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Definitions

In an experiment, the  independent variable  is the variable that is varied or manipulated by the researcher.

The  dependent variable  is the response that is measured.

For example:

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How to recognize nurs study methodology: independent | dependent variables.

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• Independent | Dependent Variables

Independent v Dependent Variables

Variables are any characteristics in the study that can take on different values. The main difference between independent and dependent variables is cause and effect. The independent variable is not expected to be impacted by the study (it's independent), but to cause the difference in the dependent variable. The dependent variable is the effect. The dependent variable expected to change because of the independent variable (it depends on the other factors involved). 

Independent Variables - What to look for

Is this a variable that the researchers deliberately introduced or that would have occurred regardless of the study?

The independent variable is the cause, not the effect. So if researchers introduce something in the experiment, like an intervention, that's the independent variable. For observational studies, the independent variable is what was already present in the patients before the outcome that's being measured. 

An observational study wants to know if patients who worked high stress jobs had more strokes. Having a high stress job is the independent variable. It's not really the variable that's being measured. It's the variable that may or may not cause strokes.

An experimental study wants to know if training soccer players on knee stability exercises reduces the number of injuries in a season. The knee stability training is the independent variable. Here, the researchers deliberately introduced training on knee stability exercises. It's not what they want to measure; they want to measure injuries. But this variable that they've introduced is what may or may not cause a reduction in injuries.

Dependent Variables - What to look for

Is this the variable that is being studied/measured?

The easiest way to know what is the dependent variable is to look at what the study is trying to measure. That's the dependent variable, it's what the researchers expect will be impacted by other factors in the study, it's the factor that they're wanting to measure. 

If this is an experimental study, is this the variable that would be impacted by the intervention?

The dependent variable  depends  on the other variables. It is the thing that will be affected by the other variables in the study. 

An observational study wants to know if patients who worked high stress jobs had more strokes. Having or not having a stroke is the dependent variable. 

An experimental study wants to know if training soccer players on knee stability exercises reduces the number of injuries in a season. The number of injuries in the season is the dependent variable. 

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• Volume 2, Issue 4
• The fundamentals of quantitative measurement
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• Donna Ciliska , RN, PhD * ,
• Nicky Cullum , RN, PhD 2 ,
• Alba Dicenso , RN, PhD *
• * School of Nursing, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
• 2 Centre for Evidence Based Nursing, Department of Health Studies, University of York, York, UK

https://doi.org/10.1136/ebn.2.4.100

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The main purpose of the EBN Notebook is to equip readers with the necessary skills to critically appraise primary research studies and to provide a more detailed description of some of the methodological issues that arise in the papers we abstract. In the July 1999 issue of Evidence-Based Nursing, the EBN Notebook explored the concept of sampling. 1 In this issue we will provide a basic introduction to quantitative measurement of health outcomes, which may be assessed in studies of treatment, causation, prognosis, diagnosis, and in economic evaluations. Examples of health related outcomes are blood pressure, quality of life, patient satisfaction, and costs.

Health can be measured in many different ways; the various aspects of health that can be measured are referred to as variables . 2 For example, in the treatment study by Dunn et al in this issue of Evidence-Based Nursing (p 117), the interventions (known as the independent variables) were lifestyle and structured exercise programmes and the outcomes (known as the dependent variables) were physical activity and cardiorespiratory fitness. In a treatment study, the independent variables are those that are under the control of the investigator, and the dependent variables are the outcomes that may be influenced by the independent variable. In a causation study, the investigator relies on natural variation between both variables and looks for a relation between the 2 variables. For example, when determining whether smoking causes lung cancer, smoking is the independent variable and lung cancer is the dependent variable. In the abstracts included in Evidence-Based Nursing , the independent variables are identified under the “intervention” section for treatment studies and under the “assessment of risk factors” section for causation studies. The dependent variables are identified under the “main outcome measures” section.

Types of variables

Variables can be classified as nominal, ordinal, interval, or ratio variables. Nominal (categorical) variables are simply names of categories. Some nominal variables (referred to as dichotomous variables) have only 2 possible values, such as sex (men or women), survival (dead or alive), or whether a specific feature is present or absent (eg, diabetes or no diabetes); others may have several possible values, such as race (white, black, Hispanic, and others). The actual number of categories can be determined by the researcher; for example, race can be defined as 2 options (black or non-black) or by several possible options. No hierarchy is presumed with nominal data—that is, being alive is not twice as good as being dead (although most patients would argue with us about that one). In contrast, ordinal variables are sets of “ordered” categories. 2 For example, patients are often asked to rate the severity of their pain on a scale of 0–10, where 0 is no pain and 10 is unbearable, excruciating pain. Although we can safely say that a pain rating of 8 is worse than a pain rating of 5, we do not really know how much these 2 ratings differ because we do not know the size of the intervals between each rating. 2 Ordinal scales have also been used to grade pressure sore severity and to classify the staging of various cancers (eg, stage I, II, or III). Interval variables consist of an ordered set of categories, with the additional requirement that the categories form a series of intervals that are all exactly the same size. Thus, the difference between a temperature of 37°C and 38°C is 1 degree, and between 38°C and 39°C is 1 degree, and so on. However, an interval scale does not have an absolute zero point that indicates complete absence of the variable being measured. Because there is no absolute zero point on an interval scale, ratios of values are not meaningful—that is, 2 values cannot be compared by claiming that one is “twice as large” as another. A ratio variable has all the features of an interval variable but adds an absolute zero point, which indicates none (complete absence) of the variable being measured. The advantage of an absolute zero is that ratios of numbers on the scale reflect ratios of magnitude for the variable being measured. 3 To illustrate, 100°C is not twice as hot as 50°C (interval data) but 100 cm is twice as long as 50 cm, and a pulse of 80 beats per minute is twice a pulse rate of 40 beats per minute (ratio data).

Issues in measurement

It is important to remember that most measurements in healthcare research encapsulate several things: the “real” or true value of the variable that is being measured; the variability of the measure; the accuracy of the instrument with which we are measuring; and perhaps the position of the patient or the skill and expectations of the person doing the measurement. Some of these elements are within the control of the measurer (eg, ensuring that a scale is at 0 before we weigh someone), whereas other elements are not (eg, a patient's blood pressure varies by time of day; therefore researchers try to assess blood pressure at the same time each day).

Some measures are more objective than others and are less likely to be influenced by human error or bias. Examples of objective measures include all cause mortality (ie, whether one is “dead” or “alive”) and serum cholesterol concentrations. In contrast, subjective measures may be influenced by the perception of the individual doing the measurement (eg, patient self reported pain ratings). Most paper and pencil type questionnaires are subjective measures. The Beck Depression Inventory for Primary Care described in the diagnosis study by Steer et al in this issue (p 126) is an example of a subjective paper and pencil questionnaire.

Frequency counts, such as incidence or prevalence, are often used when we want to know the extent of a disease or condition in a population. Others may be more interested in the beneficial and harmful effects of an intervention, such as differences in the rates of sexually transmitted diseases after a behavioural intervention provided to minority women (see the treatment study by Shain et al p 121).

What measurement issues should I look for when reading an article?

Are the measures reliable and valid.

These are 2 critically important properties of measurement. Reliability refers to the degree to which a measure gives the same result twice (or more) under similar circumstances, and may relate to the measure being used or the people using it. For example, if a patient's blood pressure is measured every 4 minutes on the same arm, by the same nurse, and the patient is not subject to any intervention such as activity or medication, you would expect to get similar sphygmomanometer readings. The extent to which repeated readings are similar is called reliability. Assessment of the similarity of repeated readings taken by the same nurse provides a measure of intra-rater or within-rater reliability . You would also hope that 2 different nurses measuring the same patient's blood pressure under the same circumstances would get similar readings. The extent to which the readings from 2 different nurses are similar is known as inter-rater or between-rater reliability .

Validity is the ability of a measurement tool to accurately measure what it is intended to measure. There are many different types of validity, but one of the most important is criterion related validity , which requires comparison of a given measure with a gold standard , or the best existing measure of the variable. 4 In the study by Steer et al in this issue (p 126), the results obtained from the Beck Depression Inventory for Primary Care were compared with the results of a standardised interview based on DSM-IV criteria and conducted by a physician. The interview results were considered to be the gold standard. Other examples of gold standards are direct central venous pressure readings for sphygmomanometer measures of blood pressure and serum hormone concentrations for the results of a urine test for pregnancy.

IS THE MEASURE SUBJECT TO BIAS?

There are several potential sources of bias. It is not important to remember what they are called, but you should be able to recognise sources of bias in a study. One way that bias can occur in a study is when the healthcare providers, patients, and data collectors participating in an intervention study are not masked or blinded to the treatment allocation. In an ideal world, studies would be “triple blinded”—that is, the healthcare provider delivering the intervention, the patient, and the research staff measuring the outcomes would not know which treatment the patient was receiving. Although triple blinding is possible in randomised trials evaluating new drugs, it is far more difficult to achieve in evaluations of most nursing interventions. Often, neither the nurses delivering the intervention nor the patients receiving the intervention can be masked (eg, nurses know that they are providing a patient education intervention and patients know that they are receiving it). In such studies, it is often possible, however, to mask the person measuring the outcome. By ensuring that the person measuring the outcome is masked to a patient's group allocation, researchers try to minimise the bias that could be introduced by unconscious adjustments assessors might make if they were aware of a patient's group allocation. For example, in the study by Dunn et al (p 117), which compared 2 interventions to increase physical activity, the people who assessed blood pressure, pulse rate, and body fat did not know which intervention participants had received. If they had known, this might have influenced their perceptions when they were doing the measurements, particularly if they had a clear opinion about which intervention was most effective. Similarly, participants reporting their own level of activity might alter their reporting of actual behaviour depending on whether they enjoyed or if they wished they had been allocated to a different group. Beginning with this issue of Evidence-Based Nursing , we will specify in the description of the design, whether the study was unblinded, single, or double blinded and who was blinded.

