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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.

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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

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Acknowledgements

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

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

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

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

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

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Using cinahl to find articles written by nurses.

A very useful means of finding articles written by nurses is to use CINAHL (“Cumulative Index to Nursing and Allied Health Literature”), an electronic database accessible via the “Database List” link on the homepage of the Biomedical Library . 

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In particular, the CINAHL Advanced Search has two limiters entitled “First Author is Nurse” and “Any Author is Nurse” which will narrow search results to articles written (from 2009 onwards) by authors with a nursing credential, ie., RN, BSN, MSN or equivalent foreign credential (such as the British “RGN” or “RMN”), as long as the credentials are listed in the article.  These two limiters are both found on the limits page, which is accessible under “Search Options” on the main search page of CINAHL Advanced Search or under “Show More” on the search results page in CINAHL Advanced Search.  These limiters are not available in CINAHL Basic Search at present.

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Although these two limiters will not be helpful in locating nurse-authored articles published before 2009 or articles in which the credentials of the author are not mentioned, there are other means in CINAHL of finding articles written by nurses, including the use of field codes .  Field codes in CINAHL allow you to restrict your search to one specific field that is referenced in the CINAHL record.  Fields and field codes are found in the drop-down box immediately to the right of the main search box on the CINAHL search page.

As an illustration, the CINAHL field code “AF" for the "Author Affiliation” field restricts a search to an author’s institution, i.e., where the author works, as long as this information is listed in the article itself.  Entering “nursing” in the search box on the main search page of CINAHL Advanced Search and restricting the search by using the field code “AF Author Affiliation” (located in the drop-down box between the main search box and the “Search” button) will restrict search results to articles written by authors affiliated with an institution that has the word “nursing” in the title, such as “College of Nursing,” “School of Nursing,” or “Department of Nursing.”  Since a nurse author is more likely to work at either a college of nursing, school of nursing, or department of nursing, the “AF Author Affiliation” field, by narrowing search results to articles written by authors affiliated with an institution containing the word “nursing” in the title, can be a useful means of locating articles written by nurses.   A caveat: searching by field is only available in CINAHL Advanced Search, not CINAHL Basic Search.

In addition, the “AF Author Affiliation” field makes it possible to search by nursing qualification, such as “DNP,” “CRNA” or “FNP,” if this qualification appears adjacent to the name of an author of the article in the abstract or full text of the article itself.  For example, entering “FNP” in the search box with the “AF Author Affiliation” field specified will return articles with an author who is a family nurse practitioner.

Another useful means of finding articles written by nurses is to use the SO Publication Name field code.  SO is an abbreviation for "source," i.e., the name of the journal.  Typing in “nursing” in the search box and selecting the field “SO Publication Name” in the drop-down box to the right of the search box will restrict search results to journals with the word “nursing” in the title of the journal, such as Journal of Advanced Nursing .  An even more precise way to search would be to type nurs* in the search box, instead of nursing .  Using the asterisk (*) in this manner is a useful technique called truncation , and searching the term nurs* retrieves results from journals with the four-letter word root n-u-r-s in the title, including the words nursing , nurse , or nurses .  As an illustration, entering nurs* in the search box and restricting the search by use of the SO Publication Type field code would retrieve results from the following three journals: American Nurs e , Journal of the American Psychiatric Nurs es Association , and Journal of Advanced Nurs ing .  (This technique of truncation can also be used with the “AF Author Affiliation” field code.)

A final method of searching for articles written by nurses is to use the “Nursing” limiter found in the Journal Subset drop-down box on the limits page in either CINAHL Advanced Search or CINAHL Basic Search, thus restricting search results to journals with a nursing focus.

One final note: using the “Nursing” limiter or the field codes AF or SO as described herein will limit search results to articles more likely to have a nurse author; however, you should still examine an article to check whether or not there are nursing credentials listed for the author, such as “Debra Davis RN, MSN, DSN.”

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The Experiences of Newly Graduated Nurses during Their First Year of Practice

Hanan f. alharbi.

1 Maternity and Child Health Nursing Department, College of Nursing, Princess Nourah bint Abdulrahman University, Riyadh 11671, Saudi Arabia; as.ude.unp@ibrahlafh

Jamila Alzahrani

2 Ministry of Health, Taif 26523, Saudi Arabia

Amira Hamed

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Abdulslam Althagafi

Ahmed s. alkarani.

4 Department of Nursing, Applied Medical Sciences College, Taif University, Al Mathnah, Taif 20001, Saudi Arabia

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The present study aimed to explore the experiences of newly graduated nurses during their first year of practise. A qualitative descriptive design was employed in this study. In-depth, semi-structured interviews were conducted with newly graduated nurses to gather detailed descriptions and experiences during their transition to the workplace in the first year after graduation. Thematic analysis was utilised to identify patterns and themes in the collected data. Ethical considerations were strictly enforced throughout the study. There are two main themes: factors contributing to the integration of new nurses into the workplace and the difficulties faced by new nurses in a work environment. Within the first theme, three subthemes emerged: the positive role of trainers, the gradual handling of patients, and the benefit of pre-employment training and volunteering. The theme of difficulties faced included three subthemes: difficulty dealing with the health system and devices, fear of dealing with new patients, and difficulty applying policies and procedures in the workplace. The study provides insights into the challenges faced by newly graduated nurses and the factors that contribute to their integration into practise settings. Educational departments in hospitals’ support and efficient access to policies are crucial for these nurses as they begin their early professional years.

1. Introduction

The transition from being a nursing student to becoming a professional nurse marks a significant milestone in the nursing profession [ 1 , 2 ]. This transition is accompanied by various struggles, such as being tense and suffering physical exhaustion, that newly graduated nurses (NGNs) must adapt to and cope with. It signifies the culmination of years of education and training and marks the beginning of their professional practise. However, this transition is not without its obstacles [ 1 , 3 , 4 , 5 , 6 ].

NGNs face several difficulties as they navigate the unfamiliar clinical environment and work culture. These difficulties can impede the integration and functioning of NGNs within the healthcare team. The challenges faced by NGNs during this transition period can be multifaceted and demanding [ 3 , 7 ].

