Care (MNC) is the failure to provide any necessary aspect of patient care, partially or entirely, or delay in delivering it [ 1 ]. MNCs can have severe side effects on patients, including safety threats [ 2 ] and even mortality [ 3 ]. It also significantly decreases the quality of nursing care [ 4 ]. MNC can also have adverse and destructive effects on nurses, including decreased job satisfaction, increased absenteeism, and the intention to leave their jobs [ 5 ]. As a result, MNCs have become a key focus of nursing researchers in recent years and are widely recognized as a significant global problem [ 6 ].

A literature review revealed that MNCs are multidimensional and vary significantly in frequency and elements across different research communities [ 7 ]. In Iran, information regarding MNCs is limited. According to our search, only one reliable study [ 8 ] has been conducted on this topic in the last five years. Chegini et al. conducted a study that showed that the percentage of participants who missed care was 72.1%. The most common tasks of missed nursing care included patient discharge planning and teaching, emotional support for patients and their families, interdisciplinary care conferences, and patient education regarding their illness, tests, and diagnostic procedures. Although the study by Chegini et al. has provided valuable information, the generalizability of its results is limited due to its small sample size. The study included nurses from only medical-surgical wards and used the census sampling method.

MNC is influenced by various individual and organizational factors [ 9 ]. In a systematic review, Chiappinotto et al. identified significant factors contributing to MNC, such as low nurse-to-patient ratios, high workloads, and poor work environments. Moreover, stress, job dissatisfaction, and inadequate education among nurses were recognized as crucial elements. Furthermore, patient clinical instability was found to further worsen MNC [ 10 ]. However, some researchers argue that organizational and environmental factors are more influential in causing MNC than individual factors [ 11 ].

Another influential organizational variable on nursing performance is the practice environment (PE) [ 12 ]. PE in nursing is inclusive of material and human resources, a cooperative environment, and other elements related to the environment that directly or indirectly affect how care is provided [ 13 ]. PE is involved in nurses’ burnout [ 14 ], job satisfaction, stay in nursing [ 15 ], and overall quality of nursing care [ 16 ]. Like in MNCs, evidence suggests that PE varies across different hospitals and wards within a hospital [ 17 ]. For instance, a study conducted by Choi & Boyle in the U.S. demonstrated that pediatric wards had more favorable PEs than did medical-surgical wards. However, previous studies have shown that MNCs differ across poor, moderate, and suitable PEs. Weak PE has been found to increase MNCs [ 18 ], while optimal PE reduces MNCs [ 17 ]. Due to the global significance of MNCs and PEs for quality of care and the variability of these two variables due to different sociocultural factors, it is essential to understand the weaknesses of MNCs and PEs in every community thoroughly. Therefore, this study aimed to determine the status of MNCs, the characteristics of PEs, and the relationships between these two variables among nurses working in two teaching hospitals.

The present study was cross-sectional from May 30, 2021, to January 19, 2022. The study was conducted according to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines. The study included nurses employed in the medical-surgical, emergency, and intensive care units of two major teaching hospitals in Zanjan Province. This province is situated in the northwestern region of Iran and has a population of approximately 1,016,000 people. To be eligible for participation in the study, the nurses needed to meet the following specific inclusion criteria:

A minimum of three months of work experience in the desired ward.

Holding a bachelor’s degree or higher.

Consent to participate in the study was obtained.

We utilized Formula 1 for a finite population to determine the sample size. The values used in this formula were N (total population) = 553, power (the probability of correctly rejecting the null hypothesis) = 0.80, standard deviation (SD) = 13.97, d (margin of error or precision) = 1.2, and Z (standardized value for the corresponding level of confidence) = 1.96. The formula indicated that a minimum sample size of 246 was required based on these variables. During the research, we found that a recent study comparable to our work was conducted by Park et al. [ 18 ]. For our research, we utilized the standard deviation of the variables in Formula 1. Their study recorded the mean and standard deviation of the MNC and PE as 84.06 ± 13.79 and 2.92 ± 0.25, respectively. We included the higher standard deviation (related to MNCs) to ensure a larger sample size. We prepared 270 questionnaires and distributed them among the selected nurses. We also considered the possibility of spoiled questionnaires and distributed extra questionnaires accordingly. Fifteen questionnaires were excluded from the study due to incomplete data, leaving a total of 255 questionnaires that were used for data analysis out of the 270 that were distributed.

We utilized a systematic random method to select the nurses for the study. In the first step, a list of nurses working in the desired wards was taken, and the sampling frame was prepared. In the second step, each nurse was assigned a number from a table of random numbers. This process generated a new sampling frame. In the third step, we calculated the distance between the study samples, denoted as ‘K’, using the formula K = N/n.’ We computed K by dividing the total population (N) of 553 by the sample size (n) of 270, approximately 2. To select the participants, we utilized a systematic random method. A new sampling frame was generated in the first step, as described earlier. The first nurse was selected randomly from this new sampling frame, and the subsequent samples were taken at a distance of two people from the previous nurse.

To collect the data, we used three different questionnaires: (a) a demographic profile form, (b) the Missed Nursing Care (MISSCARE) Survey, and (c) the Nursing Work Index-Practice Environment Scale (NWI-PES). The demographic profile included various variables, including sex, age, marital status, educational degree, work experience, position, shift work, employment type, and ward type.

In this study, we utilized the MISSCARE survey (MISSED) to assess MNC. We chose the MISSED based on its extensive utilization and strong psychometric properties, as evidenced in the literature. As noted by Chiappinotto et al. [ 10 ], 34 out of the 58 studies reviewed utilized a version of the MISSCARE survey, highlighting its reliability and validity in assessing MNC. The MISSCARE Survey consists of two parts: Part ‘A’ and Part ‘B’. Part ‘A’ included the most missed care components, while Part ‘B’ included the reasons for missing nursing care. We utilized part ‘A’ of the questionnaire, which constituted 24 items of the MISSCARE Survey. Each of the 24 items comprises five answer options: 1) rarely or never missed, 2) occasionally missed, 3) frequently missed, 4) always missed, and 5) nonapplicable. Kalisch & Williams included the option of ‘nonapplicable’ to account for nurses who operate in situations where certain care activities may not be performed [ 19 ]. The total score range of this survey is 24–96, where higher scores indicate a greater probability of missed care. In line with the findings of a previous study [ 17 ], we considered the combination of “frequently missed” and “always missed” options as missed care to demonstrate the frequency of missed nursing care. The MISSCARE Survey has undergone psychometric analysis, and its applicability has been approved for the nursing community in Iran [ 20 ]. The internal consistency of the tool was measured based on Cronbach’s alpha coefficient (α = 0.88) in this study.

The psychometric analysis of the NWI-PES has been conducted, and its usage has been approved [ 21 ]. Developed by Lake in 2002 and authorized by the National Quality Forum (NQF), this scale comprises thirty-one items and operates on a four-point Likert scale, with scores ranging from four to one. The response options were strongly agree = 4, somewhat agree = 3, somewhat disagree = 2, and strongly disagree = 1. According to [ 22 ], the possible score range of the whole scale and its subscales is one to four. The NWI-PES comprises five subscales:

The nurses’ participation in hospital affairs was evaluated with nine items.

‘Staffing and resource adequacy’, which includes four items.

The three items used were “Collegial nurse‒physician relations”.

‘Nursing foundations for quality of care’ with ten items.

The five items asked about nurses’ ability, leadership, and support.

A scale midpoint greater than 2.5 is considered an acceptable PE [ 22 ]. The NWI-PES demonstrated high internal consistency, with a Cronbach’s alpha of 0.93. The Cronbach’s alpha for each of the subscales of the NWI-PES was computed. The results were as follows: ‘nurse participation in hospital affairs,’ α = 0.88; ‘nursing foundations for quality-of-care,’ α = 0.72;‘staffing and resource adequacy,’ α = 0.87; ‘collegial nurse‒physician relations,’ α = 0.90; and ‘nurse manager ability, leadership, and support of nurses,’ α = 0.84.

We computed the means and standard deviations of the MNC and PE scores and utilized the Shapiro‒Wilk test to determine the normality of the data distribution. The results revealed that the data followed a normal distribution. We employed the Pearson correlation coefficient to determine the correlation between PEs and MNCs. Furthermore, we conducted a multiple linear regression test to examine whether changes in the MNC score, as the dependent variable, were associated with changes in the PE subscale scores. Before conducting the multiple linear regression analysis, we confirmed that the assumptions were met and evaluated. We confirmed the assumption of independent errors by using the Durbin–Watson test. Homoscedasticity and linearity assumptions were assessed through P-P plots. The hypothesis of multicollinearity was examined by determining the variance inflation factor (VIF) and tolerance [ 23 ]. The VIF ranged from 1.006 (TOL = 0.99) for ‘collegial nurse‒physician relations’ to 1.04 (TOL = 0.96) for ‘nursing foundations for quality-of-care.’ Independent t tests and ANOVA were used to evaluate the associations between demographic variables and MNCs. The statistical analysis of the data was conducted using SPSS software version 24, and a P value lower than 0.05 was used to indicate statistical significance.

Participants’ characteristics

The majority of the participants were females (84.3%), were married (68.2%), and were employed on a 5-year contract (46.7%). The majority of the participants were females (84.3%), were married (68.2%), and were employed on a 5-year contract (46.7%).

In addition, almost all of the participants (95.7%) had a Bachelor of Science in Nursing (BSN) degree, and a significant proportion (45.8%) worked in medical-surgical wards. Most of the respondents (91.4%) were staff nurses, and 89.8% of them worked in rotational shift work. The.

The participants’ average age and work experience were 33.94 ± 7.40 and 9.25 ± 7.14, respectively (Table 1 ).

Missed nursing care

The overall mean score for MNCs, with a score ranging from 24 to 96, was 32.34 ± 7.43. Of the total nurses, 41% reported that they always or frequently missed at least one aspect of nursing care. Based on the findings, the items with the highest mean score in descending order were attending an interdisciplinary patient care conference, patient bathing or skin care, assisting with toileting needs within 5 min of request, mouth care, and feeding the patient when the food was still warm (Table 2 ).