Another common type of bias is social desirability bias , in which people's responses to questions may reflect their desire to under report their socially unfavourable habits, such as the number of cigarettes smoked, illicit drug use, or unsafe sexual practices. Conversely, people may overestimate what they perceive to be socially desirable practices, such as exercise participation or daily intake of fruits and vegetables.

A third type of bias is recall bias , which acknowledges that human memory is fallible. Reports of seat belt use 5 years ago or fibre intake last month, for example, are not as accurate as concurrent or prospective measurements, where seat belt use or diet diaries are recorded on a daily basis.

Investigators often use strategies to try to overcome these potential biases. These strategies include having outcome assessors who do not know the purpose of a study nor which intervention the patient received; having study participants complete self report questionnaires in a private area, ensuring that their responses to sensitive or potentially embarrassing questions are confidential; and collecting information on a prospective basis (ie, as it happens), rather than on a retrospective basis (historically).

In summary, readers of research reports need to consider the type of measures that are used, the reliability and validity of the measures, and methods used to minimise bias in the measurement of outcomes. These are some of the elements considered when selecting studies for abstraction in Evidence-Based Nursing . In the next issue of the journal, the EBN Notebook will address how study outcomes are analysed and the appropriateness of the statistical test for the type of data collected.

• ↵ Thomson C. If you could just provide me with a sample: examining sampling in qualitative and quantitative research papers [editorial]. Evidence-Based Nursing 1999 Jul; 2 : 68 –70. OpenUrl FREE Full Text
• ↵ Norman GT, Streiner DL. PDQ statistics . Toronto: BC Decker, 1986.
• ↵ Gravetter FJ, Wallnau LB. Essentials of statistics for the behavioral sciences . California: Brooks/Cole, 1998.
• ↵ Anthony D. Understanding advanced statistics. A guide for nurses and health care researchers . Volume 4. Edinburgh: Churchill Livingstone, 1999.

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Nursing Experts: Translating the Evidence - Public Health Nursing

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Appraisal Concepts - Validity & Reliability

What is validity?

Internal validity is the extent to which the study demonstrated a cause-effect relationship between the independent and dependent variables.

External validity is the extent to which one may safely generalize from the sample studied to the defined target population and to other populations.

What is reliability?

Reliability is the extent to which the results of the study are replicable.  The research methodology should be described in detail so that the experiment could be repeated with similar results.

Scientific Experiment Terminology

Hypothesis - a statement that is believed to be true but has not yet been tested.

Independent variable - the component of an experiment that is controlled by the researcher (for example - a new therapy).

Dependent variable - the component of an experiment that changes, or not, as a result of the independent variable (for example - the existence of a disease). 

Bias - prejudice or the lack of neutrality.  A systematic deviation from the truth that affects the conclusions and occurs in the process or design of the research.

Confounding - a mixing of the effects within an experiment because the variables have not been sufficiently separated.  Possible confounding variables should be discussed in the report of the research.

See also Study Design Terminology from the Levels of Evidence tab in the EBM Guide .

Sample Questions for Evaluating a Study

• Has the study's aim been clearly stated?
• Does the sample accurately reflect the population?
• Has the sampling method and size been described and justified?
• Have exclusions been stated?
• Is the control group easily identified?
• Is the loss to follow-up detailed?
• Can the results be replicated?
• Are there confounding factors?
• Are the conclusions logical?
• Can the results be extrapolated to other populations?

Standards for the Reporting of Scientific/Medical Research:

• CONSORT Statement
• EQUATOR Network
• MOOSE Consensus Statement
• PRISMA Statement more... less... formerly called QUORUM
• SQUIRE Guidelines
• TREND Statement more... less... from the Centers for Disease Prevention and Control (CDC)

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Independent versus Dependent Variables

• Identify Independent and Dependent Variables
• Independent vs Dependent Variables Discusses the difference between independent variables and dependent variables, while exploring proper design of a controlled experiment. Near the end of the video are review questions to check your understanding.
• Video: INTERACTIVE: Part 1: Identify the Independent and Dependent Variables with the MythBusters!

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Definitions

Dependent Variable The variable that depends on other factors that are measured. These variables are expected to change as a result of an experimental manipulation of the independent variable or variables. It is the presumed effect.

Independent Variable The variable that is stable and unaffected by the other variables you are trying to measure. It refers to the condition of an experiment that is systematically manipulated by the investigator. It is the presumed cause.

Cramer, Duncan and Dennis Howitt. The SAGE Dictionary of Statistics . London: SAGE, 2004; Penslar, Robin Levin and Joan P. Porter. Institutional Review Board Guidebook: Introduction . Washington, DC: United States Department of Health and Human Services, 2010; "What are Dependent and Independent Variables?" Graphic Tutorial.

Identifying Dependent and Independent Variables

Don't feel bad if you are confused about what is the dependent variable and what is the independent variable in social and behavioral sciences research . However, it's important that you learn the difference because framing a study using these variables is a common approach to organizing the elements of a social sciences research study in order to discover relevant and meaningful results. Specifically, it is important for these two reasons:

• You need to understand and be able to evaluate their application in other people's research.
• You need to apply them correctly in your own research.

A variable in research simply refers to a person, place, thing, or phenomenon that you are trying to measure in some way. The best way to understand the difference between a dependent and independent variable is that the meaning of each is implied by what the words tell us about the variable you are using. You can do this with a simple exercise from the website, Graphic Tutorial. Take the sentence, "The [independent variable] causes a change in [dependent variable] and it is not possible that [dependent variable] could cause a change in [independent variable]." Insert the names of variables you are using in the sentence in the way that makes the most sense. This will help you identify each type of variable. If you're still not sure, consult with your professor before you begin to write.

Fan, Shihe. "Independent Variable." In Encyclopedia of Research Design. Neil J. Salkind, editor. (Thousand Oaks, CA: SAGE, 2010), pp. 592-594; "What are Dependent and Independent Variables?" Graphic Tutorial; Salkind, Neil J. "Dependent Variable." In Encyclopedia of Research Design , Neil J. Salkind, editor. (Thousand Oaks, CA: SAGE, 2010), pp. 348-349;

Structure and Writing Style

The process of examining a research problem in the social and behavioral sciences is often framed around methods of analysis that compare, contrast, correlate, average, or integrate relationships between or among variables . Techniques include associations, sampling, random selection, and blind selection. Designation of the dependent and independent variable involves unpacking the research problem in a way that identifies a general cause and effect and classifying these variables as either independent or dependent.

The variables should be outlined in the introduction of your paper and explained in more detail in the methods section . There are no rules about the structure and style for writing about independent or dependent variables but, as with any academic writing, clarity and being succinct is most important.

After you have described the research problem and its significance in relation to prior research, explain why you have chosen to examine the problem using a method of analysis that investigates the relationships between or among independent and dependent variables . State what it is about the research problem that lends itself to this type of analysis. For example, if you are investigating the relationship between corporate environmental sustainability efforts [the independent variable] and dependent variables associated with measuring employee satisfaction at work using a survey instrument, you would first identify each variable and then provide background information about the variables. What is meant by "environmental sustainability"? Are you looking at a particular company [e.g., General Motors] or are you investigating an industry [e.g., the meat packing industry]? Why is employee satisfaction in the workplace important? How does a company make their employees aware of sustainability efforts and why would a company even care that its employees know about these efforts?

Identify each variable for the reader and define each . In the introduction, this information can be presented in a paragraph or two when you describe how you are going to study the research problem. In the methods section, you build on the literature review of prior studies about the research problem to describe in detail background about each variable, breaking each down for measurement and analysis. For example, what activities do you examine that reflect a company's commitment to environmental sustainability? Levels of employee satisfaction can be measured by a survey that asks about things like volunteerism or a desire to stay at the company for a long time.

The structure and writing style of describing the variables and their application to analyzing the research problem should be stated and unpacked in such a way that the reader obtains a clear understanding of the relationships between the variables and why they are important. This is also important so that the study can be replicated in the future using the same variables but applied in a different way.

Fan, Shihe. "Independent Variable." In Encyclopedia of Research Design. Neil J. Salkind, editor. (Thousand Oaks, CA: SAGE, 2010), pp. 592-594; "What are Dependent and Independent Variables?" Graphic Tutorial; “Case Example for Independent and Dependent Variables.” ORI Curriculum Examples. U.S. Department of Health and Human Services, Office of Research Integrity; Salkind, Neil J. "Dependent Variable." In Encyclopedia of Research Design , Neil J. Salkind, editor. (Thousand Oaks, CA: SAGE, 2010), pp. 348-349; “Independent Variables and Dependent Variables.” Karl L. Wuensch, Department of Psychology, East Carolina University [posted email exchange]; “Variables.” Elements of Research. Dr. Camille Nebeker, San Diego State University.