Firstly, they must adapt to the new dynamics and demands of the clinical environment. The shift from the controlled and structured setting of the classroom to the fast-paced, high-pressure reality of healthcare settings can be overwhelming. NGNs are suddenly faced with the responsibility of caring for real patients, making critical decisions, and managing complex healthcare scenarios. This transition requires them to adjust quickly and apply their theoretical knowledge and skills to real-world situations [ 8 , 9 ]. In addition to the clinical challenges, NGNs also need to acclimatise to the work culture within healthcare settings. Each healthcare facility has its own unique organisational culture, norms, and expectations. NGNs must familiarise themselves with the specific policies and procedures of their workplace, understand the dynamics of interprofessional teams, and learn to collaborate effectively with colleagues from various disciplines. Building relationships and establishing effective communication channels are crucial aspects of integrating into the work environment [ 3 , 10 ]. Furthermore, NGNs may experience a lack of confidence in their abilities during this transition period. The shift from the supportive environment of a student to the autonomous role of a professional nurse can be daunting. NGNs may question their clinical skills, decision-making capabilities, and overall competence [ 11 ]. Moreover, NGNs often encounter challenges in managing their patient workload effectively. Balancing multiple patients’ needs, prioritising care tasks, and ensuring timely and safe interventions require efficient time management and organisational skills. NGNs may initially struggle with these aspects, leading to stress and feeling overwhelmed [ 10 , 12 ]. Additionally, workload may cause nurses to stop working on the clinical side [ 13 ]. Consequently, it is essential to understand the factors that contribute to the successful integration of NGNs into the work environment [ 14 ] and to understand Benner’s model and Duchscher’s theory to establish a baseline for NGNs to facilitate their integration into the workplace [ 15 ]. According to Murray, Sundin, and Cope [ 15 ], Duchscher’s transition shock theory and Benner’s theory both start from novice to expert, providing the framework for understanding NGNs transition to practise. Duchscher’s transition shock theory describes the path of new nurses entering the profession, and Benner’s theory identifies delineated competency in five stages: novice, advanced beginner, competent, proficient, and expert. Previous studies have explored the experiences of NGNs during their initial transition to the clinical setting. Rush et al. [ 11 ] found that NGNs commonly face challenges related to a lack of confidence, difficulties in managing patient workload, and a lack of support from their peers [ 11 ]. Similarly, Liang et al. [ 3 ] and Labrague and McEnroe-Petitte [ 10 ] identified struggles among NGNs in establishing professional relationships, acquiring necessary knowledge, and developing assertiveness skills [ 3 , 10 ]. The nursing profession is important, as nurses are responsible for taking care of human lives. Moreover, it is crucial to pay attention to NGNs until they become professionals. However, to the best of our knowledge, there has been no research on NGNs experiences in Taif City. Therefore, the objective of this qualitative study is to examine deeply the experiences of NGNs during their first year of practise and investigate the factors that contribute to their successful integration into the workplace and its related difficulties.

2. Materials and Methods

2.1. study design.

This study follows a qualitative descriptive design that employs in-depth interviews to explore the experiences of newly graduated nurses during their first year of practise. Qualitative research is an appropriate method for exploring individual experiences and perceptions surrounding a phenomenon, as it allows for the collection of data that goes beyond descriptive statistics [ 16 ].

2.2. Study Setting

This study was conducted in hospital settings, including governmental, private, and military hospitals within the city of Taif, Saudi Arabia. This study targeted participants who had graduated from an accredited nursing programme and were in their first year of practise.

2.3. Study Population

The study population consists of newly graduated nurses (NGNs) who are in their first year of practise within hospital settings in Taif, Saudi Arabia. The inclusion Criteria for this study were newly graduated nurses who must be NGNs who have graduated from an accredited nursing programme and are working full-time in hospitals. NGNs with fewer than 12 months of experience in clinical practise are eligible for inclusion in the study.

2.4. Sampling and Sample Size

A purposive sampling technique was used to select NGNs who were interested in participating in the study. This technique involved approaching potential participants through nurse managers in hospitals and explaining the purpose of the study. Therefore, all newly graduated nurses who are in their first year of practise within hospital settings in Taif, Saudi Arabia, were invited. Once contacted, eligible NGNs who expressed an interest in the study were provided with detailed information about the study objectives, procedures, and data confidentiality, and informed consent was obtained before their participation in the study. The sample size for this study was determined through a process of data saturation. This process involves analysing the transcripts of the interviews as they come in and then continuing to collect data until no new information is revealed [ 17 ]. According to previous literature, 15–20 participants would be sufficient to achieve data saturation [ 16 ]. Therefore, this study’s data saturation was reached throughout the 15 semi-structured interviews.

2.5. Data Collection and Analysis

Semi-structured interviews were chosen for data collection to explore personal experiences and thoughts regarding a particular phenomenon. The focus was on obtaining detailed and comprehensive descriptions of the experiences of these nurses as well as examining the factors contributing to the integration of new nurses into the workplace. The interviews included questions such as: “What type of work issues have you faced during your first year as an RN, and why?”, “What makes you more confident?”, and “What do you think would help newly-hired staff nurses in the first year?”.

The data analysis for this study was conducted based on the aims and objectives of the study. The data collected through the interviews was analysed using thematic analysis, which involves identifying patterns, concepts, and themes within the data [ 18 ]. The analysis focused on the difficulties that NGNs experience during their first year of practise and the factors that enable them to integrate into their workplace. The thematic analysis process was performed with multiple readings of the interview transcripts to become familiar with the data. The transcripts were re-read to identify the initial codes, which would be combined into candidate themes. These themes were then reviewed, refined, and clustered to identify the final themes and sub-themes. The themes that emerged were compared with the current literature to support their identification and better understand their relevance and impact. The data analysis helped in the identification of factors influencing the integration of NGNs into their workplace and overcoming the challenges that arise during their first year of practise.

Fifteen newly graduated nurses from Taif City participated in this study: nine female nurses and six male nurses. Their ages ranged between 23 and 25 years old, as shown in Table 1 . This study identified two main themes. First, factors contributing to the integration of new nurses into the workplace include three subthemes: the positive role of trainers in a work environment, the gradual handling of patients, pre-employment training, and volunteering. The second theme is difficulties faced by new nurses in a work environment, which includes three subthemes: difficulty dealing with the health system and devices in a work environment; fear of dealing with new patients; and difficulty applying policies and procedures in the workplace.

The participants’ characteristics.

3.1. Factors Contributing to the Integration of New Nurses into the Workplace

3.1.1. the positive role of trainers at the workplace.

The involvement of trainers at the start of the participants’ employment has helped them become familiar with the work environment. Thirteen of the participants agreed that trainers teach them how to deal with and cooperate with patients in different cases, teach them important knowledge and skills, and have answers to all of their questions. Therefore, it had a positive impact and helped them adapt easily, as quoted below:

“I had no idea that I was going to be employed at a critical care unit. I was employed and had a training supervisor who introduced me to the department. In the first week, I took care of zero patients. Afterwards, I was able to take care of stable patients; she would explain things and stay by my side for all of the procedures and on the system when I was entering data. Then I started to only go back to her for things I was not sure about. Her support for me was useful; she stayed for 2 months, and after that, I would only ask her if I was unsure. Gradually, I took care of patients from stable to critical ones.” (Participant 1)

“I had a supervisor, and I will never forget their blessing after God—they guided me for 3 months and taught me everything in all situations—how to deal with patients, how to finish my papers, and how to manage my time during work. They never had any relevant information with all of the nursing procedures and never faced difficulties, even though she was a foreigner. Our language was good and focused throughout the three months; her presence really helped, and we learned quickly and got familiar with everything. She helped us to an extent where we did not feel pressure, and they did not punish us for paper mistakes or any mistakes that did not involve patients; they also encouraged us.” (Participant 7)

However, not everyone received on-the-job training at the beginning of their employment. This was due to either a shortage in the nursing staff or the trainer being on annual leave, as mentioned below:

“In my case, there was no trainer—it was a holiday, and when she came back from her holiday, they placed her in the quality department. In the first month, I taught myself, and from the first week on, they gave me patience. I had early shock, job burnout, and fear at night. Then I learned and asked some of the nurses to help; some of them apologised or refused. After the first month, the trainer came and showed me what I needed, and then new nurses came a month later, and the trainer trained them. At that time, I was holding three new critical cases.” (Participant 15)

3.1.2. Gradual Handling of Patients

At the beginning of their work in the field of nursing, twelve participants gradually provided care to patients. They started by providing nursing care for stable cases. Furthermore, they took care of critical cases gradually until the number of patients increased to the normal range. Furthermore, there were others who advised and supported nurses, such as nursing directors and supervisors. Hence, this contributed to their adaptation to work and the development of their knowledge and skills, as quoted below:

“When I joined the hospital, The first patients I received in the department were chronic, stable cases. After two weeks, I gradually began to catch critical cases—after a month, I caught three critical cases in my shift. However, even if you are an expert, you sometimes need to ask others to help or consult on certain cases.” (Participant 2)

“We are in the critical care unit; we are assigned to two patients according to the type of healthcare condition. It will not deteriorate or be critical; it is an intermediate case. Hence, if I need help, I ask for it. As you know, the cases here are all critical; of course, there are no stable or simple cases here—they all need a lot of procedures, compound medicines, and IV fluids.” (Participant 10)

“Now that I have completed almost 4 months, I can work alone with critical patients and with one stable patient, like the rest of the nurses; praise be to God for help from my colleagues, that is, when I want someone to help me with the child to hold them at any time to implement nursing procedures.” (Participant 14)

3.1.3. The Benefit of Pre-Employment Training and Volunteering

Eight participants indicated that working as a locum in nursing and as a volunteer before working as staff helps with acquiring experience and gaining skills. Thus, some of the new employees do not suffer a lot at the start of their careers, as quoted below:

“I worked as a locum before starting my official work—my desire to work in critical departments—and as you know, personality also makes a difference, whether he or she is self-confident or not—I feel that I can be creative and enjoy my work in an intensive care unit. It will be good when nurses are assigned one patient in the ICU and not the other way around, where one nurse is responsible for three to four cases, because this is not intensive care.” (Participant 4)

“Locum and volunteering increase self-confidence. I experienced this myself. Helping others to nurse increases my efficiency. I had a 12-hour shift because the staff shortages were annoying for me, and there was also an intellectual difference between doctors and nurses. The nurses are serving more than their capacity in the department, and this causes us pressure—permanent cooperation in the department and nursing; every day I learn something new—my schedule and my rest day were as I asked, and they help me if I get new admissions or difficult situations.” (Participant 2)

3.2. Difficulties Faced by New Nurses in a Work Environment

3.2.1. difficulty dealing with the health system and devices in a work environment.

Ten of the participants indicated that hospitals have electronic systems and a number of different medical devices. They have sometimes not used or seen these devices before or during their studies. They do not have the knowledge or skills to deal with it. Therefore, it is necessary to have a supervisor or mentor teach them how to prepare it and use it in a good and safe way, as quoted below:

“Some of the devices I was trained in, but the respirator was difficult for me. It is difficult to use devices without this information because you may transfer infections or harm patients. I was observing the respiratory and nursing staff, and I was assigned to cases, but I did not understand how to change the settings of the device, so I asked the supervisor many times until I learned. The problem is that most of the devices are not used daily, so it is easy to forget. The good thing is that some workshops from the medical devices department help us.” (Participant 1)

“That is an issue; it was difficult because it is a new environment and there are procedures related to the health and safety of the patient; for example, how do we get the results of analyses and how do we transfer patient information into the system? These are the problems we face, and there are things in the system that if we make mistakes and mistakes are not modified, that is why supervisors are with us step by step so we can learn.” (Participant 7)

“Some devices were new to me, and the trainer explained them to me. It took me about three weeks to use them in a good and safe way—technology has made many things easier, even if they started off difficult, but as we know, technologies help us to finish our tasks more easily.” (Participant 2)

3.2.2. Fear of Dealing with New Patients

Nine participants mentioned that fear sometimes controls them while performing work. This fear can be seen when there are new and unstable disease cases that they have not dealt with before, such as COVID cases. Furthermore, in cases where there is a procedure that has not been performed before or in a different patient, such as a small child or older patient, it is difficult to deal with this during nursing procedures, as quoted below:

“I had no problems when I performed many procedures in nursing; however, difficulties are found with new diseases, new devices, or new regulations. When I start new nursing procedures with patients, it is difficult. I feel fear, but with practise, it becomes easy and can be done without fear.” (Participant 8)

“The worst situation was with a patient who mistreated me because I was new. He was not confident in me. I tried to give him an IV injection, and my hand was shaking because I was afraid. He started to get angry with me. I had only been given an IV once, but the patient was a little fat and needed experienced staff. A second bad situation was when the doctor gave a verbal order, and I was new. I did not know the policy or whether I was supposed to write it down and document it in the patient file. We carried out the doctor’s orders. The problems have been when I sometimes make mistakes. They do not consider that I am new and that I need help!” (Participant 13)

“There were no difficulties, praise be to God, but it was a matter of adapting to the new situation and taking responsibility for work and cases—organising time is important and working with team spirit, especially in critical departments; no one can do without anyone—forming relationships with the staff of my department. We depend on each other, and we share the experience. The problem was when patients died; I used to cry about that until I got used to the situation. I mean, when I had a new patient, I was afraid that I would lose him immediately.” (Participant 12)

3.2.3. Difficulty Applying Policies and Procedures in the Workplace

Health policies and procedures are important. Ten of the participants mentioned this. They also mentioned that all new nurses at work are required to not only read them but also apply them in order to practise them, because most of the problems are due to a lack of practise of nursing policies and procedures during work. This is for a variety of reasons, such as a lack of time and needing to practise, as quoted below:

“Workshops are supposed to be held on infection control and what should go into the yellow box—we need to review before practising because the one in the university differs from that in the hospital. Here, they just showed me the file of policies and procedures, but there was no motivation to read. I took a course on similar medicines under a good trainer. Hence, we need to read it, but we have no motivation or time to do that.” (Participant 1)

“Many things in the hospital system—policies and procedures—are supposed to be explained, not only shown to new nurses, but explained and practised according to priority. The daily procedure is important and different from procedures that happen every year. We need to give the new nurses time to understand because learning abilities differ from one nurse to another. Learning the documentation is more important than nursing needs for any procedure they undertake because it is a daily process. Preparing medicines is also important for them to learn and be intensive in the first period of the appointment.” (Participant 4)

“It is possible to explain the policies and procedures and apply them in practise, much better than handing them to us, so that we are more familiar with medications, for example. Practise is better than most things like sending emails or handling papers.” (Participant 14)

4. Discussion

The present study aimed to explore the experiences of newly graduated nurses during their first year of practise, focusing on the factors contributing to their integration into the workplace and the difficulties they faced.

Factors contributing to the integration of new nurses into the workplace emerged as a significant theme in our study. Within this theme, three subthemes were identified: the positive role of trainers in a work environment, the gradual handling of patients, and the benefit of pre-employment training and volunteering. These findings resonate with several previous studies that have explored the transition experiences of newly graduated nurses [ 1 , 3 , 5 , 6 , 8 , 19 , 20 , 21 , 22 ].

In their qualitative study on the transition challenges of fresh nursing graduates, it was found that the presence of supportive mentors and preceptorship programmes facilitated the integration process [ 7 ]. This finding aligns with our subtheme on the positive role of trainers in the work environment, with participants highlighting the importance of having experienced supervisors who guided them, answered their questions, and provided continuous support. Similar to another qualitative study by Gellerstedt et al. [ 8 ], which examined the experiences of newly graduated nurses in a trainee programme, our participants emphasised the value of pre-employment training and previous volunteering experiences in enhancing their confidence and skills [ 8 ].

The second theme identified in our study was the difficulties faced by new nurses in a work environment. This theme included three subthemes: difficulty dealing with the health system and devices in a work environment; fear of dealing with new patients; and difficulty applying policies and procedures in the workplace. These findings are consistent with previous research, which highlighted the challenges encountered by newly graduated nurses during their transition period [ 3 , 4 , 7 ]. Furthermore, the lack of awareness of work policies is one of the reasons for conflict between nurses in general [ 23 ].