The mean MNC score was significantly greater for male nurses than for female nurses (X̄1 = 36.25, X̄2 = 31.56; t = -3.738, p < 0.001). Other demographic and occupational variables of the nurses, such as age, marital status, degree, work experience, position, rotational shift work, type of employment, and working place, had no significant association with MNCs ( p > 0.05).

Practice environment characteristics

The overall mean score for PE was 2.25 ± 0.51. Among the different subscales of the PE scale, the highest mean score was observed for ‘collegial nurse‒physician relations’ (M = 2.45, SD = 0.72). Furthermore, the mean scores for “nursing foundations for quality of care”, “nurse manager ability, leadership, and support of nurses”, and “nurse participation in hospital affairs” were 2.43 ± 0.58, 2.23 ± 0.65, and 2.16 ± 0.58, respectively. The lowest mean score was observed for ‘staffing and resource adequacy’ (M = 1.81, SD = 0.64).

Correlations between practice environment characteristics and missed care

The study’s results indicate a significant and negative correlation between the mean score of PEs and the overall mean score of MNCs ( r = -0.18, p = 0.002). There was a strong link between the overall mean score of MNCs and two of the five NWI-PES subscales: “nursing foundations for quality of care” ( r = -0.21, p < 0.001) and “nurse manager ability, leadership, and support of nurses” ( r = -0.16, p = 0.006).

Predicting missed nursing care based on practice environment subscales

According to Table 3 , linear regression analysis showed that only “nursing foundations for quality of care” (β = -0.22, p = 0.036) of the five NWI-PES subscales could predict MNC.

The main objective of this study was to determine the status of MNCs, the characteristics of PEs, and the relationships between these two variables among Iranian nurses working in two teaching hospitals. The findings showed that 41% of nurses reported frequently or always missing at least one aspect of nursing care. A systematic review also reported that 55–98% of nurses missed at least one course of nursing care [ 24 ]. However, the overall mean score of MNCs in our study was 32.3. A literature review revealed that our study’s mean MNC score was lower than that reported in the United States, Turkey, and Australia, except for Iceland [ 25 ]. By comparing our study results with those from other countries [ 26 ], it can be concluded that low MNCs were reported in our study. Like in many previous studies, in this study, we used the self-reporting method. The reason for the lower mean score of MNCs in our study compared to that in other studies might be due to two biases: “acquiescence response style” (tendency to respond positively) and “social desirability bias” (tendency to present oneself socially to be acceptable, but it does not fully reflect the reality of the individual). Due to the two biases mentioned earlier, the ‘truth-telling’ in our survey might have been compromised. This is because we used the self-reporting method to collect data, and the nature of MNCs is one of the essential aspects of ethics in nursing. The study findings indicated that patients who participated in interdisciplinary conferences had the highest mean score. However, not attending training classes can decrease knowledge and make nursing care less updated, ultimately reducing the quality of care provided to patients [ 27 ]. This finding is consistent with that of another study conducted in Brazil [ 7 ]. Based on our field experiences and observations, several factors, including the following, seem to play a significant role in missing nursing care:

Time limitation due to a nursing shortage.

Inappropriate timing of training classes or conferences and conflicts in daily schedules.

There is a lack of support and encouragement from managers, especially hospital managers.

Inappropriate and nonequipped venues for classes.

Improper teaching methods and giving lectures instead of using new teaching methods.

There is a lack of proper alert reminders for nurses regarding the date, time, and place of meetings.

Our study revealed that the lowest scores for missed care were related to items such as ‘bedside glucose monitoring as ordered”, ‘peripheral IV/central line site care and assessments according to hospital policy’, and ‘vital signs assessments as ordered.’ The lower scores associated with this care could be attributed to the use of an accurate system for recording patients in patient files and additional unique records above patients’ beds in the current research environment, which helps staff remember and check this care more often. However, these care tasks are crucial parts of a patient’s vital nursing care and should be performed during each work shift to monitor the patient’s hemodynamic status. This information about each patient was provided to the assigned nurse during the shift handover. A lack of ‘blood sugar control’ was also indicated in the studies of Smith et al. [ 17 ] in the U.S.

Our study revealed a low PE score among the participating nurses. Given that nurses have greater responsibility for caring and have essential tasks such as performing technical procedures, making decisions, and leading patient care, such tasks are affected by poor practices. Consequently, patient and family satisfaction decreases, and adverse patient outcomes, such as mortality and infection, may increase. Azevedo Filho et al. also demonstrated a poor nursing practice environment in Brazil [ 13 ], consistent with our study results. In another study [ 17 ], the average PE score was significantly greater than that in our study and that of Azevedo Filho et al. [ 13 ]. The high score in the Smith et al. research population could be because the surveyed hospitals were magnet hospitals. In magnet hospitals, there is more focus on creating a healthier and more desirable work environment. Our study revealed a significant inverse correlation between PE characteristics and MNCs. In other words, missed nursing care increases significantly in patients with unfavorable PEs. However, this relationship was not strong. Several researchers have emphasized the importance of providing qualified nursing services and improving the nursing work environment [ 17 ].

Among the different dimensions of PE, “nursing foundations for quality of care” and “nurse manager ability, leadership, and support of nurses” had significant relationships with MNCs. These findings suggest that targeted interventions aimed at improving each dimension of PE can help reduce the incidence of MNCs. Additionally, the ability of nursing managers and leaders should be accompanied by reduced missed care because nursing managers are responsible for managing the working conditions of nurses, determining their duties, coordinating existing resources, and developing basic nursing settings for the quality of patient care [ 28 ].

Our study on the relationship between nurses’ occupational and demographic variables and MNCs contradicts the findings of Blackman et al. [ 29 ], who indicated that men’s mean score for missed care is significantly greater than women’s. A study conducted in Iran also showed that female nurses’ quality of nursing care is greater than that of male nurses [ 30 ]. Women tend to care for patients more carefully, and less missed care is provided by women. Except for gender, the results of our study suggested no correlation between MNCs and other occupational and demographic variables of nurses.

Limitations

The study offers insights into missed nursing care and its relationship with the practice environment. However, several limitations should be considered. The study’s cross-sectional design creates potential biases, which may limit our ability to establish causation. Additionally, the reliance on self-reports introduces the likelihood of response bias. Furthermore, the study focused on specific hospitals in Zanjan Province, which may restrict the generalizability of the findings to a broader context. Confounding factors, which are inherent to observational studies, might influence the observed relationships. Despite the abovementioned limitations, the study provides valuable contributions to comprehending the complex dynamics between the practice environment and missed nursing care.

According to our study, nurses consistently neglect a significant portion of nursing care, with patient-related team meetings and training sessions being the most overlooked. This is a noteworthy finding. The findings highlight a possible lack of awareness or inadequacy in planning critical sessions, which demands increased attention. Notably, basic nursing care is the second most commonly overlooked aspect of care. The unfavorable practice environment identified in the hospitals under study highlights the urgent need for improvement by planners and senior managers. Notably, our findings demonstrated a significant statistical relationship between the practice environment and unattended nursing care. This indicates that improving the practice environment could help reduce the number of missed care cases. Notably, managerial competencies, particularly leadership, are vital in preventing overlooked nursing care. These results provide essential insights for the field, highlighting the importance of targeted improvements in practice environments to improve patient care outcomes. Our research provides a foundation for future research and interventions to optimize nursing care delivery.

Data availability

No datasets were generated or analysed during the current study.

Abbreviations

Analysis of Variance

Missed Nursing Care

National Quality Forum

Practice Environment

Variance Inflation Factor

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Acknowledgements

We want to thank all the nurses who participated in this study. Their invaluable contributions were crucial in making this research possible. We would also like to thank the hospitals in Zanjan Province for their cooperation and support during the data collection. Furthermore, we would like to acknowledge the Zanjan University of Medical Sciences’ Biomedical Research Ethics Committee for approving and overseeing the ethical aspects of this research. We are grateful for their collaboration and commitment to advancing healthcare research, which made this study possible.

This work was supported by the Research and Technology Deputy of Zanjan University of Medical Sciences, Zanjan, Iran (grant number: A-11-86-17).

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Study design: KA. Data collection: SB. Data analysis: KA, FR. Study supervision: KA. Manuscript writing: KA, SB, FR. Critical revisions for important intellectual content: KA, FR.

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The research proposal with the code IR.ZUMS.REC.1399.053 was approved by the Zanjan University of Medical Sciences’ Biomedical Research Ethics Committee (ZUMS.REC). We obtained written informed consent from all participants and preserved the confidential identity of each participant throughout the study. Before using the two MISSCARE Survey and Practice Environment Scale questionnaires, permission was obtained from the developers of the participants (Professor Kalisch and Professor Lake, respectively) through email.

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Babaei, S., Amini, K. & Ramezani-Badr, F. Unveiling missed nursing care: a comprehensive examination of neglected responsibilities and practice environment challenges. BMC Health Serv Res 24 , 977 (2024). https://doi.org/10.1186/s12913-024-11386-1

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Received : 31 January 2024

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DOI : https://doi.org/10.1186/s12913-024-11386-1

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Qualitative Research on Mindfulness Interventions for Staff Nurses

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Lemke, Johanna MA, BSN, RN, NEA-BC; Evanson, Tracy A. PhD, RN, PHNA-BC

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Complexity, workforce shortages, and escalating stressors in the healthcare setting have led to increased turnover and burnout of nursing staff. Mindfulness has been demonstrated to offer a variety of benefits to nurses. This article summarizes the qualitative research on the experience of mindfulness training and practice with the goal of providing evidence-based recommendations for nurse leaders on how to design and implement effective and well-adopted mindfulness programs.

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Nursing Students’ Experiences and Challenges in Their Education During COVID 19 Pandemic: A Mixed-Method Study

Puvaneswari kanagaraj.