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Intervention research: establishing fidelity of the independent variable in nursing clinical trials

Affiliation.

• 1 School of Nursing, University of Michigan, Ann Arbor 48109, USA. [email protected]
• PMID: 17179874
• DOI: 10.1097/00006199-200701000-00007

Background: Internal validity of a randomized clinical trial of a nursing intervention is dependent on intervention fidelity. Although several methods have been developed, evaluating audio or audiovisual tapes for prescribed and proscribed interventionist behaviors is considered the gold standard test of treatment fidelity. This approach requires development of a psychometrically sound instrument to meaningfully categorize and quantify interventionist behaviors.

Objective: To outline critical steps necessary to develop a treatment fidelity instrument.

Methods: A comprehensive literature review was conducted to determine procedures used by other researchers. The literature review produced five quantitative studies of treatment fidelity, all in the field of psychotherapy, and two replication studies. A synthesis of methodologies across studies combined with researchers' experiences resulted in identification of the steps necessary to develop a treatment fidelity measure.

Results: Seven sequential steps were identified as essential to the development of a valid and reliable measure of treatment fidelity. These steps include (a) identification of the essential elements of the experimental and control treatment modalities; (b) construction of scale items; (c) development of item scaling; (d) identification of the units for coding; (e) item testing and revision; (f) specification of rater qualifications and development of rater training program; and (g) development and completion of pilot testing to test psychometric properties. Development of the Possibilities Project Psychotherapy Coding Questionnaire is described as an illustration of the seven-step process.

Discussion: The results show the essential steps that are unique to the development of treatment fidelity measures and show the feasibility of using these steps to construct a psychometrically sound treatment-specific fidelity measure.

Publication types

• Research Support, N.I.H., Extramural
• Anorexia Nervosa / therapy
• Bulimia Nervosa / therapy
• Clinical Nursing Research / methods*
• Cognitive Behavioral Therapy
• Observer Variation
• Pilot Projects
• Psychometrics / methods*
• Randomized Controlled Trials as Topic / methods*
• Reproducibility of Results
• Research Design*

Grants and funding

• 1 R55 NR 05277-01/NR/NINR NIH HHS/United States
• R01 05277-01/PHS HHS/United States

Nursing 465: Independent Variable VS Dependent Variable

• EBP & Levels of Evidence
• Evidence-Based Research Sources
• Health Statistics
• Independent Variable VS Dependent Variable
• Types of Studies
• Cohort vs Case studies
• Types of Research within Qualitative and Quantitative
• Qualitative vs Quantitative
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• Sampling Methods and Statistics
• Review vs Systematic Review vs ETC...
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Definitions

In an experiment, the  independent variable  is the variable that is varied or manipulated by the researcher.

The  dependent variable  is the response that is measured.

For example:

• << Previous: Study Designs
• Next: Types of Studies >>
• Last Updated: Jan 31, 2024 10:48 AM
• URL: https://libguides.sdstate.edu/c.php?g=1177663

• Open access
• Published: 14 May 2024

Developing a survey to measure nursing students’ knowledge, attitudes and beliefs, influences, and willingness to be involved in Medical Assistance in Dying (MAiD): a mixed method modified e-Delphi study

• Jocelyn Schroeder 1 ,
• Barbara Pesut 1 , 2 ,
• Lise Olsen 2 ,
• Nelly D. Oelke 2 &
• Helen Sharp 2  

BMC Nursing volume  23 , Article number:  326 ( 2024 ) Cite this article

Metrics details

Medical Assistance in Dying (MAiD) was legalized in Canada in 2016. Canada’s legislation is the first to permit Nurse Practitioners (NP) to serve as independent MAiD assessors and providers. Registered Nurses’ (RN) also have important roles in MAiD that include MAiD care coordination; client and family teaching and support, MAiD procedural quality; healthcare provider and public education; and bereavement care for family. Nurses have a right under the law to conscientious objection to participating in MAiD. Therefore, it is essential to prepare nurses in their entry-level education for the practice implications and moral complexities inherent in this practice. Knowing what nursing students think about MAiD is a critical first step. Therefore, the purpose of this study was to develop a survey to measure nursing students’ knowledge, attitudes and beliefs, influences, and willingness to be involved in MAiD in the Canadian context.

The design was a mixed-method, modified e-Delphi method that entailed item generation from the literature, item refinement through a 2 round survey of an expert faculty panel, and item validation through a cognitive focus group interview with nursing students. The settings were a University located in an urban area and a College located in a rural area in Western Canada.

During phase 1, a 56-item survey was developed from existing literature that included demographic items and items designed to measure experience with death and dying (including MAiD), education and preparation, attitudes and beliefs, influences on those beliefs, and anticipated future involvement. During phase 2, an expert faculty panel reviewed, modified, and prioritized the items yielding 51 items. During phase 3, a sample of nursing students further evaluated and modified the language in the survey to aid readability and comprehension. The final survey consists of 45 items including 4 case studies.

Systematic evaluation of knowledge-to-date coupled with stakeholder perspectives supports robust survey design. This study yielded a survey to assess nursing students’ attitudes toward MAiD in a Canadian context.

The survey is appropriate for use in education and research to measure knowledge and attitudes about MAiD among nurse trainees and can be a helpful step in preparing nursing students for entry-level practice.

Peer Review reports

Medical Assistance in Dying (MAiD) is permitted under an amendment to Canada’s Criminal Code which was passed in 2016 [ 1 ]. MAiD is defined in the legislation as both self-administered and clinician-administered medication for the purpose of causing death. In the 2016 Bill C-14 legislation one of the eligibility criteria was that an applicant for MAiD must have a reasonably foreseeable natural death although this term was not defined. It was left to the clinical judgement of MAiD assessors and providers to determine the time frame that constitutes reasonably foreseeable [ 2 ]. However, in 2021 under Bill C-7, the eligibility criteria for MAiD were changed to allow individuals with irreversible medical conditions, declining health, and suffering, but whose natural death was not reasonably foreseeable, to receive MAiD [ 3 ]. This population of MAiD applicants are referred to as Track 2 MAiD (those whose natural death is foreseeable are referred to as Track 1). Track 2 applicants are subject to additional safeguards under the 2021 C-7 legislation.

Three additional proposed changes to the legislation have been extensively studied by Canadian Expert Panels (Council of Canadian Academics [CCA]) [ 4 , 5 , 6 ] First, under the legislation that defines Track 2, individuals with mental disease as their sole underlying medical condition may apply for MAiD, but implementation of this practice is embargoed until March 2027 [ 4 ]. Second, there is consideration of allowing MAiD to be implemented through advanced consent. This would make it possible for persons living with dementia to receive MAID after they have lost the capacity to consent to the procedure [ 5 ]. Third, there is consideration of extending MAiD to mature minors. A mature minor is defined as “a person under the age of majority…and who has the capacity to understand and appreciate the nature and consequences of a decision” ([ 6 ] p. 5). In summary, since the legalization of MAiD in 2016 the eligibility criteria and safeguards have evolved significantly with consequent implications for nurses and nursing care. Further, the number of Canadians who access MAiD shows steady increases since 2016 [ 7 ] and it is expected that these increases will continue in the foreseeable future.

Nurses have been integral to MAiD care in the Canadian context. While other countries such as Belgium and the Netherlands also permit euthanasia, Canada is the first country to allow Nurse Practitioners (Registered Nurses with additional preparation typically achieved at the graduate level) to act independently as assessors and providers of MAiD [ 1 ]. Although the role of Registered Nurses (RNs) in MAiD is not defined in federal legislation, it has been addressed at the provincial/territorial-level with variability in scope of practice by region [ 8 , 9 ]. For example, there are differences with respect to the obligation of the nurse to provide information to patients about MAiD, and to the degree that nurses are expected to ensure that patient eligibility criteria and safeguards are met prior to their participation [ 10 ]. Studies conducted in the Canadian context indicate that RNs perform essential roles in MAiD care coordination; client and family teaching and support; MAiD procedural quality; healthcare provider and public education; and bereavement care for family [ 9 , 11 ]. Nurse practitioners and RNs are integral to a robust MAiD care system in Canada and hence need to be well-prepared for their role [ 12 ].

Previous studies have found that end of life care, and MAiD specifically, raise complex moral and ethical issues for nurses [ 13 , 14 , 15 , 16 ]. The knowledge, attitudes, and beliefs of nurses are important across practice settings because nurses have consistent, ongoing, and direct contact with patients who experience chronic or life-limiting health conditions. Canadian studies exploring nurses’ moral and ethical decision-making in relation to MAiD reveal that although some nurses are clear in their support for, or opposition to, MAiD, others are unclear on what they believe to be good and right [ 14 ]. Empirical findings suggest that nurses go through a period of moral sense-making that is often informed by their family, peers, and initial experiences with MAID [ 17 , 18 ]. Canadian legislation and policy specifies that nurses are not required to participate in MAiD and may recuse themselves as conscientious objectors with appropriate steps to ensure ongoing and safe care of patients [ 1 , 19 ]. However, with so many nurses having to reflect on and make sense of their moral position, it is essential that they are given adequate time and preparation to make an informed and thoughtful decision before they participate in a MAID death [ 20 , 21 ].

