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Comparison of education using the flipped class, gamification and gamification in the flipped learning environment on the performance of nursing students in a client health assessment: a randomized clinical trial

Raziyeh Ghafouri 1 ,
Vahid Zamanzadeh 1 &
Malihe Nasiri 2

BMC Medical Education volume 24 , Article number: 949 ( 2024 ) Cite this article

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Since effective education is one of the main concerns of every society and, in nursing, can lead to the education of successful people, the development of learning and teaching methods with greater effectiveness is one of the educational priorities in every country. The present study aimed to compare the effect of education using the flipped class, gamification and gamification in the flipped learning environment on the performance of nursing students in a client health assessment.

The present study was a Parallel randomized clinical trial study. The participants were 166 nursing students. The clinical trial data was collected from December 14, 2023, to February 20, 2024. The inclusion criteria were nursing students who had passed the first semester, who were willing to participate and install the app on their mobile devices, and who had no experience with the designed application for this study. The participants were allocated to four groups with colored carts. In the first group, teaching was performed via gamification in a flipped learning environment; in the second group, teaching was performed via the gamification method. A flipped class was implemented in the third group. In the fourth group, the usual lecture method was used. The practical performance to assess the physical health assessment with 10 questions using the key-feature questions, along with the satisfaction and self-efficacy of the students, was also checked with questionnaires.

In this study, 166 nursing students, (99 female and 67 male), with an average (standard deviation) age of 21.29 (1.45) years, participated. There was no statistically significant difference in the demographic characteristics of the participants in the four intervention groups ( P > 0.05). Comparing the results before and after the intervention, the results of the paired t test indicated a significant difference in the satisfaction, learning and self-efficacy of the learners ( P < 0.001). In the comparison of the four groups, the ANOVA results for the comparison of the average scores of knowledge evaluation and satisfaction after intervention among the four groups indicated a statistically significant difference ( P < 0.001). When the knowledge evaluation scores of the groups were compared, the scores for gamification in the flipped learning environment were significantly different from the other methods ( P < 0.05), and there was no significant difference between the scores for the flipped class and lecture methods ( P = 0.43). According to the ANOVA results, when comparing the satisfaction scores of the groups, the students in the flipped learning environment and gamification groups were more satisfied than the flipped class and lecture groups ( P < 0.01).

Based on the results of the present research, it can be concluded that teaching methods have an effect on students’ learning and satisfaction. The teaching method has an effect on the satisfaction of the students, and the use of the flipped class method with the use of gamification was associated with more attractiveness and satisfaction in addition to learning. Teachers can improve the effectiveness of education with their creativity, depending on situation, time, cost, and available resources, by using and integrating educational methods.

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Introduction

Effective education is one of the main concerns of every society [ 1 ]. Because the traditional methods of teaching, learning and management have little effectiveness [ 2 ], multiple learning strategies of active learning and the use of technologies [ 3 , 4 , 5 ], it is helpful to integrate the classroom approach among these methods. The reverse is the use of a playful method [ 6 , 7 ]. The flipped classroom was presented in 2007 by Bergmann and Sams, two chemistry teachers at Woodland Park High School in Colorado (USA). Their goal was to ensure that students who could not attend class for various reasons could proceed at the pace of the course and not be harmed due to not attending class [ 8 ]. Bergmann and Sams videotaped and distributed instructional content and found that this model allowed the teacher to focus more attention on the individual learning needs of each student [ 5 , 8 ].

In 2014, the Flipped Learning Network (FLN) was introduced, in which flipped learning was defined as “an educational approach in which direct instruction is transferred from the group learning dimension to individual learning, and in a dynamic and interactive learning environment, where the instructor guides students in applying concepts and engaging creatively with course content”. The four pillars of flexible environment, learning culture, purposeful content and professional instructor have been described in opposite directions [ 9 , 10 ]. In addition to the ever-increasing complexity of the healthcare environment and the rapid advancement of healthcare technology, a global pandemic (COVID-19) has affected educational structures. The pandemic has caused a global educational movement toward blended learning to meet students’ technological and hands-on learning needs. Indeed, at no time in history has there been such a sudden transition to this type of learning [ 11 ], where the flipped classroom was widely used [ 9 ].

In nursing education, the use of flipped classrooms [ 9 , 12 ] and technologies [ 3 , 5 ] has been emphasized. The results obtained in the systematic review of the effect of the flipped classroom on academic performance in nursing education indicated its positive effect, and the opinions of most students about this method included aspects such as its usefulness, flexibility, greater independence or greater participation [ 13 , 14 , 15 , 16 , 17 , 18 , 19 ]. According to the cognitive bases related to the Bloom’s taxonomy, with the flipped classroom method, the student works in the first stage of the learning process at home, which is the simplest stage, and in the second stage, through active learning with the help of the teacher and classmates, in class time, which is used to increase and empower more [ 20 , 21 ]. In addition, the flipped classroom method has certain advantages over traditional learning. The flipped classroom is student-centered and makes students responsible for their own learning [ 22 ], and its use in nursing has been emphasized in systematic review studies [ 3 , 23 , 24 ].

One of the interactive teaching methods using computers is the gamification method. Gamification in education includes the use of game elements to increase motivation and participation and to involve students in the personal learning process [ 1 , 25 ]. Gamification is an active education method. The gamification system increases the level of engagement and motivation of learners by provoking excitement and creating challenges for them. Additionally, with this method, it is possible to provide an opportunity for testing, and in that test, in addition to creating a challenge, learners are given the opportunity to display their achievements through competition [ 26 ].

Nursing education institutions are obliged to improve the ability of nursing students to make correct clinical judgments through various educational programs and the use of new teaching methods [ 27 , 28 ] so that when nursing students enter the clinic, they can fulfill their role as members of the medical team [ 27 ]. Therefore, it is necessary to carry out more research regarding the identification of effective teaching methods that can improve the attractiveness of education and its satisfaction among nursing students [ 1 , 27 ].

This study addresses the lack of comparative research on the effectiveness of flipped classrooms and gamification in nursing education, an area that has not been sufficiently explored. The advantages of combining education methods are that they can be used together [ 6 , 7 ]. For example, by combining education using the flipped class with gamification, more study time is provided by using the flipped class, and the attractiveness of the method is provided by gamification [ 7 ]. Therefore, considering the attractiveness of the new application that is prepared in a flipped class, the current research was conducted aimed at comparing the effects of education using the flipped class, gamification and gamification in the flipped learning environment on the performance of nursing students in terms of client health assessment.

The present study was a parallel randomized clinical trial research aimed at comparing the effect of education using the flipped class, gamification and gamification in the flipped learning environment on the performance of nursing students in a client health assessment. The clinical trial data was collected from December 14th, 2023, until February 20th, 2024.

Participants

First, in a call, 247 nursing students registered to participate in the study. After checking the entry criteria, 188 people met the entry criteria for the study. The inclusion criteria were nursing students who had passed the first semester, who were willing to participate and install the app on their mobile devices, and who had no experience with the designed application for this study. Exclusion criteria were: miss the mobile and drop out of study, for example, because of transferring, migration or do not like to continue participating in the study. So, 18 students were excluded from study for unwillingness to continue, 2 students because of migration were excluded, and 2 people were excluded for missing their mobile (Fig. 1 ).

Study and sampling process

The participants were allocated to four groups with using colored carts. Before sampling, 188 carts in 4 blue, red, black and white colors (from each color, 45 carts) were prepared in one enveloped pocket. After completing the informed consent and pre-test questionnaires, each student took a colored card from the enveloped pocket. Then, with the lottery, it was determined that the participants with the blue card participated in the gamification in a flipped learning environment, the red cart in the gamification, the black cart in the flipped class, and the white cart in the lecture method. The study and sampling process is shown in Fig. 1 .

Intervention

The education course was 4 class in 60 min of health status assessment in 4 weeks. Each group has a classroom weekly. Education content was health assessment and clinical examination courses of the Bachelor of Nursing Education curriculum. Course plan was developed based on the curriculum.

For intervention, the application was designed using the cascade model (initial analysis, system analysis, design, programming, testing (alpha and beta), implementation and modification) [ 29 , 30 ]. In the initial analysis stage, the need or the desired problem, which is the issue of education improvement, is raised, and can technical solutions be provided for it? If there are possible solutions, the practicality is evaluated, and in the analysis of the visual appeal system, the up-to-date information, simple language, and comprehensiveness of the information provided in the educational content are checked. In the design phase, the design of the desired system was written, and a program was written by the programmers according to the initial design of the system.

The educational content of the application was prepared based on the health assessment and clinical examination courses of the Bachelor of Nursing Education Program, approved by an expert panel. The application was designed in two parts: education and scenario-based games. In the education section of the application, the content of the education was presented, and in the scenario base game section, the 10 scenarios of health status assessment and clinical examination were designed based on real situations.

In the scenario base game section of the application, the application was embedded as a game in such a way that the student, at the first, observes the chief compliance of the patient, and they must complete patient examinations and choose the correct answer. If they choose correctly, they will take a green cart, and if they make a mistake, they will take a red cart. They could take 4 green carts in each scenario. A yellow cart was shown when the answer was not incorrect, but it was not an exact answer. In each scenario, they must find the correct nursing diagnosis. They must provide a nursing diagnosis based on the priority of care in the scenario.

The fundamental elements of gamification are mechanics (motivating students through points, budgets and rewards), dynamics (engaging users through stories and narratives), and aesthetics (user experiences from applications about being user-friendly and attractive) [ 31 , 32 , 33 ]. The mechanics element was considered in the application, with green carts in each stage. The dynamic element was considered in the scenarios. The aesthetic element was considered and checked in alpha and beta tests.

In the test phase, the Application was checked for errors, and it was tested for user acceptance in two parts, the alpha and beta tests. In the alpha test, the program was used by the designers (four academic nurses and 4 IT men) as users, and in the beta test, a group of users (20 nursing studentsThe fundamental elements of a flipped class are that the students must read the content before the class and do the assignment in the class. In this study, this element was considered, and the provided content was given to participants at first. The students read content for each class before the class, and they solved the assignment in the class. The provided content for the flipped class group was designed in the PowerPoint files, and for the gamification in the Flipped Learning Environment group was designed in the application.

It was improved based on their opinions, and in the next stage, the approved application by the designer and user was used in this study.

Lecture group

In the Lecture group, the content of the education was held in the lecture method, and in each section, at the end of class, a scenario of the designed was given to the students as an assignment. They must solve it by next week. At the end of the study, four scenarios were performed by the students as assignments in this group.

Flipped class group

In the Flipped class group, the content was prepared in the four voiced PowerPoints and presented them to the students in the first session. Students read the content of each class, and in class they discussed the educational content and solved the scenarios as an assignment. Eight scenarios were discussed by the students as assignments in this group.

Gamification group

In the Gamification group, in each class, after the educational content was presented, the homework was presented, and students played a scenario of application in the class. Four scenarios were performed by the students as assignments in this group.

Gamification in the flipped learning environment group

In the Gamification in the Flipped Learning Environment group, the designed mobile application was presented in the first session of the course. Students must read the content of the session before the class, and in class they discussed the educational content and solved the scenarios as an assignment. Eight scenarios were performed as homework by students in a gamification environment.

Data collection tools

In this study, a questionnaire with 10 key-feature questions (KFQs) was designed by an expert panel of 10 academic nurses. After designing a KFQ questionnaire, its validity and reliability were examined. Validity was confirmed with a content validity ratio (CVR) of 14 expert (academic nurses) and qualitative validity with 7 academic and 7 clinical nurses; reliability was checked by test-retest. The CVR of the questionnaire was 0.96 and was confirmed. All seven academic and seven clinical nurses confirmed the qualitative validity of the questionnaire. The content validity coefficient based on the number of participating professors (at least 10 people) is 0.49 as the minimum acceptable according to the Lauwshe Tables (18, 19) and the necessity of the items of tools was confirmed.

For the test-retest of KFQ questionnaire, 10 nursing students participated. They filled out the questionnaire twice, with an interval of two weeks. The correlation coefficient between their answers was 0.93 with Spearman’s correlation coefficient. The correlation coefficient above 0.7 is good [ 34 , 35 ].