In their integrative review of new graduate nurses’ transition to acute care, Hawkins et al. [ 24 ] identified similar difficulties related to the health system and devices. They found that new nurses often struggled with the use of electronic systems and unfamiliar medical devices. Similarly, our participants expressed concerns about lacking knowledge and skills in dealing with certain devices, emphasising the need for proper training and mentorship.

Fear of dealing with new patients was another subtheme that emerged in our study. This finding is in line with the results of Ke and Stocker [ 4 ], who explored the processes of growth among new nurses in the workplace. They found that new nurses often experienced anxiety and fear when faced with unfamiliar and challenging patient cases. Our participants shared similar experiences, highlighting the initial fear and apprehension they felt when encountering new and critical cases. However, with practise and support from colleagues, they gradually overcame their fears and gained confidence.

The third subtheme, difficulty applying policies and procedures in the workplace, corresponds to the findings of a study by Lee and Sim [ 22 ], which examined the gap between college education and clinical practise for newly graduated nurses. They found that new nurses often struggled to apply theoretical knowledge in real-life settings, particularly when it came to adhering to policies and procedures. Similarly, our participants mentioned the challenges of understanding and applying policies and procedures in their workplace. Therefore, many studies have highlighted the need for more practical training and guidance to bridge this gap effectively [ 22 , 23 ].

Overall, our study’s findings are consistent with the existing literature on the experiences of newly graduated nurses during their transition into the workplace. The themes and subthemes identified in our analysis align with the challenges and facilitators highlighted in the previous literature. These consistencies highlight the significance of addressing these influencing factors and challenges experienced by NGNs.

The study’s strengths include the fact that it utilises a qualitative descriptive design with in-depth interviews to explore the experiences of newly graduated nurses in their first year of practise. Data collection involved semi-structured interviews to obtain detailed descriptions and experiences. Thematic analysis was employed to identify patterns and themes in the data, while ethical considerations and participant confidentiality were ensured. The study provides rich and comprehensive data but is limited by its context-specific nature, potential biases, and small sample size.

5. Conclusions

In conclusion, this study sheds light on the challenges faced by NGNs in Taif City and the factors that contribute to their integration into practise settings. The study highlights the importance of support and resources for these nurses as they navigate their early professional years. The findings contribute to the existing literature on nursing practise and offer recommendations for improving the transition process for NGNs. However, it is important to note that the study has certain limitations, such as its specific focus on a particular context and the small sample size. Future research is highly recommended to replicate the study in different settings and with a larger sample size to ensure generalisability across the Kingdom and strengthen the validity of the findings. The result of this study indicates that educational departments in hospitals are likely to support the new nurses (e.g., teaching new nurses to understand and adapt policies to enhance their quality of nursing care). Therefore, it is essential for healthcare policymakers to explain the importance of hospitals policies on quality care.

Acknowledgments

The authors acknowledge all participants who took part in this study. They also express their gratitude to Princess Nourah bint Abdulrahman University Researchers Supporting Project (number PNURSP2023R441), Princess Nourah bint Abdulrahman University, Riyadh, Saudi Arabia.

Funding Statement

This work was supported by Princess Nourah bint Abdulrahman University Researchers Supporting Project (number PNURSP2023R441), Princess Nourah bint Abdulrahman University, Riyadh, Saudi Arabia.

Author Contributions

Conceptualization, H.F.A., J.A., A.H. and A.A.; methodology, H.F.A., A.H. and A.A.; writing—original draft preparation, H.F.A.; writing—review and editing, H.F.A. and A.S.A.; project administration, H.F.A., A.H., A.S.A. and J.A.; funding acquisition, H.F.A. and A.S.A. All authors have read and agreed to the published version of the manuscript.

Institutional Review Board Statement

The study adheres to the ethical principles outlined by the Helsinki guidelines [ 25 ], which include respect for participants’ autonomy, beneficence, and justice. Ethical approval was obtained from the Ministry of Health with the approval number 732 on 10 September 2022, and an IRB registration number with King Abdulaziz City for Science and Technology, KSA: HAP-02-T-067, to ensure compliance with ethical guidelines, including participant confidentiality, informed consent, and protection from harm. Participants were provided with written informed consent forms that detailed the study objectives, procedures, and confidentiality of their personal information. The research team also maintained strict confidentiality and anonymity throughout the data collection and analysis phases. Once collected, the data was kept safe and secure at all times and was only accessible to authorised personnel directly involved in the research process. Participants were informed that they had the right to withdraw at any time without incurring any penalty or losing any benefits to which they were entitled.

Informed Consent Statement

Informed consent was obtained from all participants involved in the study. Written informed consent has been obtained from the patients to publish this paper.

Data Availability Statement

Conflicts of interest.

The authors declare no conflict of interest.

Disclaimer/Publisher’s Note: The statements, opinions and data contained in all publications are solely those of the individual author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to people or property resulting from any ideas, methods, instructions or products referred to in the content.

Writing clinical articles: A step-by-step guide for nurses

Focus on your audience and narrow your topic. .

Editor’s note: Dissemination 101 is a series designed to help nurses share their expertise. To read other articles in the series, visit myamericannurse.com/category/dissemination-101 . 

• Writing for publication allows you to contribute to nursing practice and help build nursing and healthcare knowledge.
• Taking a step-by-step approach to writing a clinical article can help increase the chances for acceptance.

Are you thinking about writing a clinical article for publication? You can write for a general interest nursing journal that addresses a broad audience or a specialty journal that caters to nurses focused on caring for a specific patient population (for example, oncology or wound care). Most clinical articles published in general interest journals aim to help nurses understand the clinical presentation and progression of a disease or health issue and the subsequent care for a specific patient population.

To increase your chances of article acceptance for publication, take a step-by-step approach, as recommended by Mee.

Start with what you know

Write about what you’re most familiar with. Are you working on a hemodialysis unit and recently managed a patient who experienced a cardiovascular event? Then consider writing about managing cardiovascular emergencies in this patient population. Are you an endoscopy nurse who works with patients receiving endoscopic retrograde cho­lan­giopancreatography? Focus your article on the nursing implications of caring for patients after this test.

Strive to keep your topic focused so you can control manuscript length and ensure you deliver relevant content to the reader. For example, an article about caring for patients with pancreatic disorders is too broad. A narrower-focus article might cover cystic fibrosis, specifically on the impact of this condition on health-related quality of life. You can narrow the topic further by a concentrating on adolescents.

Solo vs. team writing

Are you going to write alone or with a team? Pros and cons exist for each. When writing alone, you may have better control of your timeline and content. However, compared to writing with a team, you might miss an opportunity to present a more diverse perspective of the topic. Another advantage of writing with a team includes having more access to resources, including a network of colleagues to interview. With a team, you can distribute the work among the authors and even have more proofreaders. However, delays may arise if one team member lags behind schedule or conflict emerges within the group. When writing with a team, establish authorship early in the process. The International Committee of Medical Journal Editors developed a set of four criteria to establish authorship: authors should make substantial contributions to the manuscript, draft or revise it, have final approval of the published version, and agree to be accountable for all aspects of the work.

Journal selection

Before selecting a journal, establish your intended audience. For example, are you writing for staff nurses, clinical nurse specialists, nurse practitioners, or nurse midwives? Write for the selected audience, keeping in mind what they already know about the topic.

Now you can narrow your journal choices to those that are a good match for your topic and intended audience. You can expect immediate rejection if your manuscript doesn’t match a journal’s purpose and readership. Read at least three to four issues, and explore the table of contents for similar articles related to your topic. An article on a disease or condition similar to your topic doesn’t necessarily make yours ineligible for publication. Your topic may have a different focus.