It is well established that nursing students receive inconsistent exposure to end of life care issues [ 22 ] and little or no training related to MAiD [ 23 ]. Without such education and reflection time in pre-entry nursing preparation, nurses are at significant risk for moral harm. An important first step in providing this preparation is to be able to assess the knowledge, values, and beliefs of nursing students regarding MAID and end of life care. As demand for MAiD increases along with the complexities of MAiD, it is critical to understand the knowledge, attitudes, and likelihood of engagement with MAiD among nursing students as a baseline upon which to build curriculum and as a means to track these variables over time.

Aim, design, and setting

The aim of this study was to develop a survey to measure nursing students’ knowledge, attitudes and beliefs, influences, and willingness to be involved in MAiD in the Canadian context. We sought to explore both their willingness to be involved in the registered nursing role and in the nurse practitioner role should they chose to prepare themselves to that level of education. The design was a mixed-method, modified e-Delphi method that entailed item generation, item refinement through an expert faculty panel [ 24 , 25 , 26 ], and initial item validation through a cognitive focus group interview with nursing students [ 27 ]. The settings were a University located in an urban area and a College located in a rural area in Western Canada.

Participants

A panel of 10 faculty from the two nursing education programs were recruited for Phase 2 of the e-Delphi. To be included, faculty were required to have a minimum of three years of experience in nurse education, be employed as nursing faculty, and self-identify as having experience with MAiD. A convenience sample of 5 fourth-year nursing students were recruited to participate in Phase 3. Students had to be in good standing in the nursing program and be willing to share their experiences of the survey in an online group interview format.

The modified e-Delphi was conducted in 3 phases: Phase 1 entailed item generation through literature and existing survey review. Phase 2 entailed item refinement through a faculty expert panel review with focus on content validity, prioritization, and revision of item wording [ 25 ]. Phase 3 entailed an assessment of face validity through focus group-based cognitive interview with nursing students.

Phase I. Item generation through literature review

The goal of phase 1 was to develop a bank of survey items that would represent the variables of interest and which could be provided to expert faculty in Phase 2. Initial survey items were generated through a literature review of similar surveys designed to assess knowledge and attitudes toward MAiD/euthanasia in healthcare providers; Canadian empirical studies on nurses’ roles and/or experiences with MAiD; and legislative and expert panel documents that outlined proposed changes to the legislative eligibility criteria and safeguards. The literature review was conducted in three online databases: CINAHL, PsycINFO, and Medline. Key words for the search included nurses , nursing students , medical students , NPs, MAiD , euthanasia , assisted death , and end-of-life care . Only articles written in English were reviewed. The legalization and legislation of MAiD is new in many countries; therefore, studies that were greater than twenty years old were excluded, no further exclusion criteria set for country.

Items from surveys designed to measure similar variables in other health care providers and geographic contexts were placed in a table and similar items were collated and revised into a single item. Then key variables were identified from the empirical literature on nurses and MAiD in Canada and checked against the items derived from the surveys to ensure that each of the key variables were represented. For example, conscientious objection has figured prominently in the Canadian literature, but there were few items that assessed knowledge of conscientious objection in other surveys and so items were added [ 15 , 21 , 28 , 29 ]. Finally, four case studies were added to the survey to address the anticipated changes to the Canadian legislation. The case studies were based upon the inclusion of mature minors, advanced consent, and mental disorder as the sole underlying medical condition. The intention was to assess nurses’ beliefs and comfort with these potential legislative changes.

Phase 2. Item refinement through expert panel review

The goal of phase 2 was to refine and prioritize the proposed survey items identified in phase 1 using a modified e-Delphi approach to achieve consensus among an expert panel [ 26 ]. Items from phase 1 were presented to an expert faculty panel using a Qualtrics (Provo, UT) online survey. Panel members were asked to review each item to determine if it should be: included, excluded or adapted for the survey. When adapted was selected faculty experts were asked to provide rationale and suggestions for adaptation through the use of an open text box. Items that reached a level of 75% consensus for either inclusion or adaptation were retained [ 25 , 26 ]. New items were categorized and added, and a revised survey was presented to the panel of experts in round 2. Panel members were again asked to review items, including new items, to determine if it should be: included, excluded, or adapted for the survey. Round 2 of the modified e-Delphi approach also included an item prioritization activity, where participants were then asked to rate the importance of each item, based on a 5-point Likert scale (low to high importance), which De Vaus [ 30 ] states is helpful for increasing the reliability of responses. Items that reached a 75% consensus on inclusion were then considered in relation to the importance it was given by the expert panel. Quantitative data were managed using SPSS (IBM Corp).

Phase 3. Face validity through cognitive interviews with nursing students

The goal of phase 3 was to obtain initial face validity of the proposed survey using a sample of nursing student informants. More specifically, student participants were asked to discuss how items were interpreted, to identify confusing wording or other problematic construction of items, and to provide feedback about the survey as a whole including readability and organization [ 31 , 32 , 33 ]. The focus group was held online and audio recorded. A semi-structured interview guide was developed for this study that focused on clarity, meaning, order and wording of questions; emotions evoked by the questions; and overall survey cohesion and length was used to obtain data (see Supplementary Material 2  for the interview guide). A prompt to “think aloud” was used to limit interviewer-imposed bias and encourage participants to describe their thoughts and response to a given item as they reviewed survey items [ 27 ]. Where needed, verbal probes such as “could you expand on that” were used to encourage participants to expand on their responses [ 27 ]. Student participants’ feedback was collated verbatim and presented to the research team where potential survey modifications were negotiated and finalized among team members. Conventional content analysis [ 34 ] of focus group data was conducted to identify key themes that emerged through discussion with students. Themes were derived from the data by grouping common responses and then using those common responses to modify survey items.

Ten nursing faculty participated in the expert panel. Eight of the 10 faculty self-identified as female. No faculty panel members reported conscientious objector status and ninety percent reported general agreement with MAiD with one respondent who indicated their view as “unsure.” Six of the 10 faculty experts had 16 years of experience or more working as a nurse educator.

Five nursing students participated in the cognitive interview focus group. The duration of the focus group was 2.5 h. All participants identified that they were born in Canada, self-identified as female (one preferred not to say) and reported having received some instruction about MAiD as part of their nursing curriculum. See Tables  1 and 2 for the demographic descriptors of the study sample. Study results will be reported in accordance with the study phases. See Fig.  1 for an overview of the results from each phase.

Fig. 1  Overview of survey development findings

Phase 1: survey item generation

Review of the literature identified that no existing survey was available for use with nursing students in the Canadian context. However, an analysis of themes across qualitative and quantitative studies of physicians, medical students, nurses, and nursing students provided sufficient data to develop a preliminary set of items suitable for adaptation to a population of nursing students.

Four major themes and factors that influence knowledge, attitudes, and beliefs about MAiD were evident from the literature: (i) endogenous or individual factors such as age, gender, personally held values, religion, religiosity, and/or spirituality [ 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 ], (ii) experience with death and dying in personal and/or professional life [ 35 , 40 , 41 , 43 , 44 , 45 ], (iii) training including curricular instruction about clinical role, scope of practice, or the law [ 23 , 36 , 39 ], and (iv) exogenous or social factors such as the influence of key leaders, colleagues, friends and/or family, professional and licensure organizations, support within professional settings, and/or engagement in MAiD in an interdisciplinary team context [ 9 , 35 , 46 ].

Studies of nursing students also suggest overlap across these categories. For example, value for patient autonomy [ 23 ] and the moral complexity of decision-making [ 37 ] are important factors that contribute to attitudes about MAiD and may stem from a blend of personally held values coupled with curricular content, professional training and norms, and clinical exposure. For example, students report that participation in end of life care allows for personal growth, shifts in perception, and opportunities to build therapeutic relationships with their clients [ 44 , 47 , 48 ].

Preliminary items generated from the literature resulted in 56 questions from 11 published sources (See Table  3 ). These items were constructed across four main categories: (i) socio-demographic questions; (ii) end of life care questions; (iii) knowledge about MAiD; or (iv) comfort and willingness to participate in MAiD. Knowledge questions were refined to reflect current MAiD legislation, policies, and regulatory frameworks. Falconer [ 39 ] and Freeman [ 45 ] studies were foundational sources for item selection. Additionally, four case studies were written to reflect the most recent anticipated changes to MAiD legislation and all used the same open-ended core questions to address respondents’ perspectives about the patient’s right to make the decision, comfort in assisting a physician or NP to administer MAiD in that scenario, and hypothesized comfort about serving as a primary provider if qualified as an NP in future. Response options for the survey were also constructed during this stage and included: open text, categorical, yes/no , and Likert scales.

Phase 2: faculty expert panel review

Of the 56 items presented to the faculty panel, 54 questions reached 75% consensus. However, based upon the qualitative responses 9 items were removed largely because they were felt to be repetitive. Items that generated the most controversy were related to measuring religion and spirituality in the Canadian context, defining end of life care when there is no agreed upon time frames (e.g., last days, months, or years), and predicting willingness to be involved in a future events – thus predicting their future selves. Phase 2, round 1 resulted in an initial set of 47 items which were then presented back to the faculty panel in round 2.