Additionally, education satisfaction was investigated with the Measuring Student Satisfaction Scale from the Student Outcomes Survey [ 27 ], which includes 20 items. The validity of it was confirmed with CVR, and the reliability was checked by Cronbach’s alpha. The CVR of the questionnaire was 0.91 and was confirmed. Cronbach’s alpha was 0.69. Cronbach’s alpha coefficient above 0.7 is good, 0.3–0.7 is good, and less than 0.3 is poor [ 34 , 35 ]. The overall Cronbach’s alpha was appropriate reliability.

The Sherer questionnaire tool was used to assess the self-efficacy of the nursing students [ 36 ]. This tool contains 17 items on a five-point Likert scale. Sherer et al., confirmed the reliability of the questionnaire with Cronbach’s alpha 0.76 [ 36 ]. Also, for this questionnaire, the validity was confirmed with CVR, and the reliability was checked by Cronbach’s alpha. The CVR of the questionnaire was 0.90 and was confirmed. Cronbach’s alpha was 0.45.

Data analysis

The analysis of the research data was performed using the Statistical Package for Social Sciences version 20. The Kolmogorov-Smirnov test was used to assess the normality of the data. Data analysis was performed by using descriptive tests, such as percentage, mean and standard deviation, and statistical tests, such as the chi-square test, paired t test, and ANOVA. In all statistical tests, a significance level was considered less than 0.05.

In the present study, 166 nursing students, 99 women and 67 men, with an average (standard deviation) age of 21.29 (1.45) years, were participated. The demographic characteristics of the participants are shown in Table 1 . The homogeneity of the intervention and control groups was checked with statistical methods, and the results are reported in Table 1 . There was no statistically significant difference in the demographic characteristics of the participants in the groups ( P > 0.05).

Comparing the results before and after the intervention, the results of the paired t test indicated a significant difference in the satisfaction, learning and self-efficacy of the learners ( P < 0.001). Table 2 shows the results of paired t tests.

The ANOVA showed that a statistically significant difference between the mean scores of knowledge and satisfaction after intervention in the four groups ( P < 0.001). The result of the ANOVA was not significant difference between the mean of the self-efficacy after intervention in the four groups ( P = 0.101).

In the analysis of the groups, there was a significant difference in the comparison of the knowledge evaluation scores, such that there was a significant difference between the average of the gamification methods in the flipped learning environment group and the gamification compared to the inverted class and lecture, considering equal variance ( P < 0.001). There were significant differences at the 0.05 level between the two gamification methods in the flipped learning environment group and the gamification group ( P = 0.03). Gamification and flipped classes had no significant difference ( P = 0.054). There was no significant difference between the two methods of flipped class and lecture ( P = 0.43).

According to the ANOVA results, when comparing the satisfaction scores of the groups, there was no significant difference between the means of gamification in the flipped learning environment and the gamification method ( P = 0.49); however, there was a significant difference between the gamification in the flipped learning environment and the gamification with the flipped class and the lecture. Additionally, there were significant differences between the flipped class and the lecture method ( P < 0.01).

Discussions

This study aimed to compare the effects of the lecture method, flipped class and gamification in a flipped learning environment on the performance of nursing students in assessing the health status of clients. The demographic characteristics of the participants (gender, age, academic semester, grade point average and theory course score) had the same distribution among the four groups, and there was no statistically significant difference ( P < 0.05).

Comparing the results before and after the training, the results of the paired t test indicated a significant difference in the satisfaction, learning and self-efficacy of the learners ( P < 0.001). The results indicate that all four teaching methods effectively affected the learning, satisfaction and self-efficacy of students in evaluating the health status of their clients. However, in the comparison of the 4 groups, ANOVA revealed a statistically significant difference ( P < 0.001). In the analysis comparing the knowledge evaluation scores of the gamification group with those of the other methods group, there were significant differences ( P < 0.05), and there was no significant difference between the two methods (Flipped class and lecture) ( P = 0.439). According to the ANOVA results, the satisfaction scores of the groups were greater for the gamification in the flipped learning environment and gamification groups than for the flipped class and lecture groups ( P < 0.01). The results of the present research indicate that teaching methods have an effect on students’ learning and satisfaction.

Rachayon and his colleagues also used a task-based learning method in combination with digital games in a flipped learning environment to develop students’ English language skills, and their results also indicated the success of combining the above methods [ 7 ]. Muntrikaeo and his colleagues also used a similar model of task-based learning in combination with games in a reversed environment for teaching English, and their findings were also successful [ 6 ]. The results of the current research, which involved the integration of the gamification in the flipped learning environment for teaching health status assessment to nursing students, are similar to those of the above research.

Zou et al., in their systematic review, found that success in the flipped classroom is related to teachers’ creativity in making the classroom interactive, students’ readiness, and the use of technology [ 37 ]. In the present study, the flipped class, along with the use of gamification in the flipped learning environment, increased learner satisfaction and learning. Therefore, their findings are similar to the findings of the present study.

Hernon and his colleagues reported that the use of technology plays a significant role in the development of nursing students’ skills [ 4 ]. Regarding the use of educational applications for health assessment, the results of their research are the same as the current research, and the use of technology not only plays a role in learning but also it has role in education satisfaction. Considering the results of the present study and similar studies, we can conclude that the use of gamification in the flipped learning environment is an interactive teaching method and can be used to improve nursing education. Gamification can increase the attractiveness of education and promote education. If a good application is designed as a flipped enviroment, it provides more time in the classroom for discussion, interaction, and scenario-based education and promotes education satisfaction.

In this study, the satisfaction with education had a significant difference between the groups, but the students’ self-efficacy, despite the significant difference before and after the intervention, did not have a significant difference between the groups. Since all three studied methods were effective in students’ learning and self-efficacy, it can be said that teachers can improve educational effectiveness and satisfaction by using different methods and combining them in educational situations by considering resources and conditions.

The gamification method was associated with higher satisfaction, but it requires more resources, equipment, and skilled personnel. The flipped class method requires fewer resources, is more cost-effective, and provides more time for practice and group discussion. By combining these two methods, the advantages of both can be used, which is confirmed by the results of the present study. It seems that the upside-down environment provides a good opportunity for life-long training, including the promotion of interaction and teamwork, and along with other methods, it is also associated with more effectiveness and benefits.

In this study, knowledge and satisfaction of education had significant differences between groups, but students’ self-efficacy had not significant difference between groups. Maybe it was due to the fact that we participated in the second and third semesters of nursing students, and the interactive skills of students were not assessed. So, the researchers recommended that more research be conducted with the aim of investigating interactive and communication skills using gamification in a flipped environment.

Therefore, this method is helpful in nursing education as well as other medical fields. It is suggested that this method could be combined with other educational methods, such as task-based and team-based methods, to develop the possibility of developing team-based education and task-based education. Integrated gamification methods in the flipped learning environment with mobile applications have greater attractiveness and satisfaction with effective education, and with the use of appropriate applications, it is necessary to create a sense of competition and learning. But, in this study, the interactive skills of students were not assessed. Finally it is emphasized that teachers can improve the effectiveness of education with their creativity, depending on situation, time, cost, and available resources, by using and integrating educational methods.

The teaching method has an effect on students’ satisfaction with the teaching method, and the use of gamification in the flipped learning environment is more effective than the flipped class method, gamification, and the lecture method. Based on the results of the present research, it can be concluded that teaching methods have an effect on students’ learning and satisfaction. The teaching method has an effect on the satisfaction of the students, and the use of the flipped class method with the use of gamification was associated with more attractiveness and satisfaction in addition to learning. Teachers can improve the effectiveness of education with their creativity, depending on situation, time, cost, and available resources, by using and integrating educational methods.

Limitations

Not installing the program on IOS phones made it impossible for these users to use the application and drop out study, so we recommended that designed application for android and IOS. The ability of the professor to teach with the method of gamification in the flipped learning environment and his mastery of the application are necessary to provide necessary training to the teachers regarding the above methods.

Integrated gamification methods in the flipped learning environment with mobile applications have greater attractiveness and satisfaction. But, in this study, the interactive skills of students were not assessed. So the researchers recommended that more research be conducted with the aim of investigating interactive and communication skills using the gamification method in an upside-down environment.

Data availability

Data is provided within the manuscript or supplementary information files.

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Acknowledgements

The authors also wish to thank all the participants and those who helped us in carrying out the research especially all the staffs of Department of Medical Surgical Nursing of School of Nursing & Midwifery of Shahid Beheshti University of Medical Sciences.

The authors received no specific funding for this work.

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Raziyeh Ghafouri & Vahid Zamanzadeh

Department of Basic Sciences, School of Nursing & Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran

Malihe Nasiri

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Contributions

VZ and RG formulates the research question that represents the systematic review objective. VZ and RG provide proposal and reports. RG collected the data. MN: Data analysis. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Raziyeh Ghafouri .

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This study was approved by the ethics committee of Shahid Beheshti University of Medical Science (IR.SBMU.PHARMACY.REC.1402.152), and all methods were carried out in accordance with the research ethical codes of the Iran National Committee for Ethics in Biomedical Research. The authors guarantee that they have followed the ethical principles stated in the Declaration of Helsinki (to protect the life, health, dignity, integrity, right to self-determination, privacy, and confidentiality of personal information of research subjects) in all stages of the research. This is the online certificate of the research ethical code: https://ethics.research.ac.ir/ProposalCertificateEn.php?id=404003&Print=true&NoPrintHeader=true&NoPrintFooter=true&NoPrintPageBorder=true&LetterPrint=true . This study was registered in the Iranian Registry of Clinical Trials ( https://irct.behdasht.gov.ir ) on 14/12/2023, with the IRCT ID: IRCT20210131050189N7. To observe ethical considerations, School of Nursing & Midwifery of Shahid Beheshti University of Medical Sciences agreed to participate in the study; the research goals and procedures were elucidated to the participants, the participants were assured of information anonymity and confidentiality, and informed written consent was obtained from each participant and documented. They participated in the study voluntarily and could leave the study at any stage.

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Ghafouri, R., Zamanzadeh, V. & Nasiri, M. Comparison of education using the flipped class, gamification and gamification in the flipped learning environment on the performance of nursing students in a client health assessment: a randomized clinical trial. BMC Med Educ 24 , 949 (2024). https://doi.org/10.1186/s12909-024-05966-2

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1 Author Affiliation: Director, Magnet Recognition Program®, American Nurses Credentialing Center, Silver Spring, Maryland.
PMID: 33882548
DOI: 10.1097/NNA.0000000000001005

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. This column explores how Magnet hospitals have built upon the foundation of seminal research to advance contemporary standards that address some of the challenges faced by healthcare organizations around the world. We offer strategies for nursing leaders to develop robust research-oriented programs in their organizations.

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Nursing Research

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Levels of Evidence

Source: Nursetopia, March 2013.