1 Department of Nursing, College of Applied Medical Sciences, University of Bisha, Bisha, Kingdom of Saudi Arabia

Judie Arulappan

2 Department of Maternal and Child Health, College of Nursing, Sultan Qaboos University, Al Khoudh, Muscat, Sultanate of Oman

Arpita Pradhan

3 Narayana Multi Specialty Hospital, Kolkata, West Bengal, India

* Current address: Durgapur City Hospital and Clinic Pvt. Limited, Durgapur, West Bengal, India.

Shimmaa Mansour Moustafa Mohammed

4 Faculty of Nursing, Zagazig University, Zagazig, Egypt

Associated Data

Supplemental material, sj-docx-1-son-10.1177_23779608241272484 for Nursing Students’ Experiences and Challenges in Their Education During COVID 19 Pandemic: A Mixed-Method Study by Puvaneswari Kanagaraj, Judie Arulappan, Arpita Pradhan and Shimmaa Mansour Moustafa Mohammed in SAGE Open Nursing

Supplemental material, sj-docx-2-son-10.1177_23779608241272484 for Nursing Students’ Experiences and Challenges in Their Education During COVID 19 Pandemic: A Mixed-Method Study by Puvaneswari Kanagaraj, Judie Arulappan, Arpita Pradhan and Shimmaa Mansour Moustafa Mohammed in SAGE Open Nursing

Introduction

The COVID-19 outbreak disrupted the nursing education across the world. The nursing students faced many challenges in their learning process.

The study explored the experiences and challenges faced by nursing students who had virtual education in India.

The study adopted an exploratory sequential mixed-methods design. The study was conducted as two phases. Phase 1: Qualitative data were collected using direct focus group interview with 18 students. Phase 2: Quantitative data were collected from 477 students using a Likert scale prepared by the investigators of the study on challenges experienced by nursing students on their education. The analysis was done using the descriptive and inferential statistics and thematic analysis.

Phase 1: The analyzed data produced seven themes and 10 sub-themes; (1) technical issues—a concern, (2) regular rhythm in educational training—but not complete, (3) stress and strain, (4) evaluation—a concern, (5) communication, (6) comfort zone, and (7) easy distraction. Phase 2: Majority of the students (54.71%) experienced high-level challenges with the nursing education during pandemic. The overall mean and SD of all the domain-wise challenges were 103.39 + 7.11 with the range from 30 to 150. The mean and SD with educational challenges were (20.27 + 3.04), environmental challenges (6.92 + 1.66), communication challenges (17.61 + 4.01), technical challenges (17.39 + 3.75), evaluation challenges (7.09 + 1.94), physical and mental challenges (20.47 + 4.33), career challenges (7.06 + 1.91), and financial challenges (6.61 + 2.1). The demographic variable gender ( P = 0.045) showed a statistically significant association with the challenges.

Considering the experiences and challenges faced by the nursing students, the nursing administrators shall design educational strategies to mitigate these challenges in nursing education during a pandemic.

Implication

Virtual nursing education offers flexibility in teaching and learning, self-paced learning opportunity, lower the costs, career advancement, comfortable learning environment, more opportunities for participation, easier to track documentation and improves skills in technology. Therefore, the challenges in virtual nursing education should be lessened to have successful teaching learning experiences.

Introduction/Background

The world faced unprecedented challenges during COVID-19 global pandemic ( World Health Organization, 2020 ). The pandemic changed the lives of people at different levels. Additionally, social distancing shaped the social relationship and behavior ( Kaveh et al., 2022 ). COVID-19 significantly strained the healthcare system. In addition, it affected the education in academic institutions and universities to a greater extent ( Dewart et al., 2020 ). As a preventive and control measure, all the schools, colleges, and universities were closed ( Mustafa, 2020 ). In April 2020, 94% of learners worldwide were affected by the pandemic, representing 1.58 billion children and youth in 200 countries ( De Giusti, 2020 ). Likewise, nursing education has undergone many radical changes both in developed and developing countries. The situation affected the learning opportunities of nursing students as their clinical placements were suspended and the face-to-face teaching moved into online teaching. Additionally, the pre-clinical activities such as laboratory and simulation-based teaching were affected due to social and organizational restrictions to limit unnecessary access and contact with others ( Tomietto et al., 2020 ).

To continue the teaching–learning activity, the academic institutions adopted various digital platforms including Zoom, Google meet, WebEx, Udemy, Edmodo, Google classroom, etc. ( Mishra et al., 2020 ). Moreover, web-based conferences were routinely organized by educational institutions during this pandemic ( Kaware, 2022 ). In addition, educational institutions have placed greater emphasis on ERP systems, library modules, fee modules, and examination modules. The virtual learning enhanced the comfort, accessibility, and encouraged remote learning ( Mukhtar et al., 2020 ). Similarly, the learners found it easy to access the online material, were able to record meetings and sessions and retrieve information ( Alsayed & Althaqafi, 2022 ). The faculty and students expressed that online education is useful during the COVID-19 pandemic; it was convenient, flexible, cost low, and encouraged self-learning ( Almahasees et al., 2021 ). Likewise, online education improved the flexibility, ability to teach large classes, increased interaction between the teachers and students and increased learning opportunities for the learners ( Hako, 2021 ). Ultimately, these educational technologies have had significant positive impact on the learning of the students. Additionally, it paves the way toward the blending of technology synchronously or asynchronously into education ( Thaheem et al., 2022 ).

Review of Literature

Although online education was beneficial to both the teachers and learners, it posed various challenges to the faculty and students ( Nimavat et al., 2021 ). Poor student attendance, loneliness, issues with internet connectivity and lack of information and technology skills were reported as challenges of online education ( Hako, 2021 ). The faculty and students indicated that efficacy of online teaching and learning is less effective than face–face teaching and learning. Moreover, online learning is ineffective for deaf and hard of hearing students. Likewise, online education is linked to lack of interaction and motivation, data privacy and security and technical issues ( Almahasees & Amin, 2021 ; Alsayed & Althaqafi, 2022 ). Furthermore, online education was inefficient in terms of maintaining academic integrity ( Mukhtar et al., 2020 ). The teachers reported difficulties in motivating the students without visual connection during online teaching ( Moustakas & Robrade, 2022 ). Also, Atout et al., (2022) reported lack of resources for the clinical learning, distracting home environment and challenging evaluation of learners as the barriers for virtual learning.

The challenges faced by the instructors includes transitional difficulties from offline to online teaching, communication barriers, changes in the teaching style and additional time and resources for preparation of teaching. The institutions experienced challenges such as need for additional training for faculty and students, technical and multimedia support, online counselling sessions for teachers and the need to have technical troubleshooting team. Students experienced challenges related to having technical skills to learn online, lack of readiness, network and speed issues, and lack of identity, interaction and participation. There were challenges related to content such as development of new material, regular assignments, multimedia tools, and checking assignments and sharing regular feedback with the students. Technological challenges included device suitability, network stability and speed, tools of conferencing software for online teaching and ease of use. Lastly, the motivational factors included lack of sense of job security, non-availability of salary on time, and lack of family support, mental and emotional support from colleagues and higher authorities ( Siddiquei & Kathpal, 2021 ).

To enhance the online teaching and learning, technical aptitude enhancement, resource management and utilization, time management, control over the learning environment and help seeking are essential ( Barrot et al., 2021 ). Furthermore, formal training for the teachers, and enhancement of psychosocial wellbeing of both the learners and teachers are necessary to curb the feelings of loneliness and isolation. Moreover, the nature of the problems related to the shift from face to face to online learning should be identified to combat these challenges ( Hako, 2021 ). In India, both the undergraduate and postgraduate students were badly affected during the COVID-19 pandemic and experienced many challenges with online education ( Joshi et al., 2020 ; Kamal & Illiyan, 2021 ; Muthuprasad et al., 2021 ; Pandit & Agrawal, 2022 ; Rannaware et al., 2022 ; Sengupta, 2022 ). However, very few studies explored the challenges encountered by the nursing students during the online learning ( Gaur et al., 2020a ; George et al., 2022 ; Kanagaraj et al., 2022 ; Lata & Kudi, 2022 ). Therefore, the authors decided to understand the experiences and challenges encountered by nursing students in their nursing education during the COVID-19 pandemic. We believe that the study finding will be beneficial to the educational authorities, curriculum developers, and policy makers to design appropriate measures and strategies to enhance effective learning both in nursing education and practice.

An exploratory sequential mixed-methods design was utilized in this study. The study integrated qualitative data into quantitative data to understand the experiences and challenges experienced by nursing students’ during the pandemic.

Research Setting

The study was conducted among nursing students of Narayana Hrudayalaya College of Nursing, Koshy's College of Nursing and Kirubanidhi College of Nursing, Bengaluru, Karnataka, India. These colleges initiated virtual classes from April 2020. Therefore, these colleges were selected as settings for the study.

The target population of the study included both Diploma and BSN students. The accessible population included both Diploma and BSN students studying in Narayana Hrudayalaya College of Nursing, Koshy's College of Nursing and Kirubanidhi College of Nursing, Bengaluru, Karnataka, India.

Sample, Sample Size, and Sampling Techniques

Three nursing colleges were conveniently selected for the study. In Phase 1, the researchers used purposive sampling technique to collect the qualitative data from six students in each college (Narayana Hrudayalaya College of Nursing, Koshy's College of Nursing and Kirubanidhi College of Nursing, Bengaluru, Karnataka, India). The data collection was done face to face. Thus, in total, 18 students participated in the focused group interview during phase I. For Phase 2, the sample size calculation was done based on the previous cross-sectional study ( Thapa et al., 2021 ). Having the expected proportion of challenges experienced by nursing students as 15%, with 95% confidence interval, and with the precision, the minimum required sample size was 400. In total, all the three nursing colleges had 654 students. Convenient sampling technique was used to collect the data in phase II.

Inclusion and Exclusion Criteria

The study included nursing students who were enrolled for Diploma and BSN program, exposed to online learning, and second, third, and fourth year nursing students. The study excluded those who were not willing to participate, and first year nursing students as they had limited exposure to the virtual theory and clinical classes, which may give a limited and inaccurate data. Considering the inclusion and exclusion criteria, 477 students participated in the study.