Of the 47 initial questions presented to the panel in round 2, 45 reached a level of consensus of 75% or greater, and 34 of these questions reached a level of 100% consensus [ 27 ] of which all participants chose to include without any adaptations) For each question, level of importance was determined based on a 5-point Likert scale (1 = very unimportant, 2 = somewhat unimportant, 3 = neutral, 4 = somewhat important, and 5 = very important). Figure  2 provides an overview of the level of importance assigned to each item.

Ranking level of importance for survey items

After round 2, a careful analysis of participant comments and level of importance was completed by the research team. While the main method of survey item development came from participants’ response to the first round of Delphi consensus ratings, level of importance was used to assist in the decision of whether to keep or modify questions that created controversy, or that rated lower in the include/exclude/adapt portion of the Delphi. Survey items that rated low in level of importance included questions about future roles, sex and gender, and religion/spirituality. After deliberation by the research committee, these questions were retained in the survey based upon the importance of these variables in the scientific literature.

Of the 47 questions remaining from Phase 2, round 2, four were revised. In addition, the two questions that did not meet the 75% cut off level for consensus were reviewed by the research team. The first question reviewed was What is your comfort level with providing a MAiD death in the future if you were a qualified NP ? Based on a review of participant comments, it was decided to retain this question for the cognitive interviews with students in the final phase of testing. The second question asked about impacts on respondents’ views of MAiD and was changed from one item with 4 subcategories into 4 separate items, resulting in a final total of 51 items for phase 3. The revised survey was then brought forward to the cognitive interviews with student participants in Phase 3. (see Supplementary Material 1 for a complete description of item modification during round 2).

Phase 3. Outcomes of cognitive interview focus group

Of the 51 items reviewed by student participants, 29 were identified as clear with little or no discussion. Participant comments for the remaining 22 questions were noted and verified against the audio recording. Following content analysis of the comments, four key themes emerged through the student discussion: unclear or ambiguous wording; difficult to answer questions; need for additional response options; and emotional response evoked by questions. An example of unclear or ambiguous wording was a request for clarity in the use of the word “sufficient” in the context of assessing an item that read “My nursing education has provided sufficient content about the nursing role in MAiD.” “Sufficient” was viewed as subjective and “laden with…complexity that distracted me from the question.” The group recommended rewording the item to read “My nursing education has provided enough content for me to care for a patient considering or requesting MAiD.”

An example of having difficulty answering questions related to limited knowledge related to terms used in the legislation such as such as safeguards , mature minor , eligibility criteria , and conscientious objection. Students were unclear about what these words meant relative to the legislation and indicated that this lack of clarity would hamper appropriate responses to the survey. To ensure that respondents are able to answer relevant questions, student participants recommended that the final survey include explanation of key terms such as mature minor and conscientious objection and an overview of current legislation.

Response options were also a point of discussion. Participants noted a lack of distinction between response options of unsure and unable to say . Additionally, scaling of attitudes was noted as important since perspectives about MAiD are dynamic and not dichotomous “agree or disagree” responses. Although the faculty expert panel recommended the integration of the demographic variables of religious and/or spiritual remain as a single item, the student group stated a preference to have religion and spirituality appear as separate items. The student focus group also took issue with separate items for the variables of sex and gender, specifically that non-binary respondents might feel othered or “outed” particularly when asked to identify their sex. These variables had been created based upon best practices in health research but students did not feel they were appropriate in this context [ 49 ]. Finally, students agreed with the faculty expert panel in terms of the complexity of projecting their future involvement as a Nurse Practitioner. One participant stated: “I certainly had to like, whoa, whoa, whoa. Now let me finish this degree first, please.” Another stated, “I'm still imagining myself, my future career as an RN.”

Finally, student participants acknowledged the array of emotions that some of the items produced for them. For example, one student described positive feelings when interacting with the survey. “Brought me a little bit of feeling of joy. Like it reminded me that this is the last piece of independence that people grab on to.” Another participant, described the freedom that the idea of an advance request gave her. “The advance request gives the most comfort for me, just with early onset Alzheimer’s and knowing what it can do.” But other participants described less positive feelings. For example, the mature minor case study yielded a comment: “This whole scenario just made my heart hurt with the idea of a child requesting that.”

Based on the data gathered from the cognitive interview focus group of nursing students, revisions were made to 11 closed-ended questions (see Table  4 ) and 3 items were excluded. In the four case studies, the open-ended question related to a respondents’ hypothesized actions in a future role as NP were removed. The final survey consists of 45 items including 4 case studies (see Supplementary Material 3 ).

The aim of this study was to develop and validate a survey that can be used to track the growth of knowledge about MAiD among nursing students over time, inform training programs about curricular needs, and evaluate attitudes and willingness to participate in MAiD at time-points during training or across nursing programs over time.

The faculty expert panel and student participants in the cognitive interview focus group identified a need to establish core knowledge of the terminology and legislative rules related to MAiD. For example, within the cognitive interview group of student participants, several acknowledged lack of clear understanding of specific terms such as “conscientious objector” and “safeguards.” Participants acknowledged discomfort with the uncertainty of not knowing and their inclination to look up these terms to assist with answering the questions. This survey can be administered to nursing or pre-nursing students at any phase of their training within a program or across training programs. However, in doing so it is important to acknowledge that their baseline knowledge of MAiD will vary. A response option of “not sure” is important and provides a means for respondents to convey uncertainty. If this survey is used to inform curricular needs, respondents should be given explicit instructions not to conduct online searches to inform their responses, but rather to provide an honest appraisal of their current knowledge and these instructions are included in the survey (see Supplementary Material 3 ).

Some provincial regulatory bodies have established core competencies for entry-level nurses that include MAiD. For example, the BC College of Nurses and Midwives (BCCNM) requires “knowledge about ethical, legal, and regulatory implications of medical assistance in dying (MAiD) when providing nursing care.” (10 p. 6) However, across Canada curricular content and coverage related to end of life care and MAiD is variable [ 23 ]. Given the dynamic nature of the legislation that includes portions of the law that are embargoed until 2024, it is important to ensure that respondents are guided by current and accurate information. As the law changes, nursing curricula, and public attitudes continue to evolve, inclusion of core knowledge and content is essential and relevant for investigators to be able to interpret the portions of the survey focused on attitudes and beliefs about MAiD. Content knowledge portions of the survey may need to be modified over time as legislation and training change and to meet the specific purposes of the investigator.

Given the sensitive nature of the topic, it is strongly recommended that surveys be conducted anonymously and that students be provided with an opportunity to discuss their responses to the survey. A majority of feedback from both the expert panel of faculty and from student participants related to the wording and inclusion of demographic variables, in particular religion, religiosity, gender identity, and sex assigned at birth. These and other demographic variables have the potential to be highly identifying in small samples. In any instance in which the survey could be expected to yield demographic group sizes less than 5, users should eliminate the demographic variables from the survey. For example, the profession of nursing is highly dominated by females with over 90% of nurses who identify as female [ 50 ]. Thus, a survey within a single class of students or even across classes in a single institution is likely to yield a small number of male respondents and/or respondents who report a difference between sex assigned at birth and gender identity. When variables that serve to identify respondents are included, respondents are less likely to complete or submit the survey, to obscure their responses so as not to be identifiable, or to be influenced by social desirability bias in their responses rather than to convey their attitudes accurately [ 51 ]. Further, small samples do not allow for conclusive analyses or interpretation of apparent group differences. Although these variables are often included in surveys, such demographics should be included only when anonymity can be sustained. In small and/or known samples, highly identifying variables should be omitted.

There are several limitations associated with the development of this survey. The expert panel was comprised of faculty who teach nursing students and are knowledgeable about MAiD and curricular content, however none identified as a conscientious objector to MAiD. Ideally, our expert panel would have included one or more conscientious objectors to MAiD to provide a broader perspective. Review by practitioners who participate in MAiD, those who are neutral or undecided, and practitioners who are conscientious objectors would ensure broad applicability of the survey. This study included one student cognitive interview focus group with 5 self-selected participants. All student participants had held discussions about end of life care with at least one patient, 4 of 5 participants had worked with a patient who requested MAiD, and one had been present for a MAiD death. It is not clear that these participants are representative of nursing students demographically or by experience with end of life care. It is possible that the students who elected to participate hold perspectives and reflections on patient care and MAiD that differ from students with little or no exposure to end of life care and/or MAiD. However, previous studies find that most nursing students have been involved with end of life care including meaningful discussions about patients’ preferences and care needs during their education [ 40 , 44 , 47 , 48 , 52 ]. Data collection with additional student focus groups with students early in their training and drawn from other training contexts would contribute to further validation of survey items.

Future studies should incorporate pilot testing with small sample of nursing students followed by a larger cross-program sample to allow evaluation of the psychometric properties of specific items and further refinement of the survey tool. Consistent with literature about the importance of leadership in the context of MAiD [ 12 , 53 , 54 ], a study of faculty knowledge, beliefs, and attitudes toward MAiD would provide context for understanding student perspectives within and across programs. Additional research is also needed to understand the timing and content coverage of MAiD across Canadian nurse training programs’ curricula.