Study Design 101 Tutorial by George Washington University. Describes different study designs.
Presenting research to clinicians: strategies for writing about research findings Nurse Researcher 2006. Vol. 13, Iss. 4; p. 66 (9 pages) Marilyn H Oermann, Elizabeth A Galvin, Judith A Floyd, Janna C Roop
Translating research into evidence-based nursing practice and evaluating effectiveness Coopey, M & Nix, MP Journal of Nursing Care Quality (2006) 21(3), 195-202.
The integrative review: updated methodology Whittemore, R., & Knafl, K. (2005). The integrative review: Updated methodology. Journal of Advanced Nursing, 52(5), 546-553. https://doi.org/10.1111/j.1365-2648.2005.03621.x
How to undertake a literature search: a step-by-step guide Watson, M. (2020). How to undertake a literature search: A step-by-step guide. British Journal of Nursing (Mark Allen Publishing), 29(7), 431-435. https://doi.org/10.12968/bjon.2020.29.7.431
Differentiating Between Research and Quality Improvement Gregory, K. (2015). Differentiating Between Research and Quality Improvement. The Journal of Perinatal & Neonatal Nursing, 29 (2), 100-102. doi: 10.1097/JPN.0000000000000107.
What is a Systematic Review? As defined by the Cochrane Consumer Network, A systematic review summarises the results of available carefully designed healthcare studies (controlled trials) and provides a high level of evidence on the effectiveness of healthcare interventions. Judgments may be made about the evidence and inform recommendations for healthcare. Source: Cochrane Consumer Network
Randomized Controlled Trial A study design that randomly assigns participants into an experimental group or a control group. As the study is conducted, the only expected difference between the control and experimental groups in a randomized controlled trial (RCT) is the outcome variable being studied. Source: Study Design 101, GWU
Cohort Study A study design where one or more samples (called cohorts) are followed prospectively and subsequent status evaluations with respect to a disease or outcome are conducted to determine which initial participants exposure characteristics (risk factors) are associated with it. As the study is conducted, outcome from participants in each cohort is measured and relationships with specific characteristics determined. Source: Study Design 101, GWU
Case Control Study A study that compares patients who have a disease or outcome of interest (cases) with patients who do not have the disease or outcome (controls), and looks back retrospectively to compare how frequently the exposure to a risk factor is present in each group to determine the relationship between the risk factor and the disease. Source: Study Design 101
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Expert Opinion defined by Merriam-Webster Dictionary a belief or judgment about something given by an expert on the subject
A tutorial on pilot studies: The what, why and how Thabane, L., Ma, J., Chu, R., Cheng, J., Ismaila, A., Rios, L. P., . . . Goldsmith, C. H. (2010). A tutorial on pilot studies: The what, why and how. BMC Medical Research Methodology, 10(1), 1-1. doi:10.1186/1471-2288-10-1
Understanding research impact: A review of existing and emerging tools for nursing. Wimmer, E. N., Rethlefsen, M. L., Jarvis, C., & Shipman, J. P. (2016). Understanding research impact: A review of existing and emerging tools for nursing. Journal of Professional Nursing, 32(6), 401-411. 10.1016/j.profnurs.2016.05.005
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Research article
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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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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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Olga Yakusheva

Dr. Olga Yakusheva is an economist and a Professor of Nursing at he Johns Hopkins School of Nursing. Furthermore, she holds the position of the Economics Editor for the International Journal of Nursing Studies (IF=8.6). Dr. Yakusheva has an academic background in mathematics (BS) and economics (MS, PhD), specializing in economic theory and methods, and big data analytics. She completed post-doctoral training in health services research at the Yale Schools of Medicine and Public Health. Internationally recognized as an expert on the economic value of nursing and its contribution to patient, societal, and organizational outcomes, Dr. Yakusheva is one of the leading economists influencing national nursing policy. In 2023, she was inducted as an Honorary Fellow of the American Academy of Nursing. Dr. Yakusheva has published her work in nursing, economics, policy, and health services research journals; she is currently a principal investigator on two R01s that examine ways to optimize nursing care delivery in hospitals; she is also funded by the American Nurses’ Association (ANA) Enterprise and the American Nurses’ Foundation for her work on the economic value of nursing and nursing payment across the care continuum. Dr. Yakusheva presently serves as an economic advisor to the ANA Enterprise, the ANA Enterprise Research Council, and The Joint Commission’s Nurse Stakeholder Committee. Alongside a nursing colleague, she co-directs the ANA’s new initiative, “Framing and Articulating the Economic Value of the Nursing Profession.” This includes leading the national summit, “Re-imagining the Economic Value of Nursing.” Dr. Yakusheva is the lead author of a recent six-part series in Nursing Outlook titled “Value-informed nursing practice and leadership” and several recent publications proposing alternatives payment models for nursing reimbursement.

Specialties and Expertise

Health Policy

Nursing Research Priorities

Research priorities.

The ANA Enterprise Research Priorities are strategically designed to address critical challenges and opportunities in nursing and healthcare. These priorities focus on enhancing healthcare access, improving safety and quality of care, and promoting the health and well-being of nurses. They also emphasize the importance of diversity, equity, and inclusion, the development of professional identity, and environmental sustainability. Together, these research priorities aim to drive impactful changes that will shape the future of nursing and healthcare on a global scale. Download the full document to learn more about how these priorities are guiding innovative research and advancing the profession.

ANA Enterprise Research Council

The ANA Enterprise Research Advisory Council provides expert guidance and recommendations to the Institute for Nursing Research & Quality Management on matters of global importance, aimed at shaping the future of nursing and healthcare. By fostering a culture of inquiry and advancing interprofessional, practice-based research, the Council drives transformative initiatives that align with the ANA Enterprise's mission to lead the profession forward.

Composed of volunteer experts, the Council unites diverse nursing voices to steer research efforts that strengthen the global impact of nursing. It ensures that frontline nurses' perspectives are central to advancing healthcare innovations. Historically focused on building research capacity, fostering collaboration, and enhancing data governance, the Council's priorities now emphasize workforce development, nurse well-being, diversity and inclusion (DEIB), expanding the scope of practice, and demonstrating the value of nursing.

Research Advisory Council

Jen bonamer.

PhD, RN, AHN-BC, NPD-BC

Nursing Professional Development – Research Specialist Education, Professional Development & Research Department Sarasota Memorial Health Care System

Jen Bonamer works as a Nursing Professional Development – Research Specialist at Sarasota Memorial Hospital in Sarasota Florida. She leads the nursing research and evidence-based practice programs and is actively focused on supporting healthy work environments and clinician well-being. Jen received her BSN from the University of Florida (Gainesville) and practiced for ten years in pediatrics (general practice and hematology/oncology/bone marrow transplant). She completed the University of South Florida’s (Tampa) Nursing BS to PhD program with her master’s of science degree (nursing education) and PhD (nursing). She is certified in both nursing professional development and advanced holistic nursing. Jen is an active member in the American Nurses Association – Enterprise (ANAE) Research Advisory Council and an independent contractor of peer review services for the Magnet program.

Catherine H. Ivory

PhD, RN-BC, NEA-BC, FAAN

Associate Nurse Executive, Nursing Excellence Vanderbilt University Medical Center

Cathy Ivory, PhD, RN-BC, NEA-BC, FAAN, Associate Nurse Executive, oversees the Office of Nursing Excellence for the Vanderbilt Health System. Through collaboration across all VUMC and Vanderbilt University entities, The Office of Nursing Excellence is responsible for professional, evidence-based nursing practice, VUMC’s shared governance and Magnet activities, and all aspects of inquiry that translates evidence into practice and improves quality, safety, patient experience, and the delivery of cost effective care across settings. Dr. Ivory facilitates nursing research activities and connects nurse investigators with collaborators across the broader research enterprise at Vanderbilt.

Dr. Ivory has more than 25 years of experience as a staff nurse, clinical specialist, system-level nursing administrator, educator, and health services researcher. Dr. Ivory’s clinical focus is perinatal nursing and she served as the 2014 President of the Association of Women’s Health, OB and Neonatal Nurses (AWHONN), representing more than 300,000 nurses who care for women and newborns. She also holds two ANCC board certifications, one as an informatics nurse (RN-BC) and one as an advanced nurse executive (NEA-BC). She was inducted as a fellow in the American Academy of Nursing in 2017.

Dr. Ivory holds a BSN, an MSN in nursing administration/healthcare informatics, and a PhD in nursing science. Her research interests include implementation science and using data generated by nurses to quantify their role in patient care, patient safety, and patient outcomes. She is passionate about the nursing profession, nursing informatics, evidence-based nursing practice, and research.

David W. Price

MD, FAAFP, FACEHP, FSACME

Professor, Family Medicine, University of Colorado Anschutz School of Medicine Senior Advisor to the President and CEO, American Board of Family Medicine Medical Education and Quality Improvement Consultant and Coach Associate, Wentz/Miller Global Services

Dr. Price is Senior Advisor to the President, American Board of Family Medicine. He is also Professor of Family Medicine at the University of Colorado School of Medicine.

Dr. Price spent 29 years in the Kaiser Permanente (KP) system in several roles, including Director of Medical Education for the Colorado Region and the (national) Permanente Federation; physician investigator with the KP Colorado Institute of Health Research; Co-director of the Kaiser Colorado Center for Health Education, Dissemination and Implementation research; Clinical Lead for Kaiser National Mental Health Guidelines; member of the Kaiser National Guideline Directors Group, and Chair of Family Medicine for the Colorado Permanente Medical Group. He served on the ABFM Board of Directors from 2003 – 2008, where he chaired the R&D and Maintenance of Certification committees and was Board Chair from 2007-2008. He is a former Senior Vice-President at the American Board of Medical Specialties. He is a past Director of the Accreditation Council for Continuing Medical Education, a past-president of the Colorado Academy of Family Physicians, past chair of the AAMC Group on Educational Affairs section on Continuing Education and Improvement, and currently serves on the AAMC Integrating Quality Initiative steering committee. He is widely published and has spoken nationally and internationally and published in areas ranging from continuing medical education/professional development, quality and practice improvement, mental health, and evidence-based medicine.

Dr. Price received his M.D. degree from Rutgers Medical School in 1985 and completed his Family Medicine Residency and chief residency at JFK Medical Center, Edison, NJ, in 1988. He is a fellow of the American Academy of Family Physicians, the Alliance for Continuing Education in the Health Professions, and the Society of Continuing Medical Education (SACME) and the recipient of the 2018 SACME Distinguished Service in CME Award.

Marianne Weiss

Professor Emerita of Nursing Marquette University College of Nursing

Dr. Weiss is Professor Emerita of Nursing at Marquette University in Milwaukee, WI. She holds a Bachelor of Science in Nursing degree from McGill University in Montreal, Canada, and Master of Science in Nursing and Doctor of Nursing Science degrees from the University of San Diego. Prior to joining the faculty of Marquette University, she held positions as clinical nurse specialist and nurse researcher in women’s services for a large healthcare system.

Dr. Weiss continues to be an active nurse researcher and research consultant. Her program of research focuses on the contribution acute care nurses make to patient outcomes. Much of her work has focused on discharge preparation, assessment of discharge readiness, and post-discharge outcomes across the range of patients discharged from acute care hospitals. Her funded research studied the impact of nurse staffing on quality and cost measures of the discharge transition from hospital to home. Dr. Weiss was the Principal Investigator for the READI multi-site study, commissioned by ANCC and conducted at 33 Magnet hospitals, that investigated implementation of discharge readiness assessment as a standard nursing practice for hospital discharge. Other related research focuses on nurse staffing, continuity of care, and nurse characteristics such as education and certification that contribute to nurse performance in achieving patient outcomes. Her goal is to document the critical role and value hospital nurses bring to patient care and outcomes during and after hospitalization.

Instrument development has been an important aspect of her work on discharge readiness. Dr. Weiss has developed and tested research scales to measure quality of discharge teaching, discharge readiness, and post-discharge coping difficulty. She has conducted tool validation studies in adult-medical surgical patients, parents of hospitalized children, and postpartum mothers. These scales have been translated into more than 15 languages and are being used extensively in clinical practice and research. Dr. Weiss collaborates frequently with researchers worldwide on the science of discharge preparation. She has published extensively with US and international colleagues.

Olga Yakusheva

Professor of Nursing and Public Health Department of Systems, Populations and Leadership Department of Health Management and Policy University of Michigan School of Nursing and School of Public Health

Dr. Yakusheva is an economist with research interests in health economics and health services research. Yakusheva's area of expertise is econometric methods for causal inference, data architecture, and secondary analyses of big data. The primary focus of Yakusheva’s research is the study of economic value of nursing/nurses. Yakusheva pioneered the development of a new method for outcomes-based clinician value-added measurement using the electronic medical records. With this work, Yakusheva was able to measure, for the first time, the value-added contributions of individual nurses to patient outcomes. This work has won her national recognition earning her the Best of AcademyHealth Research Meeting Award in 2014 and a Nomination in 2018. Yakusheva is currently a PI on a AHRQ funded R01 measuring the continuity of interprofessional ICU care and an ANF/ANCC funded research grant measuring the value-added contribution of specialty nurse certifications to nurse performance and patient outcomes.

Yakusheva is a team scientist who has contributed methodological expertise to many interdisciplinary projects including hospital readmissions, primary care providers, obesity, pregnancy and birth, and peer effects on health behaviors and outcomes

Yakusheva holds a PhD in economics, an MS in economic policy, and a BS in applied mathematics.

Colleen K Snydeman

Executive Director, Office of Quality, Safety, Informatics, & Practice and the Inaugural MGH Endowed Scholar in Nursing Practice, Nursing & Patient Care Services, Massachusetts General Hospital

Dr. Snydeman’s expertise and leadership are dedicated to delivering safe, evidenced-based, high quality patient care through the continuous improvement of practice and positive outcomes with a focused commitment to the safety and well-being of the workforce. As the executive director of Massachusetts General Hospital’s Patient Care Services Office of Quality, Safety, Informatics, & Practice I provide oversight for quality and safety programs, improvement initiatives and outcomes associated with quality nursing care (falls, pressure injuries, central line blood stream infections, catheter associated urinary tract infections, and assaults on nursing personnel). I oversee a team of nine quality and informatics specialists and have a formal, non-direct reporting relationship with 75 unit based clinical nurse specialist and nurse practice specialists.