Description and Interpretation of Study Instrument

The instruments used in the study were prepared by the researchers of the study. The qualitative data collected during the first phase of the study was utilized in preparing the tool used for the quantitative phase of the study. It included four parts namely demographic variables, background variables, open-ended questions to explore the participant's experiences and challenges and Likert scale to assess the challenges.

Part 1 included the demographic variables of the participants including age, gender, course of study, year of study, residence, and place of attending online classes.

Part 2 comprised of the background variables such as gadgets used for attending online classes, source of internet, mode of theory classes taken during the last 6 months, mode of practical training, methods of teaching theory classes, audio visual aids used, and the virtual platform used.

Part 3 consisted of a questionnaire related to students’ experiences and challenges. It included 15 open-ended questions related to the aspects of theoretical learning, practical learning, study materials, teaching methodology, evaluation process, issues related to physical and mental health, issues related to technology and issues related to finance.

Lastly, Part 4 included a Likert scale on challenges having 30 questions with eight domains; educational challenges (six items), environmental challenges (two items), communication challenges (five items), technical challenges (five items), evaluation challenges (two items), physical challenges (six items), career challenges (two items), and financial challenges (two items). Dimensions were evaluated using 5-point Likert scale varying from strongly disagree (1), disagree (2), neutral (3), agree (4) and strongly agree (5). The total score ranges from 30 to 150. The domain-wise challenges were interpreted as 1–50 = low challenges, 51–100 = moderate challenges, 101–150 = high challenges. The instrument was prepared in English and no translations were done.

Reliability and Validity of the Tool

Content validity was obtained from eight experts in the field of nursing education. The calculated content validity index was 0.80. Pilot study was conducted with 10% of the study participants (42 students) to test the reliability of the tool before administering to the main study participants. Using Cronbach's alpha (inter-item reliability), the internal consistency assessed was 0.89, which is highly reliable. The participants participated in the pilot study were excluded from the main study.

Ethical Considerations

Ethical approval was obtained from the Research and Ethics Committee of Narayana Hrudayalaya College of Nursing (NHH/AEC-CL.2022-BI5 dated 22/3/2022), Kirubhanidhi College of Nursing (KCC/22/22 dated 04/3/2022), and Koshy's College of Nursing (KCN/15 dated 07/3/2022) and Institutional review board. After getting the ethical approvals, formal permission was obtained from the Head of Nursing colleges to collect data. The researchers explained the purpose of the study to the participants involved in both quantitative and qualitative data collection. The participants were informed that their participation in the study was voluntary. Since the participants were not forced to participate in the study, they were given the freedom to withdraw from the study at any time without any penalty. The participants signed the informed consent and responded to all the questions and returned the completed questionnaire. All the audio recordings were coded and password protected. It was explained to the participants that they were not exposed to any kind of risk. To keep the data anonymous, no identifying information was collected from the participants. The researchers maintained confidentiality of information throughout the study period. All the collected data were stored in a password protected file. Only, the investigators of the study had access to the data.

Data Collection (Qualitative Phase)

In Phase I of the study, three focus groups were selected using purposive sampling technique. Each group included six participants with a total of 18 nursing students. After getting the consent, the participants shared their experiences and challenges faced during their educational training in the pandemic. The interviews were conducted from 25/2/2022 to 25/3/2022 and each interview lasted for 1.30 h to 2 h. The first and third authors conducted the interview. The first author is a PhD and the third author is a BSN holder. The first author is an assistant professor and the third author is a staff nurse. Both of them were females. Both of them were trained in qualitative data collection. The researchers established rapport with the study participants. The researcher used 15 open-ended probing questions and the participants were given the freedom to express additional views and comments. All the interviews were conducted in person in the college and audio recorded with their consent. Focus group discussions were continued till the data saturation occurred. The transcripts were returned to the participants for their correction.

Data Collection (Quantitative Phase)

In Phase II, the quantitative data were collected using convenient sampling technique. The total number of students participated in the study were 477. The questionnaires were transferred to Google forms and were circulated to the students after explaining the objectives and getting the informed consent. The quantitative data were collected from 11/04/2022 to 20 /04/2022. The response rate was 72.9% (477) which included Narayana Hrudayalaya College of nursing (88 participants), Koshy's College of nursing (235 participants) and Kirubanidhi College of nursing (154 participants).

Data Analysis (Qualitative Phase)

The data were analyzed using thematic analysis. The collected data were transcribed and analyzed using Braun and Clarke's thematic analysis. Reflexive thematic analysis was performed in this study ( Clarke & Braun, 2017 ).

Data Analysis (Quantitative Phase)

The quantitative data were analyzed using descriptive and inferential statistics using SPSS version 22.

Credibility, Dependability, and Transferability

To ensure credibility of the data, the researcher strongly engaged with the focused group interviews by means of observation, documentation, and taking notes. Dependability was achieved through reviews and comments given by the research guide, who is the second author of the study who has full knowledge of the study design and methodology. The data collected from participants and the findings could be applicable to other contexts, situations, times, and populations and the study setting. It ensures transferability.

The researcher adhered to rigor by carefully collecting data via audio recordings and by taking field notes. Each focus group interview was transcribed immediately after the interview. The transcripts were given to the participants for cross-checking and approval. In addition to ensuring rigor through trustworthiness criteria, the authors followed mixed-methods research legitimation criteria by ensuring design quality, design suitability, within design consistency, design fidelity, and analytic adequacy ( Teddlie & Tashakkori, 2009 ).

Trustworthiness

Trustworthiness was established by using an unbiased approach in selecting the participants and by participant's being honest, clearly recorded, and accurately presented inputs. The transcriptions, coding, and themes–subthemes were discussed by the research team for their verification. Then based on the themes and subthemes the quantitative questionnaire was created by the researchers.

Phase 1 Qualitative Phase

Table 1 shows the frequency and percentage distribution of background variables of 18 participants who shared their experiences and challenges faced during their educational training in the pandemic. Table 2 shows the frequency and percentage distribution of participants’ background variables.

Table 1.

Frequency and Percentage Distribution of Demographic Variables of Nursing Students.

Demographic variables	Qualitative data		Quantitative data
	Frequency		Frequency
	Phase 1 ( = 18)	Percentage	Phase II ( = 477)	Percentage

18–23 years	16	88.9	432	90.6
23–29 years	2	11.1	45	9.4
Gender
Male	4	22.2	111	23.3
Female	14	77.8	366	76.7
Course
B.Sc. Nursing	14	77.8	331	69.4
GNM	4	22.2	146	30.6
Year of study
Second year	4	22.2	226	47.4
Third year	9	50	226	47.4
Fourth year	5	27.8	25	5.2
Residence
Urban	11	61.1	216	45.3
Semi-urban	2	11.1	113	23.7
Rural	5	27.8	148	31
From where you attended the online classes most of the time
Home	7	38.9	79	16.6
Hostel	11	61.1	398	83.4

Table 2.

Frequency and Percentage Distribution of Baseline Variables of Nursing Students.

Demographic variables	Qualitative data		Quantitative data
	Frequency		Frequency
	Phase 1 ( = 18)	Percentage	Phase II ( = 477)	Percentage
Gadget used for attending online classes (multiple choice)
Mobile	18	100	469	98.3
Laptop	2	11.11	52	10.9
Tablet	1	5.55	13	2.7
Desktop			4	0.8
Source of internet (multiple choice)
WiFi	3	16.66	87	18.2
LAN	-	-	1	0.2
Mobile data	18	100	451	94.5
Mode of theory classes taken for the last 6 months
Online	1	5.6	69	14.5
Offline	5	27.7	157	32.9
Both online and offline	12	66.7	251	52.6
Mode of the practical training
Online	1	5.6	50	10.5
Offline	7	38.9	289	60.6
Both online and offline	10	55.5	138	28.9
Methods of teaching used for theory classes (multiple choice)
Lecture cum discussion	18	100	451	94.5
Seminar	1	5.55	98	20.5
Role play	-	-	38	8
AV aids used (multiple options)
Power point presentation	17	94.4	445	93.3
Videos	7	38.9	218	45.7
White / Black board	-	-	88	18.4
Virtual platform used (multiple options)
Zoom	8	44.4	250	52.4
Google meet platform	10	55.6	286	60
Cisco	-	-	106	22.2
Web-ex	4	22.2	179	37.5

Experiences and Challenges Faced by the Nursing Students

In Phase 1, the experiences and challenges experienced by nursing students with their educational training during the pandemic were analyzed using thematic analysis. Table 3 reports seven themes and 10 sub-themes. The themes identified includes: (1) technical issues—a concern, (2) regular rhythm in educational training—but not complete, (3) stress and strain, (4) evaluation—a concern, (5) communication, (6) comfort zone, and (7) easy distraction. The sub-themes were: (1.1) problems with internet connectivity, (1.2) issues with the digital platform, (2.1) theoretical learning experience-better, (2.2) deficient practical skills, (3.1) physical stress, (3.2) mental stress, (4.1) unfair evaluation and lack of feedback, (5.1) decreased quality of communication, (6.1) very convenient, and (7.1) difficult to concentrate.

Table 3.

Themes and Subthemes of Experiences and Challenges Faced by Nursing Students.

S. no.	Themes	Sub-themes
	Technical issues—a concern	1.1. Problems with internet connectivity
	Technical issues—a concern	1.2. Issues with the digital platform
	Regular rhythm in educational training—but not complete	2.1. Theoretical learning experience-Better
	Regular rhythm in educational training—but not complete	2.2.Deficient practical skills
	Stress and strain	3.1.Physical stress
	Stress and strain	3.2.Mental stress
	Evaluation—a concern	4.1.Unfair evaluation
	Communication	5.1.Decreased quality of communication
	Comfort zone	6.1.Very convenient
	Easy distraction	7.1.Difficult to concentrate

Theme 1: Technical Issues: A Concern

Modern technology is progressive in all sectors. With this technology, it was possible to deliver training in all educational sectors including nursing education during COVID-19. Though it was helpful, technical problems interrupted the teaching–learning process. Most of the participants expressed their concern related to technical issues. It includes issues with internet connectivity, and issues with the digital platform.