The implementation of MAiD is complex and requires understanding of the perspectives of multiple stakeholders. Within the field of nursing this includes clinical providers, educators, and students who will deliver clinical care. A survey to assess nursing students’ attitudes toward and willingness to participate in MAiD in the Canadian context is timely, due to the legislation enacted in 2016 and subsequent modifications to the law in 2021 with portions of the law to be enacted in 2027. Further development of this survey could be undertaken to allow for use in settings with practicing nurses or to allow longitudinal follow up with students as they enter practice. As the Canadian landscape changes, ongoing assessment of the perspectives and needs of health professionals and students in the health professions is needed to inform policy makers, leaders in practice, curricular needs, and to monitor changes in attitudes and practice patterns over time.

Availability of data and materials

The datasets used and/or analysed during the current study are not publicly available due to small sample sizes, but are available from the corresponding author on reasonable request.

Abbreviations

British Columbia College of Nurses and Midwives

Medical assistance in dying

Nurse practitioner

Registered nurse

University of British Columbia Okanagan

Nicol J, Tiedemann M. Legislative Summary: Bill C-14: An Act to amend the Criminal Code and to make related amendments to other Acts (medical assistance in dying). Available from: https://lop.parl.ca/staticfiles/PublicWebsite/Home/ResearchPublications/LegislativeSummaries/PDF/42-1/c14-e.pdf .

Downie J, Scallion K. Foreseeably unclear. The meaning of the “reasonably foreseeable” criterion for access to medical assistance in dying in Canada. Dalhousie Law J. 2018;41(1):23–57.

Nicol J, Tiedeman M. Legislative summary of Bill C-7: an act to amend the criminal code (medical assistance in dying). Ottawa: Government of Canada; 2021.

Google Scholar  

Council of Canadian Academies. The state of knowledge on medical assistance in dying where a mental disorder is the sole underlying medical condition. Ottawa; 2018. Available from: https://cca-reports.ca/wp-content/uploads/2018/12/The-State-of-Knowledge-on-Medical-Assistance-in-Dying-Where-a-Mental-Disorder-is-the-Sole-Underlying-Medical-Condition.pdf .

Council of Canadian Academies. The state of knowledge on advance requests for medical assistance in dying. Ottawa; 2018. Available from: https://cca-reports.ca/wp-content/uploads/2019/02/The-State-of-Knowledge-on-Advance-Requests-for-Medical-Assistance-in-Dying.pdf .

Council of Canadian Academies. The state of knowledge on medical assistance in dying for mature minors. Ottawa; 2018. Available from: https://cca-reports.ca/wp-content/uploads/2018/12/The-State-of-Knowledge-on-Medical-Assistance-in-Dying-for-Mature-Minors.pdf .

Health Canada. Third annual report on medical assistance in dying in Canada 2021. Ottawa; 2022. [cited 2023 Oct 23]. Available from: https://www.canada.ca/en/health-canada/services/medical-assistance-dying/annual-report-2021.html .

Banner D, Schiller CJ, Freeman S. Medical assistance in dying: a political issue for nurses and nursing in Canada. Nurs Philos. 2019;20(4): e12281.

Article   PubMed   Google Scholar  

Pesut B, Thorne S, Stager ML, Schiller CJ, Penney C, Hoffman C, et al. Medical assistance in dying: a review of Canadian nursing regulatory documents. Policy Polit Nurs Pract. 2019;20(3):113–30.

Article   PubMed   PubMed Central   Google Scholar  

College of Registered Nurses of British Columbia. Scope of practice for registered nurses [Internet]. Vancouver; 2018. Available from: https://www.bccnm.ca/Documents/standards_practice/rn/RN_ScopeofPractice.pdf .

Pesut B, Thorne S, Schiller C, Greig M, Roussel J, Tishelman C. Constructing good nursing practice for medical assistance in dying in Canada: an interpretive descriptive study. Global Qual Nurs Res. 2020;7:2333393620938686. https://doi.org/10.1177/2333393620938686 .

Article   Google Scholar  

Pesut B, Thorne S, Schiller CJ, Greig M, Roussel J. The rocks and hard places of MAiD: a qualitative study of nursing practice in the context of legislated assisted death. BMC Nurs. 2020;19:12. https://doi.org/10.1186/s12912-020-0404-5 .

Pesut B, Greig M, Thorne S, Burgess M, Storch JL, Tishelman C, et al. Nursing and euthanasia: a narrative review of the nursing ethics literature. Nurs Ethics. 2020;27(1):152–67.

Pesut B, Thorne S, Storch J, Chambaere K, Greig M, Burgess M. Riding an elephant: a qualitative study of nurses’ moral journeys in the context of Medical Assistance in Dying (MAiD). Journal Clin Nurs. 2020;29(19–20):3870–81.

Lamb C, Babenko-Mould Y, Evans M, Wong CA, Kirkwood KW. Conscientious objection and nurses: results of an interpretive phenomenological study. Nurs Ethics. 2018;26(5):1337–49.

Wright DK, Chan LS, Fishman JR, Macdonald ME. “Reflection and soul searching:” Negotiating nursing identity at the fault lines of palliative care and medical assistance in dying. Social Sci & Med. 2021;289: 114366.

Beuthin R, Bruce A, Scaia M. Medical assistance in dying (MAiD): Canadian nurses’ experiences. Nurs Forum. 2018;54(4):511–20.

Bruce A, Beuthin R. Medically assisted dying in Canada: "Beautiful Death" is transforming nurses' experiences of suffering. The Canadian J Nurs Res | Revue Canadienne de Recherche en Sci Infirmieres. 2020;52(4):268–77. https://doi.org/10.1177/0844562119856234 .

Canadian Nurses Association. Code of ethics for registered nurses. Ottawa; 2017. Available from: https://www.cna-aiic.ca/en/nursing/regulated-nursing-in-canada/nursing-ethics .

Canadian Nurses Association. National nursing framework on Medical Assistance in Dying in Canada. Ottawa: 2017. Available from: https://www.virtualhospice.ca/Assets/cna-national-nursing-framework-on-maidEng_20170216155827.pdf .

Pesut B, Thorne S, Greig M. Shades of gray: conscientious objection in medical assistance in dying. Nursing Inq. 2020;27(1): e12308.

Durojaiye A, Ryan R, Doody O. Student nurse education and preparation for palliative care: a scoping review. PLoS ONE. 2023. https://doi.org/10.1371/journal.pone.0286678 .

McMechan C, Bruce A, Beuthin R. Canadian nursing students’ experiences with medical assistance in dying | Les expériences d’étudiantes en sciences infirmières au regard de l’aide médicale à mourir. Qual Adv Nurs Educ - Avancées en Formation Infirmière. 2019;5(1). https://doi.org/10.17483/2368-6669.1179 .

Adler M, Ziglio E. Gazing into the oracle. The Delphi method and its application to social policy and public health. London: Jessica Kingsley Publishers; 1996

Keeney S, Hasson F, McKenna H. Consulting the oracle: ten lessons from using the Delphi technique in nursing research. J Adv Nurs. 2006;53(2):205–12.

Keeney S, Hasson F, McKenna H. The Delphi technique in nursing and health research. 1st ed. City: Wiley; 2011.

Willis GB. Cognitive interviewing: a tool for improving questionnaire design. 1st ed. Thousand Oaks, Calif: Sage; 2005. ISBN: 9780761928041

Lamb C, Evans M, Babenko-Mould Y, Wong CA, Kirkwood EW. Conscience, conscientious objection, and nursing: a concept analysis. Nurs Ethics. 2017;26(1):37–49.

Lamb C, Evans M, Babenko-Mould Y, Wong CA, Kirkwood K. Nurses’ use of conscientious objection and the implications of conscience. J Adv Nurs. 2018;75(3):594–602.

de Vaus D. Surveys in social research. 6th ed. Abingdon, Oxon: Routledge; 2014.

Boateng GO, Neilands TB, Frongillo EA, Melgar-Quiñonez HR, Young SL. Best practices for developing and validating scales for health, social, and behavioral research: A primer. Front Public Health. 2018;6:149. https://doi.org/10.3389/fpubh.2018.00149 .

Puchta C, Potter J. Focus group practice. 1st ed. London: Sage; 2004.

Book   Google Scholar  

Streiner DL, Norman GR, Cairney J. Health measurement scales: a practical guide to their development and use. 5th ed. Oxford: Oxford University Press; 2015.

Hsieh H-F, Shannon SE. Three approaches to qualitative content analysis. Qual Health Res. 2005;15(9):1277–88.

Adesina O, DeBellis A, Zannettino L. Third-year Australian nursing students’ attitudes, experiences, knowledge, and education concerning end-of-life care. Int J of Palliative Nurs. 2014;20(8):395–401.

Bator EX, Philpott B, Costa AP. This moral coil: a cross-sectional survey of Canadian medical student attitudes toward medical assistance in dying. BMC Med Ethics. 2017;18(1):58.

Beuthin R, Bruce A, Scaia M. Medical assistance in dying (MAiD): Canadian nurses’ experiences. Nurs Forum. 2018;53(4):511–20.

Brown J, Goodridge D, Thorpe L, Crizzle A. What is right for me, is not necessarily right for you: the endogenous factors influencing nonparticipation in medical assistance in dying. Qual Health Res. 2021;31(10):1786–1800.

Falconer J, Couture F, Demir KK, Lang M, Shefman Z, Woo M. Perceptions and intentions toward medical assistance in dying among Canadian medical students. BMC Med Ethics. 2019;20(1):22.

Green G, Reicher S, Herman M, Raspaolo A, Spero T, Blau A. Attitudes toward euthanasia—dual view: Nursing students and nurses. Death Stud. 2022;46(1):124–31.