After you select the target journal, carefully read the author guidelines, which usually can be found on the journal’s website. Follow directions for formatting the manuscript, and comply with page or word limitations. Consider querying the journal editor before submitting your manuscript (in fact, many journals require this step). Querying can help ensure your topic is appropriate for the journal. In addition, the editor may provide feedback to help you focus the manuscript accordingly before submission.

Article type

Elements of a clinical review article.

Clinical review articles typically include the following sections:

• Etiology. The cause or origin of the disease.
• Pathophysiology. The pathologic and physiologic processes associated with the disease.
• Epidemiology. Discussion of disease frequency (number of new cases in a given population) or prevalence (number of cases present at a point in time).
• Clinical presentation. What are the signs and symptoms of the disease?
• Diagnostics. This includes relevant tests and normal and abnormal laboratory values.
• Treatment and interventions. Depending on the journal guidelines, this section might include medications, medical and nursing procedures, and key nursing considerations.
• Patient education. This section focuses on key points for patient education. If your article discusses best practices in your setting, consider including a patient education handout that can be incorporated into any organization.
• Nursing implications. Includes the nursing process from assessment to interventions and outcomes. Some journals want a separate section devoted to nursing implications.

Case studies 

Most nurses are familiar with case studies, first from learning how to write them in nursing school and then in clinical practice when reading progress notes. If you’re a novice writer, you’ll find reading case studies in journals to be helpful.

Published case studies can evolve from real case reports or be a simulated, fictional case. If you choose to write about a real case, obtain permission from the patient and your organization. Although the patient’s identity will be concealed in your article, you may run the risk of readers identifying the patient. Also, don’t choose a case that’s so rare that the reader may never encounter such a situation.

Case studies typically begin with the patient’s health history followed by a discussion of the common clinical presentation, pathophysiology, nursing process, psychosocial considerations, and treatments. Keep in mind that you’re using the case to teach readers, not merely reporting what you experienced.

How-to articles 

How-to articles focus on teaching a skill, procedure, or intervention. For example, caring for patients with a colostomy, proning patients with COVID-19 who haven’t been intubated, or attending to patients after cardiac catheterization. When writing a how-to article, focus on what’s most meaningful to nurses who provide direct care, such as patient and family education, and cite evidence-based recommendations.

Do your research

A fundamental motto for writing is “Read. Read. Read. Write. Write. Write.” In other words, do your research. When you read a wide range of literature on your topic, including relevant nursing models or theories, and access key databases, you’ll soon be ready to write. Organize your notes (paper or digital) and maintain a complete and accurate account of your references, which should be as current as possible.

Create an outline

Use an outline to organize your thoughts and help you stick to one main focus or purpose that’s appropriate for the intended audience. At this stage, you’ll also want to consider what information can be best covered in tables or figures rather than in text. For example, you can create a table that lists signs and symptoms in column one and related pathophysiology in column two. Such a table can effectively present a large amount of information that doesn’t need to be repeated in the text of the article.

Writing and editing

Knowing where to start can be daunting. Consider starting on the section you know best or one for which you have the most information to help build your confidence and spur development of other sections. Other writing tips that can enhance the chances your article will be accepted for publication and engage readers include the following:

• Passive: The patient’s medications were reviewed by the nurse before discharge.
• Active: The nurse reviewed the medications with the patient before discharge.
• Cite relevant references. Support statistics and practice guidelines with appropriate recent references. Follow the journal’s author guidelines for number of references and style.

After completing your manuscript, let a day or two pass and then read it again and start editing. Note that your overall goal during editing is to make the manuscript concise and meaningful for the reader. Check that it aligns with the journal’s author guidelines and requirements. Ask colleagues (including an expert, novice, or someone who’s not familiar with your topic) to read your manuscript, and request their honest feedback. Review tables, figures, and other graphics to ensure they provide relevant information and that they adhere to the journal’s author guidelines. Consider including a box with key points, such as nursing implications.

Follow the journal’s article submission guidelines. Some journals request submission through an author portal that requires you to create an author account, while others prefer to receive submissions via email. Most journals require that you attach a cover letter, sign copyright release and conflict-of-interest forms, and submit information about all authors.

Advance nursing practice and science

When you publish, you contribute to nursing practice and help build nursing and healthcare knowledge by providing guidance for practitioners and future researchers. Regardless of the type of article, include implications for nursing practice and, when appropriate, education, policy, and research. Writing involves hard work, but it’s rewarding and a great way to build your credentials.

Rhoda Redulla is director of nursing excellence and Magnet Recognition at NewYork-Presbyterian in New York, New York, associate editor of Gastroenterology Nursing Journal, and author of Fast Facts for Making the Most of Your Career in Nursing . 

Eldh AC, Almost J, DeCorby-Watson K, et al Clinical interventions, implementation interventions, and the potential greyness in between – a discussion paper. BMC Health Serv Res. 2017;17(1):16. doi:10.1186/s12913-016-1958-5

International Committee of Medical Journal Editors. Defining the role of authors and contributors.

Mee C. Writing the clinical article. In: Saver C ed. Anatomy of Writing for Publication for Nurses. 4th ed. Indianapolis, IN: Sigma; 2021.

Morton P, Ketefian S, Redman R. Writing the research report. In: Saver C, ed. Anatomy of Writing for Publication for Nurses. 4th ed. Indianapolis, IN: Sigma; 2021.

Oermann MH, Ingles TM. Writing manuscripts about quality improvement: Squire 2.0 and beyond. Health. April 30, 2019.

Roush K. What types of articles to write. Am J Nurs. 2017;117(5):68-71. doi:10.1097/01.NAJ.0000516278.97098.02

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I could have used this when I was writing articles years ago. Excellent resource

Thank you for this helpful article. I believe that when we publish good articles, we help healthcare providers to give a high quality of care to patients. I encourage all knowledgeable healthcare to write and publish many articles in order to help others for the betterment of patients. Thank you

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Best Nursing Research Topics for Students

What is a nursing research paper.

• What They Include
• Choosing a Topic
• Best Nursing Research Topics
• Research Paper Writing Tips

Writing a research paper is a massive task that involves careful organization, critical analysis, and a lot of time. Some nursing students are natural writers, while others struggle to select a nursing research topic, let alone write about it.

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

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

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

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

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

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

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

About Nursing Research Papers

When do nursing students write research papers.

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

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

Do Nursing Students Conduct Original Research?

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

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

Example Research Project Scenario:

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

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

What Does a Nursing Research Paper Include?

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

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

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

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

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

How to Choose a Nursing Research Topic

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

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

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

The Best Research Topics for Nursing Students

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

1. Clinical Nursing Research Topics

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

2. Community Health Nursing Research Topics

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

3. Nurse Education Research Topics

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

4. Mental Health Nursing Research Topics

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

5. Pediatric Nursing Research Topics

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

6. The Nursing Profession Research Topics

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

Tips for Writing a Nursing Research Paper

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

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

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

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

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

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

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

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

Helpful Nursing Research Writing Resources:

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

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

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

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

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

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

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Finding Research Articles in PubMed and CINAHL

Finding nursing authors in cinahl plus, finding son authors in pubmed.

To find articles authored by nurses in CINAHL Complete :

After entering your search topic, under Limit Your Results, click on either:

• First Author is Nurse: If you apply this limit, you will only retrieve records where it is confirmed that the first author of an article is a nurse, according to credentials noted in the article.
• Any Author is Nurse: If you apply this limit, you will only retrieve records where at least one author is a nurse, according to the credentials noted in the article.