During the unprecedented COVID-19 era I led and supported a full implementation of Circle Up Huddles in all PCS inpatient areas, implementation of hospital-wide Proning Teams (recognized by Johnson & Johnson as a top ten innovation), pressure injury research, qualitative research on the experiences of bedside nurses and respiratory therapists, and implementation of resiliency and wellbeing strategies. In collaboration with RGI analytics, we have developed an algorithm using live streaming electronic health record data to alert nurses on their iphones to changes in patient’s fall risk and the associated interventions needed to prevent falls. Preliminary statistical findings are promising.

I have over forty years of progressive nursing leadership experience. My background in nursing leadership and critical care nursing led to my dissertation work using a quasi-experimental pre/post-test design with intervention and control groups to measure the impact of a theory based adverse event nurse peer review program on safety culture and the recovery of medical errors in the critical care setting. A linear mixed model analysis suggested that critical care nurses who participated in the program had a more critical view of safety culture and work environment, along with increased accountability and responsibility for their role in using strategies to keep patients safe. Further interdisciplinary safety research is underway.

Johana Rocio, Fajardo (Almansa)

Advanced Heart Failure & Transplant Nurse Practitioner, Duke University Hospital

As a doctor of nursing practice with a specialty in heart failure, transplant and mechanical support, my research is focused on improving patient outcomes through the development and implementation of best practices for the care of advanced heart failure patients. My clinical activities are centered on reducing healthcare inequities and improving Health Related Quality of Life (HRQoL) throughout the disease trajectory by optimizing interdisciplinary management and transitional care. Additionally, I have worked on database creation for both clinical and academic purposes as well as leveraging information technology to promote clinical practice standardization, minimize medical errors, and reduce cost of care.

Lastly, I have assisted in the establishment of centers of excellence by building the organizational, clinical, and educational infrastructures to deliver integrative, efficient, and specialized care to the Amyloidosis and Sarcoidosis populations. Furthermore, I have participated as a keynote speaker at national and international medical symposiums and have served as editor in chief and writer of textbooks. During my tenure as an Assistant Professor at Georgetown University School of Medicine, my research focused on the implementation of translational and organizational research to address specific issues in clinical practice and patient care delivery. Additionally, my work in the utilization of Inotropic support in rare cardiomyopathies was recognized as innovative in the field. By providing evidence and simple clinical approaches, this body of work has changed the standards of care for rare cardiomyopathy patients and will continue to provide assistance in relevant medical settings well into the future. I have served in the capacity of Principal Investigator, Co-Investigator, task leader, and technical consultant on projects supported by the government, industry and internal funding sources. In addition, I have successfully collaborated in randomized clinical trial conduction (e.g. patient screening, enrollment, and monitoring), and produced peer-reviewed publications.

Kathy Casey

PhD, RN, NPD-BC

Professional Development Specialist, Denver Health Adjunct Professor, University of Colorado, College of Nursing Adjunct Faculty, Colorado Christian University

Kathy Casey, PhD, RN, NPD-BC, is nationally and internationally known for her Casey-Fink Survey design work supporting graduate nurse role transition, nurse retention, and readiness for professional practice.

Kathy is certified in Nursing Professional Development, and currently serves as a Professional Development Specialist at Denver Health, in Denver, Colorado. She is an Adjunct Professor at the University of Colorado College of Nursing and Adjunct Faculty teaching EBP and Research at Colorado Christian University. Kathy is a lead appraiser for the American Nurses Credentialing Center Practice Transition Accreditation Program (PTAP).

In March 2023, Kathy received the Association for Nursing Professional Development's Marlene Kramer Lifetime Achievement Award for her contributions and research on survey development for use in education and practice programs. In October 2023, Kathy will be inducted as a fellow in the American Academy of Nursing.

Kathy received her Bachelor of Science in Nursing from Pacific Lutheran University, her Master's Degree in Nursing Administration from the University of Colorado, College of Nursing, and her Doctorate in Nursing Education from the University of Northern Colorado, School of Nursing.

Kortney James

PhD, RN, PNP-C

Dr. Kortney James is a PhD prepared nurse and Associate Health Policy Researcher at RAND Corporation. Her research focuses on improving access to quality reproductive health services to minoritized populations. Dr. James is also the Associate Editor of the Nursing for Women's Health Journal, a role in which she is committed to recruiting and supporting manuscripts and research that reflect diverse perspectives and identities. Dr. James recently completed a postdoctoral fellowship in the National Clinician Scholars Program, a continuation of the Robert Wood Johnson Foundation, in the School of Medicine at the University of California, Los Angeles. During her postdoctoral fellowship Dr. James has published several manuscripts in high impact journals. Select publications include "NIH funding: Hone efforts to tackle structural racism" featured in Nature and "Factors associated with postpartum maternal functioning in Black women," featured in Journal of Clinical Medicine. Thus far, Dr. James has been awarded $230,000 to support her research related to Black perinatal mental health. She received $30,000 from the Iris Cantor UCLA Women's Health Center to support her mixed methods study that aims to identify and understand culturally and racially relevant influences on their journey to healing from perinatal mood and anxiety disorders. Dr. James also received $200,000 from the American Nurses Foundation to implement an educational intervention to support ambulatory care nurses and other healthcare staff to care for Black pregnant and postpartum people’s mental health needs with culturally relevant resources. Dr. James has a wide range of clinical experience in acute inpatient care, primary care, and public health. Dr. James is a pediatric nurse practitioner with over a decade of experience in acute newborn care and pediatric primary care. Dr. James has extensive experience in perinatal care due to her time as a registered nurse in the highest volume birthing hospital in the country with an average of around 25,000 births a year (and counting). Dr. James has also held an executive leadership position in the Office of Nursing, Maternal Child Health, and Infectious Disease divisions at the Georgia Department of Public Health in Atlanta, GA.

Ultimately, Dr. James' mission is to co-create solutions with Black women and people capable of pregnancy to achieve health equity.

For questions or inquiries please contact the ANCC Research Council members at [email protected] .

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Snapshot: This document provides an overview of nursing research, a summary of the research process, including discussion of the popular “Iowa Model,” in addition to research terminology and a library of links.

Nursing Research: Overview & Scope

As is true for other healthcare professionals, many nurses rely upon custom, habit or institutional norms to guide nursing practice. One of the central goals of nursing research is to subject such practice to rigorous, scientific inquiry.
An example of basic research would be investigating the way cancer cells use signaling pathways to multiply. The research might or might not subsequently yield insights into the pathophysiology of cancer, and to new cancer treatments.
An example of EBP would be encouraging early ambulation as tolerated for post-surgical patients because a randomized control trial demonstrated that this practice led to a statistically significant reduction in rates of pneumonia and shorter hospital stays.
An example of QI/PI would be formulating a set of clinically validated guidelines for reducing falls, such as mandating that RN’s complete a fall-risk assessment on admission, and then measuring and re-measuring over time the implementation and impacts of such a tool on fall rates within the organization.
Nursing research – in all its various forms – comprises one ‘leg’ of the ‘three-legged stool’ of nursing education, nursing practice, and nursing research. Ideally, these three activities are interdependent: each is mutually dependent upon the other, and contributes to betterment of the profession.

The Research Process

Research is not simply a body of knowledge. It is a dynamic process with distinct steps and phases. Below is a broad overview of that process.

Formulate the Question. The first step in any research project is to decide what will be investigated. The best research questions are clear, concise and focused. For example, the research question “what challenges do new nurses face?” is too broad, and would be very difficult to investigate. A better question might be, “what are the leading challenges to retaining bachelors-prepared nurses in their first year of practice in a major academic medical center?”
Define the Purpose or Goal. Nursing research is an inherently applied discipline: its purpose is to improve the breadth and depth of nursing knowledge, and to thereby improve nursing practice. When you conduct research, keep in mind your intended audience, and what you hope to achieve with your research. If you cannot answer these questions, you should return to your research question and re-formulate it.
Choose a Theoretical Framework & Research Design. While nursing research is typically ‘practice oriented,’ it is nonetheless important to be cognizant of how the themes and concepts in your research fit together, and to spell out how you will investigate your topic for your audience. Will you be investigating individuals’ feelings and narratives? Will you be measuring the statistical significance of a particular clinical intervention? Will you be synthesizing the results of previous studies, or conducting original research? Your answers to these questions will help determine the purpose, methods, assumptions and limits of your research.
Perform a Literature Review. Research never exists in a vacuum, and any research project should survey existing research. A competent literature review, however, is not simply a dry recitation of past findings. Rather, it should be a dynamic summary and analysis of existing knowledge that points out the links between this past work and the new research being conducted. The literature review is a useful introduction for the research audience that both situates the author’s research in a broader context, and helps to justify the importance of and need for the research question the author investigates.
Select the Population and Sample. Regardless of your research goals, framework or methodology, you will need to define who will be included in your study, and who will not. The population or sample you investigate needs to match your research question, and just as importantly, must be available for you to study. Populations may be defined by any number of variables, such as age, gender, clinical role/status, or professional setting.
Perform Ethical Review & Obtain Approval. An essential part of the research process is to ensure that your research topic is ethically sound, and to obtain clearances from your organization or institution to conduct the research. This concern is always important, but perhaps especially so for nurses, who often deal with private and highly sensitive medical data, access to which may be restricted by HIPAA and other regulations. You will probably need to present your research proposal to an Institutional Review Board (IRB), or other similar institution for approval. Plan ahead, because review and approval can be a lengthy process, and the panel may require that you make revisions or otherwise alter your research design.
Collect & Analyze Data. Once you know your research design and methodology, you’ll need to gather and interpret your data. This data may be qualitative or quantitative, or a mix of both. Before you do your collection, make sure you have the knowledge and means to make sense of your data. You may need to use statistical analysis for quantitative research, or determine your methodology for analyzing subjective feelings, values and narratives for qualitative research. Again, allow time: data collection and analysis is often challenging and time-consuming.
Organize, Write & Edit. Your research question, methodology, and population sample should help you structure your write-up of the project. One way to structure your paper is to think in terms of broad categories: introduction, methods, results, discussion, and conclusions and recommendations. Using headings and sub-headings to ‘break up’ your research is often helpful to readers. Also be sure to acknowledge the limitations of your research and areas for further inquiry.
Compose Citations, Sources & Bibliography. Every research study must clearly acknowledge sources and properly cite them. To do so is not only important for reasons of intellectual integrity, but also because readers should be able to reference your sources should they choose to do further reading and investigation. Follow your organization or institution’s accepted format; one commonly used format in nursing research is the American Psychological Association (APA) style.
Communicate Findings. This final stage in the research process is a crucial one. After all, research that never finds its way to its intended audience is inert. Communicating your findings often includes publication; it may also include speaking about and presenting your research to professional audiences and to the public. However this communication occurs, be open to feedback. The questions and debates your research inspires may form the basis for your next investigation, or for research conducted by others in conversation with your own.

The Iowa Model

The Iowa Model of Evidence-Based Practice to Promote Quality Care is a practice-driven research framework that has become a standard in professional nursing and nursing research.
The topic should be aligned with an organizational priority. If it is not, the Model prompts the nurse researcher to consider a different “trigger,” or basis for the research.
Once a topic has been selected, the next steps in the Model dictate forming a team, and then assembling, synthesizing, reviewing and critiquing the available research on the topic.
Should the pilot project prove successful or encouraging, the practice change can then be ‘rolled out’ and gradually integrated within the organization on a larger scale.
The team must continue to communicate and collaborate throughout this process to select evidence-based practice driven goals, collect data, monitor processes and outcomes, and modify the practice change as appropriate.
The team is encouraged to communicate internally to implement the change, and externally with other organizations and stakeholders to expand nursing knowledge and to encourage the wider adoption of evidence-based practice driven changes in nursing.
First, the team could choose to pursue the practice change on the basis of weaker forms of evidence, such as case reports and expert opinion. Alternately, the team could also choose to conduct its own research, and once further research has been completed, then return to the question of whether there exists a sufficient research basis for piloting and potentially implementing the proposed practice change.
The Iowa Model integrates theory and practice to help professional nurses discover, formulate and advocate for evidence-based practice changes. It also possesses the great advantage of never leaving practitioners without a ‘next step.’ No matter what the professional nurse and his or her team encounter, the Model has clear recommendations and guidelines for a course of action.