Hosseinzadeh K, Rafiei H. Nursing student attitudes toward euthanasia: a cross-sectional study. Nurs Ethics. 2019;26(2):496–503.

Ozcelik H, Tekir O, Samancioglu S, Fadiloglu C, Ozkara E. Nursing students’ approaches toward euthanasia. Omega (Westport). 2014;69(1):93–103.

Canning SE, Drew C. Canadian nursing students’ understanding, and comfort levels related to medical assistance in dying. Qual Adv Nurs Educ - Avancées en Formation Infirmière. 2022;8(2). https://doi.org/10.17483/2368-6669.1326 .

Edo-Gual M, Tomás-Sábado J, Bardallo-Porras D, Monforte-Royo C. The impact of death and dying on nursing students: an explanatory model. J Clin Nurs. 2014;23(23–24):3501–12.

Freeman LA, Pfaff KA, Kopchek L, Liebman J. Investigating palliative care nurse attitudes towards medical assistance in dying: an exploratory cross-sectional study. J Adv Nurs. 2020;76(2):535–45.

Brown J, Goodridge D, Thorpe L, Crizzle A. “I am okay with it, but I am not going to do it:” the exogenous factors influencing non-participation in medical assistance in dying. Qual Health Res. 2021;31(12):2274–89.

Dimoula M, Kotronoulas G, Katsaragakis S, Christou M, Sgourou S, Patiraki E. Undergraduate nursing students’ knowledge about palliative care and attitudes towards end-of-life care: A three-cohort, cross-sectional survey. Nurs Educ Today. 2019;74:7–14.

Matchim Y, Raetong P. Thai nursing students’ experiences of caring for patients at the end of life: a phenomenological study. Int J Palliative Nurs. 2018;24(5):220–9.

Canadian Institute for Health Research. Sex and gender in health research [Internet]. Ottawa: CIHR; 2021 [cited 2023 Oct 23]. Available from: https://cihr-irsc.gc.ca/e/50833.html .

Canadian Nurses’ Association. Nursing statistics. Ottawa: CNA; 2023 [cited 2023 Oct 23]. Available from: https://www.cna-aiic.ca/en/nursing/regulated-nursing-in-canada/nursing-statistics .

Krumpal I. Determinants of social desirability bias in sensitive surveys: a literature review. Qual Quant. 2013;47(4):2025–47. https://doi.org/10.1007/s11135-011-9640-9 .

Ferri P, Di Lorenzo R, Stifani S, Morotti E, Vagnini M, Jiménez Herrera MF, et al. Nursing student attitudes toward dying patient care: a European multicenter cross-sectional study. Acta Bio Medica Atenei Parmensis. 2021;92(S2): e2021018.

PubMed   PubMed Central   Google Scholar  

Beuthin R, Bruce A. Medical assistance in dying (MAiD): Ten things leaders need to know. Nurs Leadership. 2018;31(4):74–81.

Thiele T, Dunsford J. Nurse leaders’ role in medical assistance in dying: a relational ethics approach. Nurs Ethics. 2019;26(4):993–9.

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JS received a student traineeship through the Principal Research Chairs program at the University of British Columbia Okanagan.

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Schroeder, J., Pesut, B., Olsen, L. et al. Developing a survey to measure nursing students’ knowledge, attitudes and beliefs, influences, and willingness to be involved in Medical Assistance in Dying (MAiD): a mixed method modified e-Delphi study. BMC Nurs 23 , 326 (2024). https://doi.org/10.1186/s12912-024-01984-z

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Quantitative research on the impact of COVID ‐19 on frontline nursing staff at a military hospital in Saudi Arabia

Loujain sharif.

1 Faculty of Nursing, King Abdulaziz University, Jeddah Saudi Arabia

Khalid Almutairi

2 King Fahad Armed Forces Hospital (KFAFH), Jeddah Saudi Arabia

Khalid Sharif

Alaa mahsoon, maram banakhar, salwa albeladi, yaser alqahtani, zalikha attar, farida abdali, rebecca wright.

3 Johns Hopkins School of Nursing, Baltimore Maryland, USA

Associated Data

The data that support the findings of this study are available from the corresponding author upon reasonable request.

The aim of the study was to examine the relationship between stress, psychological symptoms and job satisfaction among frontline nursing staff at a military hospital in Saudi Arabia during the COVID‐19 pandemic.

Descriptive cross‐sectional study.

Data were collected using an online survey. All Registered Nurses ( N  = 1,225) working at a military hospital between February to April 2021 were contacted, 625 responded (51%). Data were analysed using descriptive and multivariate analysis, Student's t‐test for independent samples and one‐way analysis of variance followed by Tukey's multiple comparison tests.

Stress was experienced more significantly than depression or anxiety. Approximately 29% of the change in scores for psychological symptoms was explained by age group, being a Saudi national and working in emergency departments ( F [3,620]  = 19.063, p  < 0.0001). A 37% change in nursing stress scores was explained by nationality and work department. ( F [5,618]  = 19.754, p  < 0.0001). A 29% change in job satisfaction scores was explained by nationality and work department ( F [3,620]  = 19.063, p  < 0.0001).

1. INTRODUCTION

Saudi Arabia reported its first case of coronavirus disease 2019 (COVID‐19) on March 2, 2020 (Reuters Staff,  2020 ; Zu et al.,  2020 ). The World Health Organization has identified the COVID‐19 outbreak as a public health emergency and global pandemic (World Health Organization,  2020 ). The impact of COVID‐19 on those who have contracted it received rapid investigation and documentation (Harper et al.,  2020 ). However, healthcare workers were quickly recognized to be experiencing a secondary impact of COVID‐19, owing to vulnerability to stressors such as inadequate resources, long shifts, sleep problems, work−life imbalances and new occupational hazards (Sasangohar et al.,  2020 ). Notably, previous research on the impact of other coronavirus syndromes (severe acute respiratory syndrome, Middle East respiratory syndrome) found that approximately 62% of healthcare workers reported general health concerns, fear, insomnia, psychological distress, burnout, anxiety, depressive symptoms, posttraumatic stress disorder, psychosomatic symptoms and perceived stigma (Sasangohar et al.,  2020 ).

Compared with other healthcare professionals, nursing staff are particularly susceptible to the negative impact of a pandemic, with a higher vulnerability to negative outcomes associated with working in high‐risk departments (Shaukat et al.,  2020 ). Moreover, the impact is not limited to psychological effects. One systematic review on estimated COVID‐19 infections and deaths among healthcare workers reported 37.2 deaths per 100 infections in nursing staff aged at least 70 years (Bandyopadhyay et al.,  2020 ). Another study conducted in the UK found that out of 157 COVID‐19‐related deaths among medical health workers, 48 (30.6%) were nurses (Kursumovic et al.,  2020 ). This combination of physical (e.g. infection transmission and the underlying manifestations) and psychological effects (e.g. burnout, stress, anxiety and depression) caused by the pandemic (Hu et al.,  2020 ) has led to substantial concerns for nursing staff, with statistically significant bearing on job satisfaction (Del Carmen Giménez‐Espert et al.,  2020 ).

2. BACKGROUND

There has been a concerted effort in Saudi Arabia to understand and mitigate the impact of COVID‐19 on nursing staff, with studies investigating stress, fear of infection and resilience in relation to COVID‐19 (Tayyib & Alsolami,  2020 ); stress and coping strategies in dealing with COVID‐19 (Muharraq, 2021); and nursing knowledge and anxiety related to COVID‐19 (Alsharif,  2021 ). However, these studies give descriptive statistics with relatively small samples of less than 300 nurses, and, to the best of our knowledge, no study has yet focused on assessing multiple psychological symptoms (depression, anxiety, and stress) collectively in relation to job satisfaction. Furthermore, the effects of COVID‐19 among nursing staff in military hospitals have not yet been explored.

This is a key setting for investigation, as military hospitals in Saudi Arabia are considered highly specialized healthcare organizations, providing all forms of health care to an exclusive population of military personnel and their family members (Walston et al.,  2008 ). Healthcare providers recruited for military hospitals must meet high standards and requirements that differ from those in non‐military care settings (Olenick et al.,  2015 ). Because of higher standards and higher pay levels compared with other healthcare organizations in Saudi Arabia, military hospitals often employ healthcare providers, and nurses in particular, from different countries worldwide (Almalki et al.,  2011 ). Despite the higher salaries and expectations of care associated with urgent needs, military hospitals have had to adapt their policies and protocols in response to greater and new patient needs as a result of COVID‐19. Therefore, these hospitals have also been impacted by the brutal reality, thereby leading to an increase in resignations among nursing staff. Probable reasons for this increase include greater workloads, mandatory overtime, withholding of annual leave and switching of nurses from less demanding areas (e.g. outpatient clinics) to more demanding care areas (e.g. inpatient units), along with the risk of contracting COVID‐19 (King Fahad Armed Forces Hospital,  2020 ). These changes suggest that nursing staff at military hospitals have experienced many of the same mental and physical side effects as nurses in non‐military hospitals, with the same consequential burnout and resignations. However, it is also commonly reported that nurses avoid seeking psychological support and services (Knaak et al.,  2017 ). This may be due to a fear of stigma and discrimination in the workplace, where needing mental health help can be perceived as weakness (Jones et al.,  2020 ), which is a phenomenon that is particularly common among military personnel (Hernandez et al.,  2014 ).