NOTE:   The written by a nurse limiters apply only to records from November 2009 and forward.

To find articles authored by University of Washington nurses:

After entering your search topic, in the second Search box enter University of Washington and change the drop-down menu to:  AF Author Affiliation.

When checking your Results, look at the Affiliation field to see if author is from the UW School of Nursing.

To find articles authored by University of Washington School of Nursing faculty in PubMed :

Use the AD Address field.

Add the following to your search topic:  nursing [ad] AND "university of washington" [ad]

         Example:  irritable bowel syndrome AND nursing [ad] AND "university of washington" [ad]

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Florence Nightingale overcame the limits set on proper Victorian women – and brought modern science and statistics to nursing

Professor Emeritus of English and Women’s Studies, Arizona State University

Disclosure statement

Melissa Pritchard does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.

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For nearly 200 years, Florence Nightingale’s name has been synonymous with gentle compassion and mercy .

In the mid-19th century, Nightingale became perhaps the most celebrated woman of her era – second only to Queen Victoria – for instituting sanitation practices that sharply cut death rates among British soldiers fighting in the Crimean War. A handsome bronze statue in London’s Waterloo Place has immortalized Nightingale as a slight, graceful figure carrying a lamp, the embodiment of selfless womanhood.

But this iconic image overshadows many other accomplishments. Nightingale also transformed nursing into a respectable profession, founded the world’s first nursing school , used the relatively new science of statistics to improve health care outcomes and redesigned hospitals . She was also one of Western history’s first advocates of health care for all .

Over the five years I spent researching and writing my biographical novel about Nightingale, “ Flight of the Wild Swan ,” published March 12, 2024, my vaguely sentimental notions about her were replaced by respect for her visionary achievements. I resolved to bring into sharper focus this woman who, along with her legendary work as a war nurse, spent half a century pioneering advances in health care.

The 19th century ushered in a series of revolutionary medical advancements. Nightingale’s contributions were a significant part of this era.

Called to serve the suffering

Florence Nightingale was born in Florence, Italy , on May 12, 1820, to William and Frances Nightingale, a wealthy British couple. The Nightingales raised their two daughters, Florence and her sister Parthenope, on two estates in England. William homeschooled the girls, giving them the equivalent of his own Cambridge University education.

From an early age, Nightingale displayed a formidable intellect , with a particular interest in mathematics. At 16, she experienced a transcendent call to serve the suffering, a call that eventually coalesced into her determination to become a nurse. Her family objected, however, because nursing was an unsuitable occupation for young Victorian women of privilege. It was considered disreputable work with a status even lower than that of servants.

But Nightingale gradually overcame her family’s objections , receiving training in Germany and France. In 1853, she became the superintendent of a small hospital in London for “distressed gentlewomen .” The majority of her patients were educated, unmarried governesses whose health had broken down under the strain of long hours of work and negligible pay.

A little over a year later, she was on her way to the Crimean War .

Bringing sanitation to medicine

In October 1854, Nightingale brought 38 female nurses under her supervision to Scutari Barrack in Constantinople – today’s Istanbul. Originally a gargantuan stone barracks for the Turkish army, Scutari was now a British hospital housing thousands of wounded English and Irish soldiers.

At Scutari, she and her nurses found few provisions, little medicine or edible food, and overcrowded hospital wards full of rats, lice and raw sewage. More soldiers were dying of cholera and other infectious diseases than of battle wounds. Nightingale and her nurses set to work cleaning and procuring food, soap, bandages, medicine, clean bedding and clothes for patients. As living standards improved, Scutari’s appalling death rate began to decline .

It was there that Nightingale’s reputation as the “Angel of the Crimea” and the “ Lady with the Lamp ” began. Wartime journalists telegraphed their newspapers with dramatic accounts of her work. These stories ignited the public’s imagination and created the indelible image of a slight, feminine figure carrying her lamp through hospital wards at night.

In January 1855, British Prime Minister Henry John Temple, 3rd Viscount Palmerston, dispatched a newly formed Sanitary Commission to the Crimea to investigate high mortality rates in the military hospital . Nightingale observed firsthand the dramatic decline in death rates as the commission cleaned out the hospital’s befouled sewer systems, limewashed its walls – in effect killing surface bacteria – and made numerous other sanitation improvements.

Nightingale was already a proponent of hygiene, fresh air and proper diet in medical care; this experience made her a committed sanitarian .

When the war ended in 1856, Nightingale returned home, permanently bedridden with chronic brucellosis, then called “Crimean fever.” This didn’t stop her from spending the rest of her life applying herself to improving health care systems in Great Britain and other countries.

Using numbers to cure

Statistics was a relatively new science in Nightingale’s time, but it aligned with her early interest in mathematics. Ultimately, Nightingale would come to believe that statistics used to help reduce mortality rates were “the true measure of God’s purpose.”

Collaborating with William Farr , a leading figure in applying statistics to epidemiology, Nightingale analyzed extensive data on army mortality rates during the Crimean War, proving that most deaths were attributable to preventable diseases rather than battlefield injuries. She was particularly innovative in her use of graphic diagrams such as her famous “rose,” or “coxcomb,” diagram, rightly believing that attractive visuals were more impactful than the dry numbers tables favored by the era’s statisticians.

As a result, in 1858, in recognition of her use of the statistical method in army sanitary reform, Nightingale was inducted into the Royal Statistical Society as the organizations’s first female fellow . In 2020, the Royal Statistical Society established an annual Florence Nightingale Award for Excellence in Health and Care Analytics .

In a revolutionary step, Nightingale extended her statistical methods and data visualization to other areas, ranging from hospital administration and health care management to public sanitary reform and the sources of preventable diseases. These analyses further exposed the causes of both military and civilian mortality .

Educating future nurses

In 1860, seeking to elevate nursing into both a science and an art, Nightingale founded the world’s first school of nursing : the Nightingale Training School for Nurses at St. Thomas’ Hospital, London.

The female students – numbering 20 to 30 at a time – lived at school and wore nurses’ uniforms to rigorous classes on anatomy, surgical nursing, physiology, chemistry, sanitation and ethics. By the 1880s, Nightingale had accepted the newer “germ theory” of disease spread, and this became part of the curriculum.

At the conclusion of the one-year program, Nightingale sent her nurses into the world as certified and paid health professionals.

By the turn of the century, the school had graduated nearly 2,000 certified nurses . Known as “Nightingales,” they fanned out across Great Britain to practice skilled patient care, develop nursing care systems, teach, train and mentor.

The Nightingale Training School became a pioneering model for nursing education throughout Great Britain. Similar schools would be established in Africa, America, Australia, Canada and other countries.

Nightingale also wrote a bestselling book , 1859’s “ Notes on Nursing ,” that guided Victorian wives in keeping members of their households healthy.

Advocating for public health

Nightingale’s long, ultimately successful effort to bring trained nurses and midwives into England’s and Ireland’s notorious workhouses has gone largely unacknowledged.

During Victorian times, paupers in workhouses who became ill could be cared for only by other destitute workhouse residents . Nightingale wrote numerous articles emphasizing the need for public health nurses to care of the sick in these institutions, and during the 1860s she called for the abolition of England’s harsh poor laws .

As a result of these efforts, workhouse nursing reforms gradually spread across England.

I believe that a more fully realized understanding of Nightingale’s life and achievements beyond being “the lady with the lamp” can provide an inspirational role model for those considering careers in nursing, medical science and public health today.