Research Concepts & Terminology

Research Hypothesis. The supposition or proposed explanation a researcher wishes to investigate or test. The hypothesis should propose a relationship between two or more variables.
Null hypothesis. The supposition that there is no relationship between the variables or phenomena a researcher is investigating.
Control group. The group of individuals in an experiment who are not subjected to the experimental intervention. The control group serves as a benchmark for measuring the effects of the experimental intervention on the treatment group.
Independent vs. dependent variable. In experimental research, the independent variable is the “input” variable that is believed to influence or affect the dependent variable, or “output” variable. The independent variable is therefore unchanged by experimental manipulation, whereas the dependent variable is changed by such manipulation.
Inductive vs. deductive reasoning. Inductive reasoning is the “bottom up” process of reasoning from specific examples or observations to formulate general principles. In contrast, deductive reasoning is a “top down” process of reasoning from the basis of one or more general principles to formulate more specific hypotheses, predictions, or explanations of phenomena.
Qualitative vs. quantitative analysis. Qualitative analysis is a way of interpreting non-numerical data to draw out the themes, meanings and relationships between phenomena. In contrast, quantitative analysis is a way of interpreting numerical data, often using statistical analysis, to assess the significance and magnitude of the causal relationships among variables.
Observational studies. An observational study is one in which the researcher observes the behaviors of a group of subjects without intervening in the group in order to draw inferences or conclusions. Observational studies stand in contrast with experiments, such as randomized control trials, which have treatment and control groups. Observational studies include panel studies, cohort studies and case-control studies.
Cohort study. A cohort study is a type of forward-looking observational study in which a cohort (group) of individuals is followed over time. The cohort is usually investigated at regular intervals, and the characteristics or behaviors of the cohort are compared with the general population from which the cohort is drawn.
Case-control study. A case-control study is a type of backward-looking observational study in which a group of individuals who share a common characteristic such as a disease or medical condition (“the cases”) are compared with one or more groups who do not possess the characteristic (“the controls”) in order to identify what caused the condition in “the cases”.
Statistical vs. practical significance. In research, a statistically significant result is one that is not the result of chance or sampling error, thereby allowing the researcher to reject the null hypothesis. However, a statistically significant result may lack practical significance if the size or impact of the finding is not large or clinically significant.
Type I vs. Type II error. In statistics, a Type I Error or “false positive result,” is defined as incorrectly rejecting a true null hypothesis. A Type II Error or “false negative result” is defined as failing to reject a false null hypothesis. Consequently, a Type I Error will lead a researcher to falsely conclude that a meaningful relationship or effect exists, whereas a Type II Error will lead a researcher to fail to detect a meaningful relationship or effect.
Hierarchy of Evidence. A hierarchy of evidence is a way of grading the quality and relative authority of various types of research studies. Systematic reviews and meta-analyses are typically at the top of the hierarchy, followed by randomized control trials, cohort, case control and cross sectional studies; case studies, expert opinion and anecdotal observations are typically at the bottom. Many researchers believe clinical guidelines should be based on the highest possible level of evidence.
Meta-Analysis. A meta-analysis is “review of reviews,” or an analysis of multiple research studies in order to draw out the studies’ most well-supported findings and conclusions. Meta-analysis is employed in many systemic reviews, and according to many researchers occupies the highest level of evidence in the hierarchy of evidence.
Double-Blind Experiment. A double-blind experiment is one in which neither the person conducting the experiment (the researcher) or the subjects of the experiment know information about the experiment that could lead to conscious or unconscious bias. For example, if a researcher was evaluating whether a drug was more effective than a placebo, in a double-blind experiment neither the researcher nor the test subjects would know which group of patients received the drug under investigation, and which received the placebo.
External vs. internal validity. In research, a study with findings that can be easily generalized to the general population is said to possess external validity. A study with high internal validity is one in which confounding variables have been successfully eliminated, and the causal relationship under investigation has been clearly established by the researcher. These forms of validity each exist on a continuum, and a study may be high in both kinds of validity, low in both, or high in one but not in the other.
Reliability vs. validity. Reliability is concept in statistics and psychometrics that refers to the overall consistency of a given type or method of measurement. There are several different kinds or reliability, such as inter-method reliability (the degree to which different methods for measuring a given variable are consistent), inter-rater reliability (the degree to which the measurements or ratings made by different individuals of a given variable are consistent), and test-retest reliability (the degree to which a given test yields the same results when repeated over time). In contrast, validity measures the degree to which a given measurement is measuring what a researcher intends to measure.

Links & Resources

NINR funds and promotes professional nursing research, and trains and educates current and future nurse research professionals.
The website has a repository of video and audio resources for nurse researchers, provides news of interest to the nursing and broader medical research community, and offers summaries of the latest funded NINR research. Check out the website’s Grant Development and Management Resources page, which includes valuable information, links and resources for both research grant applicants and funded nurse researchers.
The organization also offers both “intramural” (on-site) and “extramural” (off-site) research programs. Research encompasses a wide range of professional nursing and practice concerns, from health disparities to disease prevention to end of life care. NINR staff can also assist in each stage of the grant application process – from preparation, to review, to funding and post-grant management.
The American Nursing Association (ANA) offers a Research Toolkit that offers a valuable overview of and introduction to nursing research and evidence based practice. The Toolkit offers links to numerous research resources, and access to a repository of reviews of research articles. You have register as a member on the site to get access.
Essential Nursing Resources (ENR) provides a compilation of print and online resources of interest to nurse researchers. The Table of Contents clearly breaks down resources by category, and each resource is helpfully flagged as online or print, and fee- or no-free required for access.
The National Database of Nursing Quality Indicators (NDNQI), part of the ANA’s National Center for Nursing Quality (NCNQ), is a national nursing quality measurement program that offers hospitals nursing unit-level performance data, benchmarked against state, regional and national averages. Such data is often valuable to nurse researchers. NDNQI currently has over 1,500 participating U.S. hospitals.
The AHRQ supports research to subject clinical practice to critical, evidence-based standards, and to improve health outcomes. AHRQ is making a concerted effort to encourage contributions to nurse researchers to this broader mission of health research.
Nursing research funded by AHRQ is summarized on the AHRQ Nursing Research web page. AHRQ provides extramural (off-site) funding for nursing-related health research, and follows the same peer-review process as NIH (the National Institutes of Health).
The agency offers a Research Activities Online Newsletter that summarizes study findings of interest to professional nurses and nurse researchers.

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How Does Research Start?

Capili, Bernadette PhD, NP-C

Bernadette Capili is director of the Heilbrunn Family Center for Research Nursing, Rockefeller University, New York City. This manuscript was supported in part by grant No. UL1TR001866 from the National Institutes of Health's National Center for Advancing Translational Sciences Clinical and Translational Science Awards Program. Contact author: [email protected] . The author has disclosed no potential conflicts of interest, financial or otherwise. A podcast with the author is available at www.ajnonline.com .

Editor's note: This is the first article in a new series on clinical research by nurses. The series is designed to give nurses the knowledge and skills they need to participate in research, step by step. Each column will present the concepts that underpin evidence-based practice—from research design to data interpretation. The articles will also be accompanied by a podcast offering more insight and context from the author.

This article—the first in a new series on clinical research by nurses—focuses on how to start the research process by identifying a topic of interest and developing a well-defined research question.

Clinical research aims to deliver health care advancements that are “safe, beneficial, and cost-effective.” 1 It applies a methodical approach to developing studies that generate high-quality evidence to support changes in clinical practice. This is a stepwise process that attempts to limit the chances of errors, random or systematic, that can compromise conclusions and invalidate findings. 2 Nurses need to be well versed in the research in their field in order to find the best evidence to guide their clinical practice and to develop their own research. To effectively use the literature for these purposes, it is imperative to understand the principles of critical appraisal and basic study design.

There are many roles for nurses in research. Nurses can be consumers who stay abreast of current issues and trends in their specialty area, nurse champions who initiate quality improvement projects guided by the best clinical evidence, members of an interprofessional research team helping to address a complex health problem, or independent nurse scientists developing a line of scientific inquiry. Regardless of the nurse's role, a common goal of clinical research is to understand health and illness and to discover novel methods to detect, diagnose, treat, and prevent disease.

This column is the first in a series on the concepts of clinical research using a step-by-step approach. Each column will build on earlier columns to provide an overview of the essential components of clinical research. The focus of this inaugural column is how to start the research process, which involves the identification of the topic of interest and the development of a well-defined research question. This article also discusses how to formulate quantitative and qualitative research questions.

IDENTIFYING A TOPIC OF INTEREST

The motivation to explore an area of inquiry often starts with an observation that leads to questioning why something occurs or what would happen if we tried a different approach. Speaking to patients and hearing their concerns about how to manage specific conditions or symptoms is another way to be inspired. Exploring new technologies, examining successful techniques, and adapting the procedures of other fields or disciplines can be other sources for new insights and discoveries. 2 Nurses working in a cardiac setting, for example, may take an interest in using fitness watches to monitor adherence to a walking program to reduce blood pressure and body weight. Their ease of use, cost, and availability may be what draws nurses to exploring the potential uses of this technology. Since the goal of research is to improve patients' lives, it's vital that anyone engaging in clinical research be curious and willing to understand clinical issues and explore the problems that need solving.

Reviewing the literature . Developing a research project requires in-depth knowledge of the chosen area of inquiry (for example, the etiology and treatment of hypertension, which is the hypothetical area of inquiry in this article). Ways to become immersed in the topic include speaking to experts in the field and conducting a comprehensive literature review. Two main types of review found in the literature are narrative and systematic.

Narrative reviews present an overview of current issues and trends in the area of interest and can address clinical, background, or theoretical questions. They can summarize current findings, identify gaps in research, and provide suggestions for next steps. 3 On the downside, narrative reviews can be biased because they are based on the author's experience and interpretation of findings and lack systematic and objective selection criteria. 4

Systematic reviews differ from narrative reviews in that they use a systematic approach to select, appraise, and evaluate the literature. Systematic reviews start with a clinical question to be answered by the review. They use clearly defined criteria to determine which articles to include and which to exclude. Systematic reviews can help nurses understand what works and what doesn't in terms of intervention-based research, and they are excellent resources if an area of inquiry is an intervention-based project. (For the categories of interventional studies, see Table 1 .)

Reviewing citations from published papers is another way to find relevant publications. A frequently cited publication in a particular area may indicate a landmark paper in which the authors present an important discovery or identify a critical issue. An essential goal of the literature review is to ensure that previous studies in the area of interest are located and understood. Previous studies provide insight into recent discoveries in the field, as well as into the dilemmas and challenges others encountered in conducting the research.

DEVELOPING THE RESEARCH QUESTION

The two main branches of research methods are experimental and observational. Randomized controlled trials and non–randomized controlled trials belong in the experimental category, while analytical studies with control groups and descriptive studies without control groups belong in the observational category. Types of analytical studies include cohort and case–control studies; types of descriptive studies include ecological and cross-sectional studies, and case reports.

Despite their differences, the common thread among these research methods is the research question. This question helps guide the study design and is the foundation for developing the study. In the health sciences, the question needs to pass the “So what?” test. That is, is the issue relevant, is studying it feasible, and will it advance the field?

Cummings and colleagues use the mnemonic FINER ( F easible, I nteresting, N ovel, E thical, R elevant) to define the characteristics of a good research question. 2

Feasible . Feasibility is a critical element of research. Research questions must be answerable and focus on clear approaches to measuring or quantifying change or outcome. For example, assessing blood pressure for a study on the benefits of reducing hypertension is feasible because methods to measure blood pressure, the stages of hypertension, and the positive results associated with achieving normal blood pressure are established. For research requiring human participants, approaches to recruiting and enrolling them in the study require careful planning. Strategies must consider where and how to recruit the best participants to fit the study population under investigation. In addition, an adequate number of study participants is necessary in order to conduct the study. The allotted time frame to complete the study, the workforce to perform the study, and the budget to conduct the study must also be realistic. Research studies funded by private or public sponsors usually have defined time frames to completion, such as two or three years. Funders may also request a timeline showing when various aspects of the research will be achieved (institutional review board [IRB] approval, recruitment of participants, data analysis, and so on).