Subtheme 1: Problems with Internet Connectivity

Constant network issues were an unavoidable fact for many students. Students could not be connected to the virtual class on time due to the internet connectivity issues and they had to miss attending the classes.

“Sometimes it keeps on showing error code and by the time I get connected the class is completed by the faculty” (5A).

Students stated that they faced technical and network issues while attending the classes.

“During online classes, we have faced a lot of technical and network issues” (2A).

In addition, fluctuations in the network connectivity were another technical issue faced by students and it affected the virtual learning of the students.

“I faced fluctuations in my network during a natural calamity in my place so I missed many classes during that time” (13A).

Subtheme 2: Issues with the Digital Platform

There are various platforms used to deliver online educational training. The participants expressed their difficulties as they had hitches in updating the digital platforms, and mentioned that the lack of experience in using the platforms affected their learning.

Digital platform did not work if the application is not updated on time. This was stated as below;

“If I did not update the app on time, it will not work” (1A).

Students faced problems in joining the virtual platform due to issues with the virtual platform.

“Sometimes I faced problems with joining with the virtual platform” (8A).

Lack of experience in using the virtual platform by both the faculty and student was another challenge stated by the students.

“Had struggle to join the meeting initially for both students and faculties because it was very new to us” (5A).

Students faced difficulties in submitting the assignments and answer sheets, as they did not have previous experience in submitting it through digital platforms.

“I struggled while submitting the answer sheets /assignment through digital platforms” (4A).

Theme 2: Regular Rhythm in Educational Training: But not Complete

Virtual education is a boon during pandemic. It took the education system in a rhythmic manner. Though the online lectures were beneficial, at times, students faced few challenges.

Subtheme 1: Online Theoretical Learning Experience

The students utilized the opportunities to learn from online classes with few challenges in attending online classes.

Commencement of online classes helped the students to have continuity in their studies. As the online classes were started on time immediately, it did not affect their theoretical learning.

“…It was not at all possible for the colleges to continue the offline classes so that the apex body instructed to start with online classes and it's good that we were in touch with our studies” (12A).

Different methods and techniques of teaching adopted during online classes enhanced interest in their learning.

“During online classes teacher used to teach with PPTs, and some good videos to make the session interesting. Sometimes they used to conduct lecture cum discussion. That time I was interested to listen to the class” (15A).

“I was interested to attend the online theory classes when teachers used to take a class by showing some videos related to theory content. It was good” (16A).

Students encountered issues with the storage of study materials as they had minimal storage space in their gadgets.

“Teachers used to send notes in PDF form in the mail or by WhatsApp. When I have storage issues in my gadgets, I deleted the content because of storage issues” (18A).

Subtheme 2: Deficient Practical Skills

Practical training is a major part of nursing profession. Students faced many challenges while attending online practical classes.

Most of the students stated that their theoretical learning through virtual mode was excellent. However, students felt that learning practical skills through direct clinical experience is rewarding than learning through virtual platform.

“…theory classes were very good. But in case of practical, like IV infusion, it was very easy to watch the procedure in a virtual platform, but it was very difficult to perform. I feel offline clinical exposure is better than online” (3A).

Students stated that they learnt basic nursing skills through direct clinical experience before the pandemic. However, the students lack confidence in performing the skills that they learnt through videos. The students felt nervous while performing the skills directly on the patients, as they did not get hands-on experience during virtual learning.

“…During my first-year clinical posting, I learnt basic procedure like vital signs checking, wound care, surgical dressing, etc with the direct clinical experience, suddenly everything goes on online, the faculty used to show us best videos. While watching videos I feel I can do. But when it's time to do directly, my hands were shivering and I was not confident. I feel offline exposure is better, we can get more exposure” (1A).

Huge gap in practical learning due to the pandemic affected the learning of the students. Thus, the students did not recommend online learning for learning the skills.

“I did not get adequate practical posting in my first year because of COVID-19. It continued with the second year too. So I have a huge gap with practical learning. For practical learning, online learning is not appropriate” (7A).

Theme 3: Stress and Strain

Prolonged online training affects the students’ physical as well as mental health. They felt more stressful.

Subtheme 1: Physical Stress

Students experienced physical symptoms such as strain in the eyes, neck pain, back pain and numbness in the legs due to prolonged usage of phone and sitting.

“I have to write my notes by seeing my phone. Every time I need to continuously see my mobile and make notes. It was straining my eyes and stressful for me” (16A).

“While attending online classes I used to keep my video on and listen to the class. Due to prolonged sitting, I have neck pain, eye strain also” (5A).

“I felt back pain and numbness in my leg while attending the online classes with prolonged sitting. I used to walk in between for some time to reduce the numbness” (12A).

Subtheme 2: Mental Stress

Students were anxious, as they could not complete the given tasks in online classes.

“I was anxious because I did not complete my task given in online classes, I was lazy” (4A).

As the students did not get practical experience in the clinical area, their confidence levels were low during the pandemic. Moreover, as the students did not get any opportunity to practice directly in the clinical area during the pandemic, they felt tensed and lacked confidence to directly practice on the patient after the pandemic.

“Due to lack of practice in clinical, my confidence had come down” (8A).

“I felt stressed out when I am thinking about my practical learning. I did not get adequate opportunity to practice” (10A).

“After lockdown when I came in the clinical setting, I was tensed about how I will handle the patient” (15A).

Theme 4: Evaluation: A Concern

Evaluation is the process of providing feedback to the students to improve themselves. The test, examination, assignment, and evaluation were new for the students and faculty during the pandemic and there were malpractice incidences by the students.

Sub-Theme 1 - Unfair Evaluation and Lack of Feedback

Students felt conducting exam using Google form as useful.

“Some faculties conducted few exams in Google Form, it was good because at that time I studied and attend the exam” (16A).

Malpractice in the online exam could be observed in the students during virtual learning.

“For the online exam, I never used to study because I can copy from PPT, my screenshots, or from Google and score good marks” (2A, 8A, 17A, 18A).

Students stated that they did not get proper feedback on their assignments.

“In my point of view, some faculties did not give us proper feedback on my assignment writing” (6A).

One student stated the unfair evaluation as the students copied scored well.

“I feel very bad when I write without copying and score very less marks; while the students who did malpractice scored well. So the evaluation was going very wrong” (4A).

Theme 5: Communication

It is necessary to build proper communication between the teachers and students to continue a smooth training session online. However, students felt that this distance learning created a communication gap between teachers and students.

Sub Theme 1- Decreased Quality of Communication

Limited and disrupted communication with the friends and teachers created distress in the students.

“It was not possible for me to communicate face to face with my friends and teachers during the online classes. It was quite distressing” (1A).

“Online class communication was the major problem. We could not communicate with faculties and peers like offline” (18A).

Students felt that they could not clarify their doubts with the faculty. However, faculty responded to their queries through WhatsApp and social media.

“If it comes to communication, it was very limited… During offline we can directly ask doubts to the faculty, but not now” (2A).

“During the online classes communication was not easy like face to face communication. But teachers were responding by WhatsApp and other social media after class time also” (6A).

Theme 6: Comfort Zone

Online classes were attended by the students either from hostel or home.

Subtheme 1: Very Convenient

Students felt comfortable staying home and attending online classes.

“It was convenient for me. Because I can stay at home, take care of my family and attend class also” (8A).

“For me, it was convenient, I got more time and can get up late to attend classes” (2A, 3A, 7A).

Students expressed that their transport expenses could be minimized, as they were not required to travel during the pandemic.

“I could save time. Even transport expenses could be minimized” (10A).

Theme 7: Distraction

Distraction was very high in online classes.

Sub-Theme 1: Difficult to Concentrate

Students were distracted during the online classes due to many notifications received from other online applications and disturbance from their siblings.

“As my internet is on I will get many notifications from other apps during class, it was a distraction for me” (4A, 9A, 11A).

“I attended online classes from my home only. I had disturbance from siblings, during my online classes” (7A, 16A).

Students themselves got distracted as they were using social media in between the online classes.

“I used to browse on Facebook, Instagram, YouTube, etc. during the online classes” (13A).

Phase 2: Quantitative Phase

Table 1 shows the frequency and percentage distribution of participant's demographic variables. Majority (90.6%) of the participants were in the age group between 18 and 23 years. Most of them were females (76.7%). 69.4% of the students were undergraduate (BSN) nursing students, while the rest were in Diploma nursing program. 47.4% of the participants were in their second and 47.4% were in their third year of study. Nearly half (45.3%) were from urban areas and 23.7 were from semi-urban areas, while the remaining (31%) were from rural areas. A large number (83.4%) of students attended the online classes from their hostels.

Table 2 outlines the frequency and percentage distribution of participants’ background variables. The results showed that the majority (98.3%) of the students used mobile phones to attend online classes. Most of them (94.5%) used the mobile data to have the internet connection. Almost half of the participants (52.6%) attended both online and offline classes. More than half (52.6%) of the participants had both online and offline practical exposure, and around 33% had offline clinical exposure. Most of the students (94.5%) attended lecture and discussion sessions. A huge number (93.3%) used power point presentation, and 45.7% of them used videos for teaching. Majority (60%) used Google Meet, while 52.4% used Zoom. The remaining used multiple platforms like Cisco, and Webex.

Figure 1 describes the frequency and percentage of distribution of level of challenges. It was classified as low, moderate, and high level of challenges. Majority of them (54.71%) experienced high-level challenges, 44.6% encountered moderate-level challenges, and the remaining experienced low-level challenges related to their nursing education during the pandemic.

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Object name is 10.1177_23779608241272484-fig1.jpg

Frequency and Percentage Distribution of Challenges Faced by Nursing Students During Their Educational Training.

The domain-wise challenges with nursing education during pandemic were shown in Table 4 . The eight domains included educational challenges, environmental challenges, communication challenges, technical challenges, evaluation challenges, physical and mental challenges, career challenges, and financial challenges. The mean and standard deviations for educational challenges is (20.27 ± 3.04), environmental challenges (6.92 ± 1.66), communication challenges (17.61 ± 4.01), technical challenges (17.39 ± 3.75), evaluation challenges (7.09 ± 1.94), physical and mental challenges (20.47 ± 4.33), career challenges (7.06 ± 1.91), and financial challenges (6.61 ± 2.1). The overall mean and S.D. of all the domain was 103.39 ± 1 7.11 with the range from 30 to 150.