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• Florence Nightingale

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Nursing Overview: Writing Assignments by Class

• Evidence Based Practice
• Purpose of Nursing Papers
• Writing Assignments by Class
• Nursing Journal Articles
• Nursing Texts
• How do I find this particular article?
• Other useful resources
• Lexicomp Drug Database
• APA 7-Citations
• APA 7-Layout
• APA 7 Style
• Word Tip Videos
• Plagiarism Tutorial
• HESI & NCLEX
• Faculty Resources
• Comments/Suggestions
• Movies About Health Care
• Scholarships

How to write a paper

• Finding Sources
• Foundations/Clinicalas
• Complex: TBON Paper
• Complex: Global Health Paper

As you begin learning to write nursing papers, you may find it difficult to find "good" articles.  Nursing papers are different than anything you have written before.  You are no longer repeating information you found or writing a paper that "says what you want to say."  Now you will be telling the reader about an empirical study/original research [evidence] and how the results of that study impact nursing [practice].

This is where you librarian is your best friend! I can find those sneaky sources for you!  Want to know a secret?  Many nursing instructors just ask the librarian to find articles for them, too!  When you are a working nurse, you'll probably ask a librarian to help you find resources.  There is no shame is not knowing how to find resources!  If everyone could do it on their own, I'd be out of a job!  Let's agree that when I need a shot, I'll come to you, and when you need any kind of research, you'll come to me.  Deal?

What this paper is about

The purpose of the culture paper is to identify a health issue that is common in the cultural group you selected.  You need to explain to your reader how a nurse would help a patient from your identified culture with the identified health issue. 

The introductory paragraph will explain to the reader who your cultural group is and what health condition you will be discussing. 

Each body paragraph will be a summation of the articles you find. 

The conclusion will be your explanation of how a nurse would help (intervention).

The following databases will assist you in locating relevant articles.

Information about Cultures

These resources have useful information about cultures that may be helpful in your paper.

Ethnomed: https://ethnomed.org/

This website has wonderful information about health conditions as they relate to culture as well as how some cultural aspects relate to health care.   

Think Cultural Health From the Office of Minority Health (OMH), U.S. Department of Health & Human Services , Think Cultural Health is an OMH initiative that provides health and health care professionals with information, continuing education opportunities, and resources to learn about and implement Culturally and Linguistically Appropriate Services (CLAS) and the National CLAS Standards. Explore other Think Cultural Health resources related to the National CLAS Standards: https://thinkculturalhealth.hhs.gov/resources/library

Health Policy Institute: https://hpi.georgetown.edu/cultural/#

Agency for Healthcare Research and Quality Improving Patient Safety Systems for Patients With Limited English Proficiency: https://www.ahrq.gov/health-literacy/professional-training/lepguide/index.html

Cultural competence and patient safety: https://psnet.ahrq.gov/perspective/cultural-competence-and-patient-safety#_edn20, tulane university school of public health and tropical medicine how to improve cultural competence in health care: https://publichealth.tulane.edu/blog/cultural-competence-in-health-care/.

Culture and healthcare: When medicine and culture intersect: https://youtu.be/c0TquroTHxo Cultures and Health: An Introduction: https://youtu.be/wp2SSH65Kl4

Teaching Assignment

As you are putting together your presentation, remember that you will be teaching other nurses how to help patients. You will not be teaching patients.  If your assigned topic involves patient education, your presentation should include tips for nurses on how to teach patients.

Much of the information needed for this project is "background"; which you will find in text-based databases or books.

If you would like to include new techniques or practices, use the nursing journal databases.

Remember, all the databases will create APA citations for you.

If you need any help with PowerPoint, please reach out.  I can show you some tricks and tips.

There is currently no known research assignment for peds.

APA format for Nurse Practice Act:

Texas Board of Nursing. (2021). Nursing practice act, nursing peer review & licensure compact: Texas occupations code . https://www.bon.texas.gov/pdfs/law_rules_pdfs/nursing_practice_act_pdfs/NPA2021.pdf

[Be sure to put this into hanging indent format once you paste it to your paper.]

Health Issues Around the World

In this paper, you are comparing the degree of severity of a health condition in American to the degree of severity in another country or around the world, presenting information about factors associated with the condition, and then explaining how nurses can help (based on the information presented in the paper).  Sometimes helping involves educating the patient; sometimes helping requires being a patent advocate; sometimes helping just means educating yourself.  Once you understand the problem, you can determine how to best help.

For this paper, you will need to find (I believe): 2 nursing texts, 3 nursing journal articles , and perhaps a professional website or two.

Text sources provide background information about a clinical condition or health issue. These kinds of sources help you better understand a condition and how you, the nurse, can help.  These sources represent what is historically known about an issue. The nursing texts can include your textbook, but do not have to. For a second nursing text, try the Nursing Reference Center database. Click on the tab Finding Articles , drop down to Nursing Texts , then select Nursing Reference Center. When you find an article, be sure to email it to yourself with the APA 7 citation.

Journal articles are studies related to the health issue. These sources provide new information about an issue.  What is the latest treatment, technique, or understanding of an issue or condition? In order to stay up to date on how to provide the best care for a patient, nurses need to regularly read journal studies. The best place to locate nursing journal articles is in the CINAHL database.  Click on the tab Finding Articles , drop down to Nursing Journal Articles , then select CINAHL . When you find an article, be sure to email it to yourself with the APA 7 citation.

Professional websites include those that provide statistics that allow you to compare the rates of a disease or condition.  For international health stats, I recommend the World Health Organization ( who.int ). For health stats from the US, try the Centers for Disease Control and Prevention ( cdc.gov ). To see how to site these source, click on the tab APA 7 and drop down to APA 7 Citations .

It may take years for the new information from a study to become part of the historical literature, so it is important to be familiar with both types of sources.

Ultimately, all nursing research is about determining the nurse's role in the helping the patient. 

Here is a possible structure of the paper:

Introduction:

What is the health issue? How does this health issue impact people or countries or economies, etc.? How bad is it around the world vs. the US?

Share what was found in the text sources. What is the background of the issue?

Share what you learned from the journal studies.  What was the objective of the study? How was the study conducted? What was learned from the study?

Conclusion:

Nursing interventions based on information presented.  What can one nurse do independently to help a patient?  All interventions must be a result of the information presented from research. Be specific.  (A general statement that nurses should be 'educated' is meaningless. It would be better to say, "Nurses should educate themselves on the symptoms of this rare condition in order to avoid any possibility of misdiagnosis." Now you have explained the 'what' and the 'why' of the education.)

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• Last Updated: May 20, 2024 2:13 PM
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Health Care Access & Coverage

Top 5 Reasons Why U.S. Nurses Are Leaving Their Jobs

Study suggests hospitals could improve working conditions to retain nursing staff, julia hinckley, jd.

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The seismic departures in the nursing workforce threaten to impair access and quality of care across the country. And these trends concerned health care leaders and policymakers even before the major disruptions of the COVID-19 pandemic. 

Today, hospitals continue struggling to fill openings even though the U.S. has never had more actively-licensed nurses (5.6 million), driven by record-breaking graduations from schools and a robust job forecast. 

To understand what is driving the exodus, Penn LDI researchers surveyed more than 7,800 nurses who left employment between 2018 and 2021, and published their findings in a recent study in JAMA Network Open . 