Interesting . Several factors may drive a researcher's interest in an area of inquiry. Cummings and colleagues use the term interesting to describe an area the investigator believes is important to examine. 2 For some investigators, an experience or an observation is the motivation for evaluating the underpinnings of a situation or condition. For some, the possibility of obtaining financial support, either through private or public funding, is an important consideration in choosing a research question or study subject. For others, pursuing a particular research question is the logical next step in their program of research.

Novel . Novel research implies that the study provides new information that contributes to or advances a field of inquiry. This may include research that confirms or refutes earlier study results or that replicates past research to validate scientific findings. When replicating studies, improving previously used research methods (for example, increasing sample size, outcome measures, or the follow-up period) can strengthen the project. A study replicating an earlier hypertension study may add a way to assess dietary sodium intake physiologically instead of only by collecting food records.

Ethical . It is mandatory that research proceed in an ethical manner, from the protection of human and animal subjects to data collection, data storage, and the reporting of research results. Research studies must obtain IRB approval before they can proceed. The IRB is an ethics committee that reviews the proposed research plan to ensure it has adequate safeguards for the well-being of the study participants. It also evaluates the potential risk versus benefit of the proposed study. If the level of risk posed by the study outweighs the benefits of the potential outcome, the IRB may require changes to the research plan to improve the safety profile, or it may reject the study. For example, an IRB may not approve a study proposing to use a placebo for comparison when well-established and effective treatments are available. The National Institutes of Health offers an excellent educational resource, Clinical Research Training ( https://ocr.od.nih.gov/clinical_research_training.html ), a free online tutorial on ethics, patient safety, protocol implementation, and regulatory research. Registration is required and each module takes 15 to 90 minutes to complete.

Relevant . Relevant research questions address critical issues. A relevant question will add to the current knowledge in the field. It may also change clinical practice or influence policy. The question must be timely and appropriate for the study population under investigation. For instance, to continue our hypothetical hypertension study example, for individuals diagnosed with hypertension, it is recognized that reducing the dietary intake of sodium and increasing potassium can lower blood pressure and reduce the risk of heart disease and stroke. Therefore, in conducting a dietary study to reduce blood pressure, an investigator might target the intakes of both sodium and potassium. Focusing solely on one and not the other ignores the best available evidence in the field.

GUIDELINES FOR QUESTION DEVELOPMENT: PICO, PEO

Guidelines are available to help frame the research question, and PICO and PEO are among the most common. PICO is best suited for quantitative studies, while PEO is appropriate for qualitative studies. Quantitative and qualitative methodologies approach research using different lenses. In quantitative research, numerical data is produced, necessitating statistical analysis. Qualitative research generates themes, and the outcome of interest is the understanding of phenomena and experiences. It's important to note that some topics may not fit the PICO or PEO frameworks. In those cases, novice researchers may want to consult with a mentor or academic research adviser for help in formulating the research question.

PICO questions incorporate the following components: P opulation, I ntervention, C omparison, and O utcome.

Population is the people or community affected by a specific health condition or problem (for instance, middle-age adults ages 45 to 65 with stage 1 hypertension, or older adults ages 65 and older with stage 1 hypertension living in nursing homes).
Intervention is the process or action under investigation. Interventions can be pharmaceutical agents, devices, or procedures; changes in a process; or patient education on diet and exercise. They can be either investigational or already available to consumers or health care professionals.
Comparison means the group or intervention being compared with the intervention under investigation (for instance, those eating a vegan diet compared with those eating a Mediterranean-style diet).
Outcome is the planned measure to determine the effect of an intervention on the population under study. For example, in the study comparing a vegan diet with a Mediterranean-style diet, the outcomes of interest could be the percent reductions in body weight and blood pressure.
PEO questions incorporate the following components: P opulation, E xposure, and O utcome.
Population centers on those affected and their problems (for example, middle-age adults who have hypertension and smoke).
Exposure focuses on the area of interest (for example, experience with smoking cessation programs or triggers of smoking). Since qualitative studies can denote a broad area of research or specific subcategories of topics, the exposure viewpoint depends on the framing or wording of the research question and the goals of the project. 5
Outcome might encompass a person's experience with smoking cessation and the themes associated with quitting and relapsing. Since the PEO model is best suited for qualitative studies, the outcome tends to include the definition of a person's experiences in certain areas or discover processes that happen in specific locations or contexts. 6

How to formulate a research question using the PICO and PEO frameworks is reviewed in Table 2 .

GOING FORWARD

This has been a brief review of how to find an area of interest for your research and how to form an effective research question. For some, the inspiration for research will come from observations and experiences in the work setting, colleagues, investigations in other fields, and past research. As has been noted, before delving into developing a research protocol it's important to master the subject of interest by speaking with experts and gaining a firm understanding of the literature in the field. Then, consider using the FINER mnemonic as a guide to determine if your research question can pass the “So what?” test and the PICO or PEO model to structure the question. Formulating the appropriate research question is vital to conducting your research because the question is the starting point to selecting the study design, population of interest, interventions or exposure, and outcomes. The next column will discuss the process for selecting the study participants.

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Relevant factors affecting nurse staffing: a qualitative study from the perspective of nursing managers

1 Department of Nursing, Jinan University, Guangzhou, China

2 Department of Nursing, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China

3 Department of Nursing, Guangdong Pharmaceutical University, Guangzhou, China

Jiangfeng Pu

Zhanghao xie.

4 Department of Nursing, Shantou University Medical College, Shantou, China

Tiemei Shen

Huigen huang.

Su-I Hou, University of Central Florida, United States

Associated Data

The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.

To understand the current situation of nursing manpower allocation, explore the factors affecting nurse staffing, improve nurse staffing level, and provide reference for better formulation of nursing human resources staffing standards.

A descriptive research method was used to conduct semi-structured interviews with 14 nursing managers. The data were analyzed and refined by content analysis. The sample size was subject to content saturation.

Nine themes and twenty sub-themes of influencing factors for nursing staffing were identified across four levels: hospital level, department level, patient level, and nurse level.

Hospital and department managers need to comprehensively consider the factors of affecting nurse staffing. Adopting multidimensional optimization measures, improving relevant systems, optimizing nurse structure, and establishing flexible and mobile nurse database to cope with public emergencies, so as to effectively improve nurse staffing and nursing service quality.

1. Introduction

The global nursing workforce shortage has been a major challenge in the medical field. In 2020, the World Health Organization reported a shortage of 5.7 million nurses and midwives ( 1 ). By the end of 2022, the total number of health workers in China was 14.411 million. Among them, the total number of registered nurses is 5.224 million ( 2 ). Compared with the 2025 China nursing career planning target, there is still a gap of 276,000 ( 3 ). The number of registered nurses in China in 2022 is 3.17 per 1,000 population, which is far lower than the global median density proposed by WHO (4.86 per 1,000 population) ( 4 ). In the evolving healthcare sector, ensuring optimal nurse staffing remains a key issue in hospital administration and nursing management ( 5 , 6 ). Adequate nurse staffing is critical not only to provide high quality patient care, but also to maintain nurse job satisfaction and reduce turnover ( 7 , 8 ). However, the factors that influence nurse staffing are multifaceted and complex, including a range of variables from institutional policies to the characteristics of individual nurses. At present, researchers mainly focus on quantitative studies on nurse staffing and nursing quality, patient outcomes and nurse outcomes ( 9 , 10 ). However, there are few qualitative studies on the influencing factors of nurse staffing. Nursing managers play a key role in staffing decisions, pay close attention to day-to-day operational dynamics and challenges, and are uniquely positioned to provide insights into the various factors that affect nurse staffing ( 11 ). Therefore, this study aims to explore the influencing factors of nurse staffing through the perspective of nursing managers, and through in-depth interviews and thematic analysis, reveal the human resource challenges and considerations faced by nursing managers in their efforts to ensure appropriate nurse staffing levels. The results of this study will help develop more effective staffing strategies and policies, ultimately improving the quality of care provided to patients and improving the working environment for nurses.

2. Research objectives

This qualitative study explores the influencing factors of nurse staffing. Two nursing managers were selected for pre-interview, and the final interview outline was revised according to the feedback of the pre-interview. See Table 1 for details.

Interview outline.

Question
1 What is the current situation of nursing staffing in your ward? And what do you think of the current situation of nurse staffing?
2 What problems do you encounter when staffing? And how did you solve these problems?
3 What do you think are the factors that affect the staffing of nurses?
4 What are your suggestions for nursing staffing?

3. Materials and methods

3.1. participant recruitment.

From December 2023 to February 2024, nursing managers in a Grade 3 hospital in Guangdong Province were selected as interview subjects by purpose sampling method. Inclusion criteria: (a) Engaged in clinical work ≥10 years; (b) Engaged in management work ≥3 years; (c) have intermediate or above professional titles; (d) Informed consent and voluntary participation in this study.

3.2. Data collection methods

The development of the interview outline was based on the research objectives and a review of relevant literature, following a systematic process ( 12 ). An initial draft of the interview guide was formulated to focus on the research theme. This draft was refined through discussions in project team meetings. Before the formal interviews, two nursing managers were invited to participate in pilot interviews, and since no further revisions were needed, the pilot interview data were included in the subsequent analysis. The qualitative research involved conducting semi-structured, in-depth face-to-face interviews with the participants. Before each interview, one researcher (LGG) obtained informed consent from the interviewees, explaining the purpose, methods, and content of the interview. The interviews were recorded and noted, and were conducted in the interviewee’s office to ensure privacy. To protect the confidentiality of the participants, two researchers (LGG and WWE) were responsible for questioning and recording, respectively, using pseudonyms N1 to N14 instead of real names. The interviews were conducted in easily understandable language, encouraging participants to express their feelings and thoughts fully. Active listening, clarification, and probing techniques were employed, along with noting non-verbal cues. Each interview lasted between 30 and 60 min, with an average duration of 39 min.

3.3. Data analysis methods

Data collection and analysis in this study were conducted simultaneously. Within 48 h after each interview, the recordings were transcribed verbatim, and the non-verbal information recorded during the interviews was integrated into the documents, forming complete interview transcripts. We used thematic analysis to analyze the data ( 13 ), organizing the materials with NVivo Plus 11 software. Throughout the analysis process, the two researchers (LGG and WWE) maintained an open and neutral attitude, repeatedly reading the transcripts and non-verbal notes. By continuously comparing and inductively analyzing the data, we extracted themes to gain a deeper understanding of the participants’ actual meanings. Text from individual interviews was divided into meaning units that were condensed and coded. The themes in the table were derived from the initial codes, with similar codes grouped into subcategories and categories, which were then further organized into themes ( 14 ). The first author identified the initial codes, while the other authors reviewed the coded interview samples. Any disagreements regarding themes were resolved through discussions among all authors until a consensus was reached.

4.1. Sample size

The sample size was by information saturation ( 15 ). Finally, a total of 14 participants participated in this study, among which 13 were female and 1 was male, and the average age of all participants was 45.86 years old (33 ~ 52 years old). The average duration of clinical work was 25.57 years (11–23 years) and the average duration of managerial work was 11.21 years (4–16 years). The demographic characteristics of participants are shown in Table 2 .

General data sheet for participants.

ID	Gender	Age	Educational level	Professional title	Clinical working time	Manage working time
N1	Female	33	Bachelor	Supervisor nurse	11	6
N2	Female	52	Bachelor	Supervisor nurse	34	16
N3	Female	46	Bachelor	Chief nurse	21	12
N4	Female	45	Bachelor	Deputy chief nurse	21	10
N5	Female	48	Bachelor	Deputy chief nurse	21	10
N6	Female	44	Bachelor	Supervisor nurse	21	9
N7	Female	50	Bachelor	Deputy chief nurse	22	15
N8	Female	47	Bachelor	Deputy chief nurse	21	12
N9	Female	51	Bachelor	Deputy chief nurse	23	15
N10	Female	50	Bachelor	Supervisor nurse	23	14
N11	Female	42	Bachelor	Deputy chief nurse	18	4
N12	Male	39	Bachelor	Deputy chief nurse	16	9
N13	Female	47	Bachelor	Supervisor nurse	21	12
N14	Female	48	Bachelor	Deputy chief nurse	22	12

4.2. Hospital level

4.2.1. imperfect policies and systems.