Table 4.

Assessment of Mean and Standard Deviation of Domain-Wise Challenges Faced by the Nursing Students n = 477.

Domain-wise challenges	Mean	Standard deviation	Range
Educational challenges	20.27	3.04	6–30
Environmental challenges	6.92	1.66	2–10
Communication challenges	17.61	4.01	5–25
Technical challenges	17.39	3.75	5–25
Evaluation challenges	7.09	1.94	2–10
Physical and mental challenges	20.47	4.33	6–30
Career challenges	7.06	1.91	2–10
Financial challenges	6.61	2.1	2–10
Total

Table 5 displays the item-wise challenges. The results of Educational Challenges indicated that almost 38.57% responded that they lack interest in learning. 15.93% either strongly agreed or agreed that face-to-face learning is very effective than E-learning. A larger portion (78.62%) of participants mentioned that the notes and lectures were inadequate. More than half of the participants (54.3%) agreed that virtual demonstration is not very effective for the practical patient care, and 61.21% mentioned that they lack confidence while taking care of patients. The participants provided similar responses during the qualitative phase of the study. The students lack confidence in performing the skills that they learnt through videos. Similarly, the students felt nervous while performing the skills directly on the patients, as they did not get hands-on experience during virtual learning. However, one third of the respondents (33.75%) expressed that they could learn the modern ways of handling patients through videos.

Table 5.

Item-Wise/Domain-Wise Analysis of Challenges Faced by Nursing Students.

S. no	Items	Strongly agree		Agree		Neutral		Disagree		Strongly disagree
S. no	Items	f	%	f	%	f	%	F	%	f	%

1	Lack of interest in learning	74	15.51	110	23.06	214	44.86	43	9.01	36	7.55
2	Face-to-face learning is more effective than E-learning	30	6.29	46	9.64	140	29.35	126	26.42	130	27.25
3	Notes/Lecture content are not adequate	224	46.96	151	31.66	72	15.09	16	3.35	14	2.94
4	Virtual demonstration is not very effective—practical patient care.	113	23.69	146	30.61	155	32.49	35	7.34	28	5.87
5	Lack of confidence while taking care of patients	162	33.96	130	27.25	117	24.53	44	9.22	24	5.03
6	Learnt modern ways of handling patients through videos.	56	11.74	105	22.01	185	38.78	80	16.77	51	10.69

7	Distracted very easily while attending online classes	142	29.77	139	29.14	133	27.88	38	7.97	25	5.24
8	My environment was very comfortable during pandemic to attend online classes	85	17.82	113	23.69	150	31.45	77	16.14	52	10.9

9	Difficulty in sharing my view with the teachers	83	17.4	141	29.56	169	35.43	55	11.53	29	6.08
10	Process of teacher–students interaction became passive.	74	15.51	145	30.4	197	41.3	48	10.06	13	2.73
11	Socializing with peer groups has decreased	109	22.85	167	35.01	151	31.66	27	5.66	23	4.82
12	Experience of loneliness without interacting much with peer groups.	115	24.11	155	32.49	151	31.66	32	6.71	24	5.03
13	Missed interaction with my seniors/college mates	94	19.71	138	28.93	167	35.01	43	9.01	35	7.34

14	Uncertain internet connection interrupts the learning process.	70	14.68	140	29.35	174	36.48	63	13.21	30	6.29
15	Teachers had difficulty in using technical aspects of the online platforms.	69	14.47	109	22.85	143	29.98	87	18.24	69	14.47
16	Good internet connection was there at my place.	140	29.35	148	31.03	125	26.21	38	7.97	26	5.45
17	Faced technical issues with learning platform /device.	114	23.9	151	31.66	146	30.61	37	7.76	29	6.08
18	Difficulty while submitting the answer sheets /assignment through digital platforms	140	29.35	144	30.19	122	25.58	44	9.22	27	5.66

19	Online evaluation may create irrational discrimination between students.	99	20.75	145	30.4	168	35.22	39	8.18	26	5.45
20	Evaluation/test conducted online was unfair	121	25.37	127	26.62	158	33.12	39	8.18	32	6.71

21	Experience of physical strain like headache, backache, neck pain, eye strain	147	30.82	149	31.24	158	23.27	43	9.01	27	5.66
22	I did not feel much mental stress	47	9.85	92	19.29	165	34.59	106	22.22	67	14.05
23	Developed insomnia	88	18.45	137	28.72	162	33.96	54	11.32	36	7.55
24	Addicted to phone due to prolonged using of phone other than learning purpose.	96	20.13	127	26.62	149	31.24	64	13.42	41	8.6
25	Regular life style has changed	125	26.21	146	30.61	148	31.03	38	7.97	20	4.19
26	Worry about online teaching applications that lack proper security system	99	20.75	131	27.46	160	33.54	55	11.53	32	6.71

27	Virtual practical training will affect my career as a registered nurse.	115	24.11	154	32.29	151	31.66	38	7.97	19	3.98
28	I may not be able to work as a skillful nurse	91	19.08	143	29.98	152	31.87	56	11.74	35	7.34

29	Extra money for my expenses for good internet package	149	31.24	128	26.83	126	26.42	40	8.39	34	7.13
30	Bought a new laptop/mobile/electric gadgets to attend virtual classes.	89	18.66	94	19.71	111	23.27	68	14.26	115	24.11

With regard to Environmental challenges , 41.51% expressed that they were comfortable with their home or hostel environment to attend online classes. However, more than half (58.91%) said that they were easily distracted while attending classes. Similar findings were seen in the qualitative phase of the study. Students were distracted during the online classes due to many notifications received from other online applications and disturbance from their siblings. Further, the students were distracted as they were using social media during the online class.

In terms of Communication challenges , almost half of them (46.96%) expressed that they had difficulty in sharing their view with the teachers, and 45.91% said that teacher–student interaction was passive. More than half (57.86%) of them expressed that peer group socialization has decreased, missed interaction (48.64%) with other college mates/seniors and experienced loneliness (56.6%) without interacting much with peer groups. Similar to these findings in the quantitative phase, in qualitative phase, the students mentioned that limited and disrupted communication with the friends and teachers created distress in the students. Moreover, the students could not clarify their doubts with the faculty.

Regarding Technical challenges , 44.03% had uncertain internet connection that interrupted the learning process. Around 37.32% expressed that the teachers had difficulty in using technical aspects of the online platforms initially. Around 39.63% had internet issues in their place. Almost 55.56% students faced technical issues with learning platform/device and around 59.54% had difficulty while submitting the answer sheets/assignment through digital platforms. Likewise, the qualitative findings revealed that the students faced technical and network issues while attending the classes. In addition, fluctuation in the network connectivity was another technical issue faced by students and it affected virtual learning. The participants expressed their concerns as they had difficulties in updating the digital platforms, and mentioned that the lack of experience in using the platforms affected their learning. Students faced difficulties in submitting the assignments and answer sheets, as they did not have previous experience in submitting it through digital platforms.

Related to Evaluation challenges , almost half of them (51.15%) mentioned that the online evaluation might create irrational discrimination between students with network issues, and 51.99% of them said that the evaluation/test conducted online was unfair. Consistent findings could be noted during the qualitative phase of study. Students mentioned that malpractice in the online exam occurred and it affected their grades. In addition, students stated that they did not get proper feedback on their assignments.

With respect to Physical and mental challenges , more than half 62.06% experienced physical strain like headache, backache, neck pain, and eye strain, 47.17% experienced insomnia, around 70.86% had mental stress, 46.75% got addicted to phone due to prolonged usage other than for learning purpose, 56.82% mentioned that the regular life style has changed, and lastly 48.21% were worried about the online teaching applications which lack proper security system. Likewise, same results are discovered in the qualitative phase of the study. Students experienced physical symptoms such as strain in the eyes, neck pain, back pain, and numbness in the legs due to prolonged sitting and continuous usage of phone. Additionally, students were anxious, as they could not complete the given tasks in online classes. Further, as the students did not get practical experience in the clinical area, their confidence levels were low and they felt tensed and lacked self-confidence to directly practice on the patients after the pandemic.

In terms of Career challenges , 56.4% agreed that virtual practical training may affect their career as a registered nurse, and 49.06% agreed that they may not be able to work as a skillful nurse with the virtual learning. Regarding Financial challenges , almost 58.07% agreed that extra money was spent for good internet package and 38.37% bought a new laptop/mobile/electric gadget to attend virtual classes.

With regard to association of demographic variables, only gender (χ 2 = 6.218, p = 0.045) has shown statistically significant association with problems or challenges faced by the nursing students during educational training in the pandemic at p < 0.05 level of significance.

During COVID-19 pandemic, face-to-face teaching and learning were converted to virtual learning and the clinical experiences were suspended to protect the students from the pandemic ( Agu et al., 2021 ). The experiences with the online classes were very new for the nursing students. Moreover, the online education became unavoidable and was a good choice for the faculty and students during this pandemic across the world. Even though, the students and teachers had a positive view of the technology, which helped in the teaching–learning process during pandemic, it posted many challenges ( Mousavizadeh, 2022 ).

We conducted a mixed-methods study to explore the experiences and challenges faced by nursing students in their education during COVID-19 in India. The study adopted an exploratory sequential mixed-methods design. The study was conducted as two phases; the qualitative data were collected during Phase I using focus group interview with the students. The qualitative data collected during the first phase of the study was utilized in preparing the tool for the quantitative phase of the study. The quantitative data were collected using a Likert scale prepared by the investigators of the study on challenges experienced by nursing students on their education. During Phase 1, the analyzed data produced seven themes and 10 sub-themes on the challenges. These themes produced during the qualitative phase further explained the challenges experienced by the nursing students in their education during COVID-19 pandemic in the quantitative phase.