Here are the top five reasons why nurses left their jobs:

• Planned retirement . Of those surveyed, 30% left employment for a retirement they had planned.
• Burnout. About 1 in 4 respondents reported that they left because of burnout.  
• Insufficient staffing. Related to experiencing burnout, 21% of those surveyed identified a lack of sufficient staffing as the cause of their departure.
• Poor work-life balance. The inability to balance restrictive and often unpredictable work schedules with family life led about 18% of respondents to depart from their jobs.
• Concerns related to COVID-19. Of those surveyed, 17% said concerns about COVID-19, including concern about family member exposure, led to their departure. 

The researchers point out that all of these reasons (aside from planned retirement) are factors within the control of the institutions. They argue that substantive improvements to work conditions could ease the nursing retention crisis.

The study, “ Top Factors in Nurses Ending Health Care Employment Between 2018 and 2021 ,” was published on April 9, 2024 in JAMA Network Open . Authors include K. Jane Muir , Joshua Porat-Dahlerbruch, Jacqueline Nikpour , Kathryn Leep-Lazar, and Karen B. Lasater .

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Your Health

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Why writing by hand beats typing for thinking and learning

Jonathan Lambert

If you're like many digitally savvy Americans, it has likely been a while since you've spent much time writing by hand.

The laborious process of tracing out our thoughts, letter by letter, on the page is becoming a relic of the past in our screen-dominated world, where text messages and thumb-typed grocery lists have replaced handwritten letters and sticky notes. Electronic keyboards offer obvious efficiency benefits that have undoubtedly boosted our productivity — imagine having to write all your emails longhand.

To keep up, many schools are introducing computers as early as preschool, meaning some kids may learn the basics of typing before writing by hand.

But giving up this slower, more tactile way of expressing ourselves may come at a significant cost, according to a growing body of research that's uncovering the surprising cognitive benefits of taking pen to paper, or even stylus to iPad — for both children and adults.

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In kids, studies show that tracing out ABCs, as opposed to typing them, leads to better and longer-lasting recognition and understanding of letters. Writing by hand also improves memory and recall of words, laying down the foundations of literacy and learning. In adults, taking notes by hand during a lecture, instead of typing, can lead to better conceptual understanding of material.

"There's actually some very important things going on during the embodied experience of writing by hand," says Ramesh Balasubramaniam , a neuroscientist at the University of California, Merced. "It has important cognitive benefits."

While those benefits have long been recognized by some (for instance, many authors, including Jennifer Egan and Neil Gaiman , draft their stories by hand to stoke creativity), scientists have only recently started investigating why writing by hand has these effects.

A slew of recent brain imaging research suggests handwriting's power stems from the relative complexity of the process and how it forces different brain systems to work together to reproduce the shapes of letters in our heads onto the page.

Your brain on handwriting

Both handwriting and typing involve moving our hands and fingers to create words on a page. But handwriting, it turns out, requires a lot more fine-tuned coordination between the motor and visual systems. This seems to more deeply engage the brain in ways that support learning.

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"Handwriting is probably among the most complex motor skills that the brain is capable of," says Marieke Longcamp , a cognitive neuroscientist at Aix-Marseille Université.

Gripping a pen nimbly enough to write is a complicated task, as it requires your brain to continuously monitor the pressure that each finger exerts on the pen. Then, your motor system has to delicately modify that pressure to re-create each letter of the words in your head on the page.

"Your fingers have to each do something different to produce a recognizable letter," says Sophia Vinci-Booher , an educational neuroscientist at Vanderbilt University. Adding to the complexity, your visual system must continuously process that letter as it's formed. With each stroke, your brain compares the unfolding script with mental models of the letters and words, making adjustments to fingers in real time to create the letters' shapes, says Vinci-Booher.

That's not true for typing.

To type "tap" your fingers don't have to trace out the form of the letters — they just make three relatively simple and uniform movements. In comparison, it takes a lot more brainpower, as well as cross-talk between brain areas, to write than type.

Recent brain imaging studies bolster this idea. A study published in January found that when students write by hand, brain areas involved in motor and visual information processing " sync up " with areas crucial to memory formation, firing at frequencies associated with learning.

"We don't see that [synchronized activity] in typewriting at all," says Audrey van der Meer , a psychologist and study co-author at the Norwegian University of Science and Technology. She suggests that writing by hand is a neurobiologically richer process and that this richness may confer some cognitive benefits.

Other experts agree. "There seems to be something fundamental about engaging your body to produce these shapes," says Robert Wiley , a cognitive psychologist at the University of North Carolina, Greensboro. "It lets you make associations between your body and what you're seeing and hearing," he says, which might give the mind more footholds for accessing a given concept or idea.

Those extra footholds are especially important for learning in kids, but they may give adults a leg up too. Wiley and others worry that ditching handwriting for typing could have serious consequences for how we all learn and think.

What might be lost as handwriting wanes

The clearest consequence of screens and keyboards replacing pen and paper might be on kids' ability to learn the building blocks of literacy — letters.

"Letter recognition in early childhood is actually one of the best predictors of later reading and math attainment," says Vinci-Booher. Her work suggests the process of learning to write letters by hand is crucial for learning to read them.

"When kids write letters, they're just messy," she says. As kids practice writing "A," each iteration is different, and that variability helps solidify their conceptual understanding of the letter.

Research suggests kids learn to recognize letters better when seeing variable handwritten examples, compared with uniform typed examples.

This helps develop areas of the brain used during reading in older children and adults, Vinci-Booher found.

"This could be one of the ways that early experiences actually translate to long-term life outcomes," she says. "These visually demanding, fine motor actions bake in neural communication patterns that are really important for learning later on."

Ditching handwriting instruction could mean that those skills don't get developed as well, which could impair kids' ability to learn down the road.

"If young children are not receiving any handwriting training, which is very good brain stimulation, then their brains simply won't reach their full potential," says van der Meer. "It's scary to think of the potential consequences."

Many states are trying to avoid these risks by mandating cursive instruction. This year, California started requiring elementary school students to learn cursive , and similar bills are moving through state legislatures in several states, including Indiana, Kentucky, South Carolina and Wisconsin. (So far, evidence suggests that it's the writing by hand that matters, not whether it's print or cursive.)

Slowing down and processing information

For adults, one of the main benefits of writing by hand is that it simply forces us to slow down.

During a meeting or lecture, it's possible to type what you're hearing verbatim. But often, "you're not actually processing that information — you're just typing in the blind," says van der Meer. "If you take notes by hand, you can't write everything down," she says.

The relative slowness of the medium forces you to process the information, writing key words or phrases and using drawing or arrows to work through ideas, she says. "You make the information your own," she says, which helps it stick in the brain.

Such connections and integration are still possible when typing, but they need to be made more intentionally. And sometimes, efficiency wins out. "When you're writing a long essay, it's obviously much more practical to use a keyboard," says van der Meer.

Still, given our long history of using our hands to mark meaning in the world, some scientists worry about the more diffuse consequences of offloading our thinking to computers.

"We're foisting a lot of our knowledge, extending our cognition, to other devices, so it's only natural that we've started using these other agents to do our writing for us," says Balasubramaniam.

It's possible that this might free up our minds to do other kinds of hard thinking, he says. Or we might be sacrificing a fundamental process that's crucial for the kinds of immersive cognitive experiences that enable us to learn and think at our full potential.

Balasubramaniam stresses, however, that we don't have to ditch digital tools to harness the power of handwriting. So far, research suggests that scribbling with a stylus on a screen activates the same brain pathways as etching ink on paper. It's the movement that counts, he says, not its final form.

Jonathan Lambert is a Washington, D.C.-based freelance journalist who covers science, health and policy.

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