Decisions made by hospital management based on national policies, such as establishing standards for bed-to-nurse ratios in each department, inspection systems, training and promotion mechanisms, significantly impact nurse allocation. However, N12 highlights that for specialized departments like emergency care, there lacks a unified allocation standard in China ( 16 ), which complicates nurse allocation levels to some extent. Several respondents in the study noted limitations in current nurse staffing due to rigid adherence to bed-to-nurse ratios that often fall short, thereby compromising adequate staffing levels. Furthermore, the imperfect inspection, promotion, and training systems in the face of a complex and evolving clinical environment constrain nurses’ workload and career advancement opportunities, affecting both stability and quality of nursing care.

4.2.2. Insufficient manpower reserve

The hospital’s human resource reserve directly influences the quantity and quality of nurses, as well as the hospital’s capacity to address staffing shortages, temporary needs, and emergencies. Respondents in the study also noted that due to insufficient or lacking hospital manpower reserves, even submitted personnel demand applications often remain unresolved.

4.3. Department level

4.3.1. department characteristics.

In the rational allocation of nursing human resources, it is necessary to consider a variety of factors, such as the department’s patient conditions, department size, bed turnover, workload, and the need for specialized nursing. For instance, departments like emergency, intensive care, and surgery require nurses with specific professional skills and knowledge to ensure patient safety and effective treatment outcomes.

4.3.2. Cost-effectiveness driven nurse staffing

Reasonable manpower cost control can be in to ensure the quality of care under the premise of optimizing the allocation of resources, improve the efficiency of the cost. Appropriate labor cost control of department, fair and reasonable scheduling system, by ensuring reasonable salary, meet the demand of nurses reasonable help stabilize the nurse team, reduce turnover and maintain the continuity and stability of the nursing work, at the same time maximize the cost-effectiveness of department, ensure quality of nursing service.

4.3.3. Cultural construction of the department

Department culture construction is one of the important factors affecting the allocation of nurses, including good working atmosphere and teamwork, effective communication and mutual understanding, and staff care. A good department culture construction can improve the satisfaction and stability of nurses, and ensure the efficiency and high quality of nursing work. In the study, respondent N1 also said that a good working atmosphere in the department would alleviate the original shortage of manpower.

4.3.4. Multi-level recognition and support

Nurses occupy a large proportion in the department and play an indispensable role. Recognition at the department level, including but not limited to the head nurse and department director, as well as the recognition and support from doctors for the work of nurses, can not only enhance nurses’ job satisfaction and loyalty but also significantly improve the efficiency and quality of nursing care. This influence helps optimize working conditions for nurses.

4.4. Patient level

4.4.1. patient profile.

With the rapid development of social economy, the demand for nursing services is gradually increasing. The basic situation of patients, including the number of patients, the complexity of the disease, the self-care ability of patients and the patient’s needs, which will virtually affect the workload of nurses, and therefore put forward requirements for the staffing of nurses.

4.5. Nurse level

4.5.1. challenges in nursing human resources.

The shortage of nurses is a significant issue in nursing human resource management, profoundly affecting nurse staffing. Insufficient nursing staff can lead to a decline in the quality of nursing services, failing to meet patient care needs, and thereby impacting treatment outcomes and patient satisfaction. Respondents to the study indicated that this shortage is expected to persist in the short term. Currently, nurses face high workloads and pressure, with long-term overwork increasing their physical and psychological burden, reducing work efficiency and quality, and leading to higher turnover rates. This exacerbates the challenges in nurse staffing.

4.5.2. Nursing professional development

The structure of nurses is an important part of human resource management, including the age, work experience, title, comprehensive ability and specialized skills of nurses. Optimizing the structure of nurses can promote the staffing of nurses. Provide continuous professional training and career development opportunities for the nursing team, including advanced studies, promotions, and specialized training. These initiatives will improve nurses’ professional skills and career satisfaction, enhancing their willingness to stay in the department and their overall stability (see Table 3 ).

Influencing factors of nursing staffing.

First-level themes	Second-level themes	Nursing manager quote
Hospital level
Imperfect policies and systems	Lack of unified standards for emergency nurses	N12:"There’s no national standard for emergency staffing, and we have talked about it, but there’s no clear target for staffing, so nurse staffing levels are definitely going to be affected.”
	Limitations of bed-to-nurse ratio standards	N2:"the current department is not up to the standard of the hospital’s bed-to-care ratio… Even with the deployment of mobile nurses and nurses from other departments, they are still unable to fill the gap.”
		N9:"Our department is the largest department in the hospital, according to the designated bed-to-nurse ratio, we need to reach 39 nurses, but currently there are only 35, and when we add the nurses who resign, retire or take maternity leave, the department’s manpower is very tight.”
		N13:"Relatively speaking, our department did not meet the hospital’s standard for bed-to-nurse ratio. Our department is unique in that nurses are also assigned to the respiratory center and outpatient department, resulting in fewer nurses available for the wards and tighter manpower resources.”
		N14:"Not every department in our hospital has established a standard for nurse-to-bed ratio, but currently, we are unable to meet this ratio and face insufficient manpower.”
	Frequent checks, and imperfect promotion and training systems	N3:"Because A Class III Grade A hospital, often face too many examinations, including our own nursing department, the hospital’s, and the state’s examinations, minimizing the pressure of such examinations on nurses, and really give the nurses back to the patient, I think the nurse is actually very willing.”
		N9:” In the area of management, I think it is possible to relax the training conditions for this specialist nurse?… Such a situation exists in our department, the ability can be reached, but the academic degree cannot be reached…”
Insufficient manpower reserve	Inability to cope with staff shortages in emergency cases	N5:"During the COVID-19 epidemic, many nurses have gone out, they can only ensure safety, and the rest cannot be managed at all… In the case of extreme manpower shortage, only basic work can be ensured “
	Inability to cope with staff shortages in emergency cases	N8:"But now, when a member of the department is sick, or there are emergencies, or even nurses need to be placed on leave, in such cases, other nurses have to work overtime because there is no other staff to supplement.”
	Inability to timely address manpower shortages	N6:"I have applied to the head nurse of the department, but the head nurse answered that many departments are short of staff, which may be difficult to solve, so I did not apply to the above, indicating that this problem may indeed exist in the past two years.”
	Inability to timely address manpower shortages	N2: “There is no way, you can only wait for a new group of nurses, or in fact, the hospital has mobile nurses, but because of the two-way selection policy, many nurses will not choose the workload of the department, it is still difficult.”
Department level
Department characteristics	Specialty nursing needs and technology	N1: “Our specialty has a higher risk of mental violence, which affects nurse staffing. Considering the risk factors, it is best to have a mix of male and female nurses. However, there are very few male nurses, resulting in a greater demand for them.”
		N11: “The current staffing is based on existing manpower, but the ICU is basically a very serious patient, and the condition can change at any time… Therefore, manpower will be taken into account “
		N12:"Because our emergency department operates under fixed conditions, our staffing requirements differ significantly from other departments. I need to consider many additional factors.”
	Departmental work	N5: “This time will be better, because it is near the New Year, and our department basically receive more elective surgeries… So it obviously seems that during this period, the patient beds are a little empty, so the manpower is not so tight “
	Departmental work	N9: “It will also take into account the working hours, and allocate personnel to work according to the situation of the time period… And gynecological preoperative preparation is very time-consuming, and each department has different specialty characteristics.”
Cost-effectiveness driven nurse staffing	Control of nurse labor costs	N1:"In accordance with the hospital provisions of the bed protection ratio standard, the department is currently able to operate, because there are too many manpower, the department’s income is not high, then everyone’s income will be lower… So the current manpower will have little impact on people’s income.”
		N3:"As nursing manager, I also do not want too many of my nurses… It is good to be able to meet the rotation of departments.”
		N11: “Due to better departmental economic performance, the department bonuses are relatively high, contributing to higher job satisfaction among the nurses.”
	Equitable and rational scheduling system	N1: “In terms of scheduling, fairness is a priority in our department due to varying workloads and flexible assignments, aiming to achieve a balanced approach.”
		N2: “Our department has maintained a rotating leave system for a long time, emphasizing the importance of fairness and considering each nurse’s needs when scheduling.”
		N6: “When it comes to scheduling, we prioritize balance and fairness. It’s not about one nurse’s workload preventing others from taking leave; rather, we strive to ensure equitable opportunities for all.”
		N13: “In our department, vacation scheduling adheres strictly to established rules. Everyone is conscientious about following these rules, ensuring a humanized approach to scheduling.”
Cultural construction of the department	Positive department atmosphere and team collaboration	N1:"The atmosphere of our department is very good. If a department has a strong cohesion, it is easier to overcome and solve any problems. Even in the absence of foreign assistance, we can also overcome the shortage of manpower.”
		N11: “In the department, everyone helps each other, so that things can be dealt with quickly and the work efficiency is high. If you share a thing with everyone, the work will be much easier, so the working atmosphere is still very important.”
		N13:"In fact, our nurses are not well treated at the moment, so team building is very important. First, as managers, we must ensure the physical and mental health of these nurses, but also put humanistic care for nurses first.”
	Effective communication and mutual understanding	N1: “Colleagues need to truly understand each other. The higher the cohesion in a department, the more likely they are to spontaneously solve many problems.”
		N6: “If a nurse in our department faces a significant issue at home, everyone works hard to help resolve it. I think this is a wonderful aspect of our team.”
		N14: “Our nurses are quite aware. If one nurse is very busy while others are unresponsive, I, as a manager, will communicate and ask everyone to help. After doing this a few times, everyone naturally starts to help out voluntarily. So, timely communication is essential.”
	Humanistic care in nursing	N5: “The atmosphere of our entire department I think is good, because if there is any problem, everyone will solve it together, I’m not gonna do this alone … I think the whole department has a good feeling, and the young people are also more motivated.”
		N9: “To foster a positive working atmosphere, as managers, we should pay close attention to nurses’ emotions, communicate promptly, and provide appropriate comfort when needed.”
		N10: “We will hold some team building activities regularly, and we will care about the family status of nurses… So the atmosphere in the department is very good. It is also important for the team to draw on the strengths of the nurses and provide timely encouragement and support.”
Multi-level recognition and support	Leadership of recognition and support	N3: “The daily work of clinical nurses is very hard, and we hope to increase the value of nurses… In fact, as managers, we are more respectful of the nurses’ willing, and the head nurse is actually just an executor. We should learn to think from the perspective of nurses, so that nurses can reduce the mentality of boredom or resignation.”
		N8: “When tasks are assigned to nurses within the department, it is important to acknowledge and appreciate their work. This recognition makes the nurses feel valued and supported.”
		N14: “I believe recognizing nurses’ work is crucial. It helps to utilize each nurse’s strengths, fostering a sense of responsibility and allowing them to realize their self-worth.”
	Doctors’ understanding and support	N3: “Doctors recognize and support the hard work and contributions of nurses. Nurses greatly need this validation and partnership, as it fosters a more enjoyable and positive work atmosphere.”
	Doctors’ understanding and support	N6: “Then the director of our department is still very good and very supportive of our nursing.”
Patient level
Patients profiles	Patient volume and condition	N2: “The patient’s condition must be taken into account, and another aspect is the patient’s self-care ability.”
		N3:"Depending on the number of patients, and also depending on the patient’s condition, if the illness is very serious, maybe you can not just the original number of shifts, sometimes necessary, really have to start some programs to help…”
		N6:"In the past, our department primarily focused on hepatobiliary surgery, where patients generally had better prognoses and basic conditions. Now, the department has shifted to pancreatic surgery, which is the most complex and severe operation in general surgery, with patients often having the most complications and poorer overall conditions.”
		N10: “According to the needs of the patients, the number of patients and the severity of the disease.”
	The patient’s needs	N4: “The first thing I will consider is the patient. I want to take good care of them by prioritizing their needs, which will guide our personnel.”
		N8: “We must certainly prioritize the patient’s needs. The patient’s needs and safety come first, while also considering our existing manpower and the demands on our nurses.”
		N9: “Of course, the staff should prioritize the patient, using the patient’s needs as a guide.”
		N13: “I believe the current schedule is more suitable for our families, especially in pediatrics. Unlike other departments, pediatrics requires a significant amount of work. Parental expectations are relatively high, and meeting these expectations is crucial.”
		N14: “Staffing is available, but we must also consider patient needs. It’s important to keep patients safe.”
Nurse level
Challenges in nursing human resources	Shortage of nurses	N2: “The shortage of nurses is also a problem facing the whole hospital. It’s not that I cannot make up for you, but I just cannot make up for so many people to give you. It turned out that there were not so many people, and then it was distributed, but it was still not enough.”
		N3: “Manpower is insufficient, I can only compress shifts… And the workload… That workload is transferred to the responsible nurses.”
		N8: “In terms of quantity, the hospital’s staffing standards are still not met, and the number of nurses is still not enough…”
		N10:"According to hospital standards, our department currently lacks two nurses, and one nurse is on maternity leave. If the two nurses who are nearing retirement also leave, the department will face challenges in scheduling shifts. Even if a new nurse is assigned to the department, she will require at least three months of training before being able to work independently.”
	Nurses are overloaded	N7: “In terms of quantity, the hospital’s staffing standards are still not met, and the number of nurses is still not enough…”
		N9: “Nurses report less rest, they cannot guarantee two days off a week, the second is busy work, long working hours, often delayed work… Then they will definitely complain, plus our low income, it will be even more dissatisfied, and there may be a problem in terms of turnover.”
		N11: “Then there are some other, temporary specialist assignments in our department… Because I do not have a specialist nurse, I do not have a full-time nurse at the moment, so I have to deploy in this group… So this is a problem in our daily work, and sometimes it is a difficult management problem.”
Nursing professional development	Skill set of nurses	N2:"Then there are some other, temporary specialist assignments in our department… Because I do not have a specialist nurse, I do not have a full-time nurse at the moment, so I have to deploy in this group… So this is a problem in our daily work, and sometimes it is a difficult management problem.”
		N4: “Years of work are the main thing, and the ability to work…”
		N5:"The first to consider the nurse’s communication … And then, when appropriate, you have to look at the mix of people.”
		N8: “The communication ability of nurses also depends on the personal ability and character of nurses.”
	Personal career development	N7: “There are also some successors of head nurses and specialist nurses who should be encouraged to continue to upgrade their academic qualifications… The head nurse should also train these talents, otherwise, the department will not be able to find a successor when the head nurse retires, and we must train talents.”
		N11: “I am encouraged by the opportunity for new studies and equal chances to explore, as this was my own experience. As long as you are eager to advance, I will provide more opportunities. It’s important for young people to learn and broaden their perspectives on the world.”
		N13: “I think the whole word… Encourage them more, take more classes, let them know that career prospects are better, reduce turnover.”