Educational Challenges

Learning motivation encourages learners’ activities and directs and maintains their progress, allowing students to immerse themselves in learning ( Kim, 2020 ). However, virtual learning decreased students’ attention and interest in classes, which then decreased their motivation to learn ( Morfaki & Skotis, 2022 ). Likewise, in the current study most of the students expressed that they lost interest in their learning. Student's interest is very important for academic achievement, so different methods of teaching and learning need to be adopted in future to improve the learning among students during online education ( Mousavizadeh, 2022 ).

During COVID-19 pandemic, the medical and nursing institutions used learning management systems (LMS) and uploaded various reading materials, videos, quizzes, and presentations to encourage the engagement of students in asynchronous learning activities. In addition, online discussion forums were created to facilitate the virtual learning process ( Atwa et al., 2022 ). Some students preferred online learning as it provides structured learning materials and enables studying from home at their own pace and convenience ( Paechter et al., 2010 ; Zheng et al., 2021 ). However, most of the students in different studies conducted across the world preferred face-to-face learning for acquiring motor skills, for establishing interpersonal relationships, and for achieving student learning outcomes ( Arias et al., 2018 ; Faidley, 2021 ; Ramani & Deo, 2021 ; Lim et al., 2021 ). Similarly, Muthuprasad et al. (2021) advocated that the online mode of learning may not be a viable option for practical/skill-oriented courses and therefore hybrid/blended curriculum involving both face to face and online modes of learning shall be adopted by the institutions.

The faculty used different methods of teaching and audio visual aids to enhance the teaching–learning process during the pandemic ( Reimers et al., 2020 ). However, students in the present study mentioned that the notes/lecture content were inadequate. Similar findings were reported in other studies that the quality and effectiveness of lecture were low; and inconsistencies were observed in some professor's lecture during COVID-19 ( Cengiz et al., 2022 ; Dziurka et al., 2022 ; Mousavizadeh, 2022 ; Mukasa et al., 2021 ; Rohde et al., 2022 ). This warrants the educational institutions to monitor the quality of teaching delivered by the faculty to their students during this pandemic. In addition, the faculty should take self-initiatives for the professional empowerment ( Osmanovic Zajic et al., 2022 ).

The professional preparation of nurses involves many hours of practical and theoretical classes which is conducted face to face, which gives a real learning experience ( Dziurka et al., 2022 ). However, COVID-19 pandemic caused alterations, restrictions, limited clinical placements and simulation training in the campus ( Rohde et al., 2022 ). Thus, many nursing institutions adopted virtual theoretical and practical learning modes. Various studies across the world including the present study reported that virtual practical learning was inappropriate and ineffective in doing practical skills. Additionally, the nursing students lack confidence in taking care of the patients as they did not have hands on training ( Cengiz et al., 2022 ; Dziurka et al., 2022 ; Gheshlagh et al., 2022 ; Mukasa et al., 2021 ; Rohde et al., 2022 ; Wajid & Gedik, 2022 ). Therefore, in addition to direct face-to-face practical training in the clinical areas, more nursing simulations, virtual reality, artificial intelligence and telenursing should be utilized to enhance the practical learning of nursing students ( Dziurka et al., 2022 ).

Environmental Challenges

Student engagement during the virtual classes are very essential. The students are expected to actively participate, show positive conduct, self-regulated, display deep learning and understanding, and should demonstrate positive reactions to the learning environment, peers, and teachers ( Bond et al., 2020 ). However, students in the current study and many other studies were distracted very easily while attending online classes, which limited their learning during pandemic ( Bergdahl, 2022 ; Farrell & Brunton, 2020 ; Fazza & Mahgoub, 2021 ; Hollister et al., 2022 ). Therefore, more peer-to-peer conversations and faculty–student exchanges are recommended to enhance the engagement and learning during the pandemic.

Communication Challenges

Effective communication between the educator and the students enhances the learning experience and creates a positive learning environment. In addition, it improves the exchange of ideas, knowledge, and thought to fulfill the purpose of teaching and learning. However, ineffective communication creates frustration, impaired interpersonal relationships, and lack of motivation ( Alawamleh e al., 2020 ). In consistent to this study, the present participants had difficulty in sharing their view with the teachers, could not socialize with peer groups, and experienced loneliness. Furthermore, studies reported that impaired communication during online learning creates uncertainties and insufficiencies in learning ( Cengiz et al., 2022 ; Mousavizadeh, 2022 ; Mukasa et al., 2021 ). Thus, effective communication with the students should be streamlined for successful virtual learning ( Mukasa et al., 2021 ).

Technical Challenges

Online education can be effectively integrated in the nursing curriculum as it guarantees effective problem-based learning. However, the nursing colleges were not adequately prepared to effectively utilize the online teaching and learning in developing and under developed countries ( Molefe & Mabunda, 2022 ). Technical aptitude was lacking among the faculty and students, which posed various challenges ( Barrot et al., 2021 ). Moreover, technical challenges limited the satisfaction of students and faculty toward online teaching and learning ( Mahyoob, 2020 ). Furthermore, failure of internet services, website failures, problems in logging into the site disrupted the teaching–learning process during the pandemic ( Fuchs, 2022 ; Gaur et al., 2020b ). Similar to these studies, the present study participants mentioned that they experienced uncertain internet connection, faced technical issues with learning platform/device, and had difficulty while submitting the answer sheets /assignment through digital platforms. In addition, the teachers had difficulty in using technical aspects of the online platforms. This calls for improving the instructional design and pedagogical methods by training the faculty and students to utilize the digital platforms effectively, which might improve the motivation and engagement of faculty and students during the online education ( Aivaz & Teodorescu, 2022 ).

Evaluation Challenges

Significant changes in the teaching and learning during the pandemic created profound opportunities and threats. Stakeholders and students reported that the evaluation during online learning was biased and ineffective ( Krishnamurthy, 2020 ) and experienced uncertainty toward the examination ( Idris et al., 2021 ). Besides, online learning affects the test scores and grades, student outcomes, attitude, and overall satisfaction with learning ( Szopiński & Bachnik, 2022 ). In the same way, the students in the current study mentioned that the online evaluation created irrational discrimination between students and the evaluation conducted online was unfair. Therefore, standard setting in the evaluation is an essential step considering the learners and educator's perspective, which would improve the teaching–learning process ( Wasfy et al., 2021 ).

Physical and Mental Challenges

COVID-19 pandemic disproportionately affected the physical and mental health of students ( Ro et al., 2021 ). Students missed eating, did not participate in extracurricular activities, and experienced computer-related physical stress ( Idris et al., 2021 ). Likewise, students experienced increased stress due to homework, social isolation and lack of social interactions ( Rao & Rao, 2021 ). In congruent with these study findings, the participants in the present study experienced headache, backache, neck pain, eye strain, insomnia, and mental stress. The authors recommend addressing the physical and mental health issues of the students by promoting the utilization of physical, emotional, and mental health support programs ( Idris et al., 2021 ).

Career Challenges

COVID-19 pandemic impacted the career preference, career perspective, and ideal workplace ( Wang et al., 2022 ). In the same way, the students struggled with the career decision-making process during the pandemic ( Jemini-Gashi & Kadriu, 2022 ). Likewise, working students lost their jobs, which affected their lives, studies, and health ( Tsurugano et al., 2021 ). In line with these studies, students of the present study expressed that virtual practical training will affect their career as a registered nurse and they may not be able to work as a skillful nurse. This calls for the initiation of a structured and well-designed practical training program for the nursing students in the hospitals before their placement as a registered nurse in the clinical practice.

Financial Challenges

The pandemic put a number of students under financial strain, which severely affected their mental well-being ( Negash et al., 2021 ). Similarly, the university students were disproportionately affected by the economic consequences of the pandemic, which escalated the economic uncertainty ( Gewalt et al., 2022 ). The students who lost their economic resources during pandemic experienced higher prevalence of depressive symptoms ( Tancredi et al., 2022 ). Participants in the current study mentioned that they had to spend extra money for good internet package and bought a new laptop/mobile /electric gadget to attend virtual classes, which increased their economic burden. To counterbalance these economic challenges, financial aid schemes for students need to be made available to relieve distress and allow students to focus on their studies ( Gewalt et al., 2022 ).

Strengths and Limitations

The study findings are limited to only few nursing colleges in India. Therefore, the study findings may not be generalizable to other states of India. As the study population was not selected through probability sampling strategy, the representativeness of samples might be lacking in the current study. Moreover, the study instruments were prepared by the investigators of the study that did not undergo rigorous standardization process, which might limit the strength of the study. Based on the study findings, the institutions where the study was conducted should design strategies to mitigate the challenges to have effective teaching and learning.

Implications for Practice

Virtual nursing education can be improved by refining the content and delivery methods, training of nursing faculty to use online educational strategies, and by reducing the technical and environmental barriers. Hybrid and blended teaching–learning strategies may further improve the learning among nursing students.

Virtual education can be very successful if we address the challenges and experiences of the students by performing appropriate groundwork by upgrading the required hardware and software, teaching how to use the facilities, and developing innovative teaching techniques and standard protocols for virtual education.

Supplemental Material

Acknowledgments.

The authors thank the students and faculty members who participated in this study. The authors are thankful to the Deanship of Graduate Studies and Scientific Research at University of Bisha, Saudi Arabia for supporting this work through the Fast-Track Research Support Program. The authors would like to acknowledge the nursing students who have participated in the study. Special thanks to the administrators and faculty members of the institutions for their motivation and support during data collection.

Author Contributions: PK designed and conducted the study and wrote the initial draft of the manuscript. JA edited and added additional content and refined the manuscript. AP collected the data. SM edited the manuscript.

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Ethical Approval: Ethical approval was obtained from the Research and Ethics Committee of Narayana Hrudayalaya College of Nursing (NHH/AEC-CL.2022-BI5 dated 22/3/2022), Kirubhanidhi College of Nursing (KCC/22/22 dated 04/3/2022), and Koshy's College of Nursing (KCN/15 dated 07/3/2022).

Funding: The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The authors are thankful to the Deanship of Graduate Studies and Scientific Research at University of Bisha, Saudi Arabia for supporting this work through the Fast-Track Research Support Program.