5. Discussion

For additional requirements for specific article types and further information please refer to “Article types” on every Frontiers journal page. From the perspective of nursing managers, this study discussed the relevant factors affecting nurse staffing, mainly from four levels: hospital, department, patient and nurse level.

The results of this study indicate that nurse staffing is related to the imperfection of hospital policies and systems, the lack or insufficiency of manpower reserves, and the control of nurse manpower costs. The formulation of policies related to nursing human resources can play a crucial role in the number of nurses. On the one hand, although China has formulated many standards, principles and plans for staffing ( 17–20 ), but at present, most medical institutions in our country still adopt a single number of beds for human staffing, ignoring the differences of condition, disease, service quantity, etc., which makes it difficult to meet the clinical practical needs of nursing human resources. On the other hand, the participants indicated that the hospital did not reserve talents or had insufficient reserves at present, and the study found that public emergencies would have a certain impact on the staffing of nurses, and the reasonable establishment of a mobile nurse base could make up for the shortage of manpower to a large extent in crisis situations ( 21 ).

At present, there is no legislation on nurse staffing in China, but there are a few areas ( 10 , 22 , 23 ), such as Victoria or Queensland in Australia and California in the United States, have made the nurse–patient ratio mandatory, and scientifically found that this measure is beneficial to patients and healthcare systems. Belgium is also reforming its nursing staffing policy and using part of its budget to hire non-nursing staff to alleviate the shortage of nurses, while India is making further efforts to revise the standards of the nurse-to-patient ratio. Yet labor costs dominate hospital budgets. They are easy targets for cuts to offset other expenses ( 24 ). The financial budget of a hospital on the cost of nursing manpower will directly affect the number of nurses, resulting in the imbalance of the nurse-to-patient ratio, and increasing the work pressure and load of existing nurses ( 25 ). In the future, when developing safe and reasonable nurse staffing, it is necessary to comprehensively consider the control of nurse labor cost and solve the problem of baseline nurse staffing, so as to better cope with the fluctuation of nurse nursing demand among patients ( 26 , 27 ).

In addition, the shortage of manpower reserve makes it difficult for hospitals to quickly deploy enough nurses in the face of emergencies (such as epidemics, natural disasters, etc.), which affects the timeliness and effectiveness of nursing work. First of all, in order to actively and effectively respond to public emergencies and other emergency events, it is necessary to establish a mobile nurse team. At the same time, it is necessary to strengthen the hospital’s leadership of the nurse team and improve the emergency level of the nurse team. Secondly, the recruitment process of new nurses should be accelerated, and the relevant training mechanism should be optimized to ensure that new nurses can quickly get on the job and adapt to the work needs. Finally, establish reasonable vacation and prepare class arrangements, to ensure that the nurse has enough during the period of vacation or sick leave substitute nurses to fill the gap, to ensure the safety of patients and the high quality nursing service.

The results of this study show that the staffing of nurses is related to the department characteristics, cost-effectiveness driven nurse staffing, department culture construction and multi-level recognition and support. Nurses with affected by the characteristics of the various specialist departments for college work, care needs and technical differences, nurse need to change accordingly, in order to ensure safe and effective nursing service. The control of nurse labor costs varies between departments and hospitals due to differing economic benefits. It is crucial to balance the relationship between existing nurse staffing and costs. A limited department budget can affect the hiring of additional nurses or the ability to increase nurses’ salaries, directly impacting nurse staffing levels. Implementing a fair and reasonable scheduling system ensures that each nurse receives adequate work and rest time, preventing overwork or underwork. This can improve job satisfaction and work efficiency, thereby reducing nurse turnover rates and fatigue ( 28 ).

Additionally, fostering a positive departmental culture is also essential. Nurses’ working environment and atmosphere, and leadership style can affect nurses’ turnover intention, thus further affecting the staffing level of nurses and the quality of nursing work by affecting nurses’ turnover intention ( 29–31 ). Active teamwork, effective communication, and mutual understanding are crucial factors in optimizing nurse allocation and improving the quality of nursing services. Good teamwork and effective communication streamline workflow, reduce redundant tasks and communication errors, and enhance nursing efficiency ( 32 , 33 ). Mutual understanding and trust among team members facilitate knowledge and experience sharing, promoting both individual and team skill development. A well-functioning department resembles a warm, supportive family, which requires managers to show concern and care for nurses, focusing on their physical and mental health needs. This helps alleviate work pressure, strengthens colleague relationships, and enhances team stability. Multi-level recognition and support from department directors, head nurses, doctors, and patients serve as key motivators for nurses, reinforcing their commitment and sense of value in their work. However, the lack of necessary material and emotional support increases job burnout and affects nurses’ intention to stay ( 34 , 35 ). Therefore, in this challenging environment, it is crucial to optimize nurse allocation, enhance the quality of care, and ensure the stability of the nursing team. This can be achieved by improving the working environment and atmosphere, fostering team cooperation, formulating reasonable scheduling plans, and establishing effective communication and feedback mechanisms.

With the accelerated aging of China’s population and the increasing prevalence of chronic diseases, the demand for long-term care and health management has risen significantly. The growing number of patients directly impacts the number of nursing staff needed in departments. A high patient load necessitates more nursing staff to ensure each patient receives adequate care. This situation poses a challenge for managers in nursing staff allocation, requiring flexible adjustments based on patient admissions and discharges to respond to fluctuating peaks and troughs.

Patients with complex conditions require higher levels of nursing skills and more hours of care, necessitating additional specialized nursing staff or more training and support. As patients’ expectations for the quality of nursing care rise, departments need to increase their nursing staff to meet these expectations. A higher level of nursing expertise can improve patient satisfaction, delivering higher quality care and greater value ( 36 ). Therefore, when planning nurse allocation, managers should consider the number of patients, the complexity of conditions, and specific nursing needs. By conducting thorough evaluations and making flexible adjustments to the nursing team, managers can effectively address the needs of different patient groups and enhance the quality and efficiency of nursing services.

Nurses are the largest group in the medical and health system, occupying an irreplaceable position, and sufficient nursing staff is the premise and basis of rational allocation of nursing human resources. The shortage of nurses is a serious problem facing the world today ( 37 , 38 ). The shortage of nurses will lead to the increase of nursing workload and labor intensity, resulting in a high turnover rate of nurses, and turnover intention is a predictive factor of turnover rate ( 39 , 40 ). The turnover intention of nurses varies significantly among different countries. The turnover intention of nurses in South Korea was 18.8% ( 41 ), 22.5% of nurses in European countries expressed their intention to quit ( 42 ) and 43% of nurses in Lebanon expressed an intention to leave within one year ( 43 ). In China, the turnover intention of nurses in East China is 43% ( 44 ) and that of nurses in Guangdong Province is as high as 64.1% ( 40 ), which means that the turnover rate of nurses in China remains high, and the gap of nurses will further increase. Attracting and retaining the existing nurse workforce is critical to maintaining high quality patient care ( 26 ). Studies have shown that nurses are the foundation of patient safety and nursing quality, and higher nurses’ satisfaction will bring better job performance, nursing quality and employee retention ( 34 , 45 ). In addition, research shows that with adequate nurse staffing, good working environment and welfare benefits, nurses will have higher job satisfaction and lower turnover intention, thus ensuring the stability of the nurse team and nursing quality ( 46 ). With the continuous improvement of medical technology, higher requirements are put forward for the education level and working ability of nurses. Nurses need to constantly enrich their theoretical knowledge and improve their nursing skills in order to meet the growing nursing needs and the speed of high-quality development of hospitals. Therefore, the nurse structure should be considered and further optimized when staffing nurses.

5.1. Limitations

The study has several limitations. First of all, in order to ensure the diversity of the study subjects, we used purpose sampling to sample the head nurses of various departments in the hospital, but the study scope was limited to one hospital, which made it difficult to obtain additional information. Secondly, the interview document data is translated from Chinese to English, and there is a certain risk of translation errors.

6. Conclusion

From the perspective of nursing managers, this study explores the related factors affecting the allocation of nurses through descriptive qualitative research, explores the specific challenges, pressures and needs of nurses in their work, and reveals the deep causes of the shortage of nurses from multiple levels and directions, rather than just stay on the quantity and statistical data. From a nursing manager’s perspective, the results of this qualitative study highlight the multifaceted and interrelated factors that influence nurse staffing. Hospital-level factors are the most critical. Improving and unifying nursing personnel staffing standards is the premise of ensuring the development of high-quality nursing. Nursing managers stressed the importance of a supportive work environment, effective communication, and continuing professional development to mitigate staffing challenges. At the same time, it reveals the influence of humanistic and emotional factors, and captures the importance of humanistic care, emotional support and professional identity experienced by nurses in the work. These factors have an important impact on the job satisfaction and retention rate of nurses, thereby indirectly affecting the staffing of nurses. Addressing these factors through integrated strategies can improve nurse retention, improve the quality of patient care, and foster a more stable and satisfied nursing workforce. This study can provide deep insight and effective strategy suggestions for understanding and solving today’s nurse staffing problems, so as to provide a unique contribution to the continuous development and improvement of the nursing profession.

Data availability statement

Ethics statement.

The studies involving humans were approved by Ethics Review Committee of Guangdong Provincial People’s Hospital. The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study. Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.

Author contributions

GL: Conceptualization, Data curation, Formal analysis, Investigation, Visualization, Writing – original draft, Writing – review & editing. WW: Conceptualization, Data curation, Formal analysis, Investigation, Writing – review & editing. JP: Conceptualization, Data curation, Writing – review & editing. ZX: Supervision, Writing – review & editing. YX: Methodology, Supervision, Writing – review & editing. TS: Methodology, Project administration, Supervision, Writing – review & editing. HH: Supervision, Writing – review & editing, Funding acquisition, Resources.

Acknowledgments

The authors would like to express their sincere gratitude to all the people who participated.

Funding Statement

The author(s) declare that financial support was received for the research, authorship, and/or publication of this article. This study was supported by the Nursing Research sub-project of China Health Personnel Training Program (Project number: RCLX2320048).

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher’s note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

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Comparison of education using the flipped class, gamification and gamification in the flipped learning environment on the performance of nursing students in a client health assessment: a randomized clinical trial

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