ORCID iDs: Judie Arulappan https://orcid.org/0000-0003-2788-2755

Shimmaa Mansour Moustafa Mohammed https://orcid.org/0000-0002-2956-610X

Supplemental Material: Supplemental material for this article is available online.

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Research Part 2: Finding Information in Scholarly Research Articles
History of nursing research
Nursing critical literature review example
(PDF) A guide to scholarly writing in nursing
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Evidence-Based Practice and Nursing Research
Evidence-based practice is now widely recognized as the key to improving healthcare quality and patient outcomes. Although the purposes of nursing research (conducting research to generate new knowledge) and evidence-based nursing practice (utilizing best evidence as basis of nursing practice) seem quite different, an increasing number of research studies have been conducted with the goal of ...
A practice‐based model to guide nursing science and improve the health
Exemplars are provided to highlight the application of this nursing research model, which can be applied to other clinical settings that aim to fill evidence gaps in the literature. ... Strategies to promote nurses' engagement in clinical research: Description of two nurse scholar programs. Journal of Professional Nursing, 36 (3), 111-115. 10 ...
Nurses' roles in changing practice through implementing best practices
Pearson, A., Jordan, Z. & Munn, Z., 2012, ' Translational science and evidence-based healthcare: A clarification and reconceptualization of how knowledge is generated and used in healthcare ', Nursing Research and Practice 2012, 792519. 10.1155/2012/792519 [PMC free article] [Google Scholar]
Nursing research: A marriage of theoretical influences
Nursing research is an amalgamation, inspired by a broad range of theories and methodological approaches. This status is what brought nursing to its present academic level: scientific nursing journals, PhD programmes, professors, nursing institutes and faculties. Risjord asks "does nursing science need a distinct kind of theory?" (p. 489 ...
AJN The American Journal of Nursing
Original Research: The Lived Experiences of Nurses as Patients: A Qualitative Study. AJN, American Journal of Nursing. 124 (8):26-33, August 2024. This qualitative phenomenological study sought to explore the experiences of, and quality of care for, nurses who were admitted as patients to a hospital directly from an ED.
Articles
Grip strength is an important indicator of muscle strength. Nursing job demands physical power, which is related to their muscle strength. However, studies on nurses' grip strength remains lacking. Cemile Savci, Ayse Cil Akinci, Safiye Sahin, Sharon Atienza, Salem Dehom and Lisa R. Roberts. BMC Nursing 2024 23 :596.
Why Nursing Research Matters
Abstract. Increasingly, nursing research is considered essential to the achievement of high-quality patient care and outcomes. In this month's Magnet® Perspectives column, we examine the origins of nursing research, its role in creating the Magnet Recognition Program®, and why a culture of clinical inquiry matters for nurses.
Journal of Research in Nursing: Sage Journals
Journal of Research in Nursing publishes quality research papers on healthcare issues that inform nurses and other healthcare professionals globally through linking policy, research and development initiatives to clinical and academic excellence. View full journal description. This journal is a member of the Committee on Publication Ethics (COPE).
The American Journal of Nursing
The American Journal of Nursing (AJN) is the oldest and largest circulating nursing journal in the world. The Journal's mission is to promote excellence in professional nursing, with a global perspective, by providing cutting edge, evidence-based information that embraces a holistic perspective on health and nursing. Clinical articles focus on ...
Nursing Research
Nursing Research is a peer-reviewed journal celebrating over 60 years as the most sought-after nursing resource; it offers more depth, more detail, and more of what today's nurses demand. Nursing Research covers key issues, including health promotion, human responses to illness, acute care nursing research, symptom management, cost-effectiveness, vulnerable populations, health services, and ...
Building a Foundation for Excellence : Advancing Evidence-Based
The improvement of patient care outcomes hinges on the advancement of nursing knowledge development at the bedside. Nurse-generated research is a cornerstone of evidence-based practice (EBP) and a mark of nursing excellence. 1 In the 2023 Magnet Application Manual, an updated requirement includes providing a description with supporting evidence of an infrastructure that supports nursing ...
Clinical Nursing Research: Sage Journals
Clinical Nursing Research (CNR) is a leading international nursing journal, published eight times a year.CNR aims to publish the best available evidence from multidisciplinary teams, with the goal of reporting clinically applicable nursing science and phenomena of interest to nursing. Part of CNR's mission is to bring to light clinically applicable solutions to some of the most complex ...
Evidence-based practice beliefs and implementations: a ...
Evidence-based practice (EBP) integrates the clinical expertise, the latest and best available research evidence, as well as the patient's unique values and circumstances [].This form of practice is essential for nurses as well as the nursing profession as it offers a wide variety of benefits: It helps nurses to build their own body of knowledge, minimize the gap between nursing education ...
The essentials of nursing leadership: A systematic review of factors
Two research team members independently reviewed each article to determine inclusion. All included studies underwent quality assessment, data extraction and content analysis. Results: 49,502 titles/abstracts were screened resulting in 100 included manuscripts reporting on 93 studies (n=44 correlational studies and n=49 intervention studies).
Nursing, research, and the evidence
Maximising the potential of evidence-based nursing. Evidence-based care concerns the incorporation of evidence from research, clinical expertise, and patient preferences into decisions about the health care of individual patients. 14 Most professionals seek to ensure that their care is effective, compassionate, and meets the needs of their ...
Research in Nursing Practice : AJN The American Journal of Nursing
A 2007 study by Woodward and colleagues in the Journal of Research in Nursing found that nurse clinicians engaged in research often perceive a lack of support from nurse managers and resentment from colleagues who see the research as taking them away from clinical practice. The distinction often drawn between nursing research and clinical ...
Nurses in the lead: a qualitative study on the ...
Roper JM, Shapira J. Ethnography in nursing research. Thousand Oaks: Sage Publications; 2000. Book Google Scholar Polit DF, Beck CT. Nursing research: Generating and assessing evidence for nursing practice, 8th Edition. Philadelphia: Wolters Kluwer Health/ Lippincott Williams & Wilkins; 2008.
The Importance of Nursing Research
Nursing research is a growing field in which individuals within the profession can contribute a variety of skills and experiences to the science of nursing care. There are frequent misconceptions as to what nursing research is. Some individuals do not even know how to begin to define nursing research. According to Polit and Beck (2006), nursing ...
Nursing Research and Practice
Nursing Research and Practice is an open access journal focusing on all areas of nursing and midwifery. The journal focuses on sharing data and information to support evidence-based practice. As part of Wiley's Forward Series, this journal offers a streamlined, faster publication experience with a strong emphasis on integrity.
Journal of Clinical Nursing
The Journal of Clinical Nursing (JCN) disseminates developments and advances relevant to all spheres of nursing practice. Covering all areas of nursing - community, geriatric, mental health, pediatric - this international nursing journal promotes idea sharing between different cultures to provide a rich insight into nursing intervention and models of service delivery worldwide.
What are nurses' roles in modern healthcare? A ...
Attempts to shape nursing work have lacked understanding of how nurses contribute to healthcare, with negative consequences. For example, the recent introduction of Nursing Associate roles (Department of Health and Social Care, 2017) in the UK, ostensibly to be a compassionate, patient-facing role and reduce costs, overlooks evidence that replacing registered nurses with other providers leads ...
A quantitative systematic review of the association between nurse skill
1.1. Background. The conceptual framework developed by McCloskey and Diers was used to guide this review and the selection of variables.McCloskey and Diers examined the effects of health policy on nursing and patient outcomes sing the work of Aiken et al. ().McCloskey and Diers modified Aiken's framework to embed the seminal work of Donabedian's structure‐process‐outcomes framework ...
Unveiling missed nursing care: a comprehensive examination of neglected
The global variable of missed nursing care and practice environment are widely recognized as two crucial contextual factors that significantly impact the quality of nursing care. This study assessed the current status of missed nursing care and the characteristics of the nursing practice environment in Iran. Additionally, this study aimed to explore the relationship between these two variables.
Examining Relationships Among Nursing Students' Views ...
Google Scholar. 3. Gustafsson T, Hemberg J. Compassion fatigue as bruises in the soul: a qualitative study on nurses. Nurs Ethics. 2022;29(1):157-170. Crossref. ... This article was published in Western Journal of Nursing Research. VIEW ALL JOURNAL METRICS. Article usage * Total views and downloads: 0 * Article usage tracking started in ...
Research capacity in nursing: a concept analysis based on a scoping
Introduction. Research capacity has received a great deal of international attention in the nursing discipline. 1 2 One reason for this attention is that nursing has gradually become an independent scientific discipline which requires its own body of knowledge. Furthermore, with evidence-based practice spreading worldwide, nurses, as healthcare professionals, are responsible for delivering ...
JONA: The Journal of Nursing Administration
Mindfulness has been demonstrated to offer a variety of benefits to nurses. This article summarizes the qualitative research on the experience of mindfulness training and practice with the goal of providing evidence-based recommendations for nurse leaders on how to design and implement effective and well-adopted mindfulness programs.
Nursing Students' Experiences and Challenges in Their Education During
Research Setting. The study was conducted among nursing students of Narayana Hrudayalaya College of Nursing, Koshy's College of Nursing and Kirubanidhi College of Nursing, Bengaluru, Karnataka, India. ... Nursing education in a pandemic: Academic challenges in response to COVID-19. Nurse Education Today, 92, 104471. 10.1016/j.nedt.2020.104471 ...

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

Conclusions

Setting and participants

Data collection

Data analysis

Ethical considerations

Distinction based on complexity of care

Organizing hospital care

Evidence-based practices in quality improvement work

Limitations

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Unveiling missed nursing care: a comprehensive examination of neglected responsibilities and practice environment challenges

Conclusions

Introduction

Participants’ characteristics

Missed nursing care

Practice environment characteristics

Correlations between practice environment characteristics and missed care

Predicting missed nursing care based on practice environment subscales

Limitations

Data availability

Abbreviations

Acknowledgements

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Qualitative Research on Mindfulness Interventions for Staff Nurses

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