Despite investigations into the types of symptoms experienced by nursing staff as outlined above, few studies have explored the relationship between psychological impact and nurses' job satisfaction within the context of military hospitals in the Middle East. Therefore, the present study aimed to examine the relationships within and between stress, psychological symptoms (including depression and anxiety) and job satisfaction among frontline nursing staff at a military hospital in Saudi Arabia during the COVID‐19 pandemic. The purpose of this study was to identify key components that may benefit not only the study site in improving nursing staff retention but also the wider healthcare field, as nursing retention is an increasingly documented challenge. We hypothesized that the abovementioned challenges encountered by nurses, as a secondary impact of COVID‐19, are likely to be linked to low job satisfaction among frontline nurses.

3.1. Design

We used a descriptive cross‐sectional design with a quantitative questionnaire. Convenience sampling was used to recruit Registered Nurses (RNs) working in all hospital units. Overall, 1,125 RNs worked at the study site. The hospital only has full‐time RNs and does not employ part‐time or agency RNs. As such there was no criteria excluding any RN employed at the hospital from participation in this study. Five hundred seventy‐six participants were required for a 50% response rate (Sataloff & Vontela,  2021 ). Data were collected from one military healthcare organization in the western region of Saudi Arabia. The hospital provides all medical services with a 420‐bed capacity, serving members of the Saudi Arabian Armed Forces and their families. The hospital is accredited by the Central Board for Accreditation of Healthcare Institutions, Joint Commission International and International Organization for Standardization, and it is the only adult cardiac surgical facility in the western region.

3.2. Method

The questionnaire comprised four sections and was in English language, with 122 items, in total and took approximately 35 minutes to complete.

Section 1 – Demographic information : We collected data on eight items: age, gender, marital status, nationality, education level, experience and department.

Section 2 – Expanded Nursing Stress Scale (ENSS; French et al.,  2000 ): The ENSS (Cronbach's alpha = 0.96) identifies the sources and frequency of stress among hospital nurses. The scale comprises a total of 57 items on the following stressful situations: death and dying patients (7 items), conflict with physicians (5 items), inadequate emotional preparation (3 items), problems related to peers (6 items), problems related to supervisors (7 items), workload (9 items), uncertainty concerning treatment (9 items), patients and their families (8 items) and discrimination (3 items). The ENSS was also used in the present study to assess the frequency in which nurses experienced work stressors, rated within a range between 0–4, on a scale modified from the original as follows: I have not encountered it (0), never stressful (1), occasionally stressful (2), frequently stressful (3) and always stressful (4). In a pilot test of the modified ENSS, conducted by the authors of this study, the Cronbach's alpha was 0.98.

Section 3 – Depression , Anxiety and Stress Scales (DASS; Lovibond & Lovibond,  1995 ): The DASS (Cronbach's alpha = 0.89) focuses on assessing depression, anxiety and stress among hospital nurses. Each of the three scales contains seven items. The depression scale assesses dysphoria, hopelessness, devaluation of life, self‐deprecation, lack of interest/involvement, anhedonia and inertia. The anxiety scale assesses autonomic arousal, skeletal muscle effects, situational anxiety and subjective experience of anxious affect. The stress scale assesses difficulty relaxing, nervous arousal and being easily upset/agitated, irritable/over‐reactive and impatient. The DASS is rated on a scale ranging between 0–3: (0) does apply to me at all , (1) applies to me to some degree or some of the time , (2) applies to me to a considerable degree or a good part of time and (3) applies to me very much or most of the time . Cronbach's alpha for the DASS in the current study was calculated as 0.969, indicating excellent reliability.

Section 4 – Job Satisfaction Survey (JSS; Spector,  1985 ): The JSS (Cronbach's alpha 0.91) assesses job satisfaction among hospital nurses. It includes 36 items with nine facets as follows: pay (4 items), promotion, supervision (4 items), fringe benefits (4 items), contingent rewards (4 items), operating procedures (4 items), co‐workers (4 items), nature of work (4 items) and communication (4 items). Items are rated on a six‐point Likert scale with responses ranging from 1 ( disagree very much ) to 6 ( agree very much ). The JSS demonstrated acceptable reliability in the current study, with a Cronbach's alpha of 0.798. Regarding the scoring system, scores for each four‐item subscale ranged from 4 to 24 and were scored as follows: dissatisfied (4–12 points), ambivalent (12–16) and satisfied (16–24). For the total 36‐item JSS, scores ranged from 36 to 216 and were scored as follows: dissatisfied (36–108 points), ambivalent (108–144) and satisfied (144–216; Spector,  1994 ).

3.3. Data collection process

After obtaining ethical approval, potential study participants who were recruited to participate through unit meetings by the head nurses of the units, who acted as gatekeepers. All relevant information on the study, including its research topic, aim, sample and significance were explained to all RNs in each unit. Within Saudi culture, in addition to communication modalities such as email, social media platforms are a common and effective method of communicating with groups within different organizations. Therefore, the head nurse in each unit sent the survey using google form as an electronic link via the social media application “WhatsApp” to all RNs who agreed to participate in the study. The survey was sent out in February 2021 and remained available until April 2021.

3.4. Analysis

Data were analysed using SPSS 26.0 Windows version statistical software (IBM, Armonk, NY, USA). Descriptive statistics (means, standard deviations, frequencies and percentages) were used to describe the quantitative and categorical variables. Student's t‐test for independent samples was used to compare the mean values of quantitative outcome variables in relation to the categorical study variable with two categories. One‐way analysis of variance, followed by Tukey's multiple comparison tests (Tukey,  1953 ), was used to compare the mean values of quantitative outcome variables in relation to the categorical study variables with more than two categories. A p ‐value of ≤0.05 was used to report the statistical significance of the results.

For the multivariate analysis, a stepwise Multiple linear regression was carried out to observe the independent relationship of variables of categorical study variables with the three quantitative variables (DASS, ENSS and JSS scores). As the study variables were categorical, dummy variables were created to include them in the model. The proportion of variability R 2 was used to observe the change in the outcome variable explained by the significant independent variables in the model. Regression coefficients were used to observe changes in the outcome variables. A p ‐value ≤0.05, was used to report the statistical significance of the estimates.

3.5. Ethics

Ethical approval was obtained from the King Fahd Armed Forces Hospital‐ Jeddah, Research and Ethics Committee (Ref. number: REC 398), confirming no risk to study participants via the application of an anonymous online survey. The cover page of the survey provided key information, including the importance and purpose, expected time necessary to complete the survey, and why survey recipients were asked to participate. A statement regarding confidentiality and anonymity was included within the online link to the survey. No financial incentives were offered.

Of the 624 nurses who completed the survey (response rate: 51%), 91.3% were women, approximately two‐thirds (66.8%) were aged between 25–35 years, and more than 50% were unmarried. The majority were Filipino (75.8%), and only 5.6% were Saudi. Approximately 90% of the sample had a bachelor's degree, and 48.4% had 1–5 years of experience; 6.3% had more than 15 years of experience. The sample was distributed among the following departments and units: emergency departments (14.6%), intensive care units (22.6%), inpatient units (39.1%) and outpatient units (9.6%); the remaining 14.1% were from other departments. A quarter of the sample (n = 156) had tested positive for COVID‐19 (Table  1 ).

Socio‐demographic and professional characteristics of participants ( N  = 624)

Table  2 shows the mean values of the three DASS subscales (depression, anxiety and stress). The mean stress score was higher than the mean scores for either depression or anxiety. Table  3 shows the ENSS scores and mean values of its nine domains, in which the mean score of the “workload” domain was highest (2.39), followed by mean scores of “patients and their families” (2.30) and “problems relating to supervisors” (2.14); the mean scores of the remaining six domains were less than 2.0 The mean value for the nine domains of the JSS was 121.07 (22.1), which indicated ambivalence (Table  4 ). The only mean score that indicted satisfaction was in the “nature of work” domain (17.04), followed by “co‐workers” (15.88) and “supervision” (15.16). The mean scores of the remaining six domains were less than 15.0, ranging from ambivalent to dissatisfied.

Comparison of mean scores of DASS sub scales and total score in relation to socio‐demographic and professional characteristics of study subjects ( n  = 624)

Note : Bolded text denotes p value of <0.05.

Comparison of mean values of nine domains and total score of ENSS scale in relation to socio‐demographic and professional characteristics of study subjects ( n  = 624)

Comparison of mean values of nine domains and total score of job satisfaction scale in relation to socio‐demographic and professional characteristics of study subjects ( n  = 624)

4.1. Bivariate and multivariate analyses

For mean DASS scores, bivariate analysis showed statistically significant differences in relation to age group, nationality and work department with further statistically significant differences found in mean anxiety scores among nurses who had tested positive for COVID‐19 ( p  = 0.030; Table  2 ). Multivariate analysis revealed that the overall regression model was statistically significant ( F [3,620]  = 19.063, p  < 0.0001), with an R 2 of 29.1 (Table  S1 ). The R 2 is the proportion of variability, which means approximately 29% of the change in DASS scores was explained by age group (25–30 years), being a Saudi national and working in emergency or “other” departments. The corresponding regression coefficients of these variables indicated that the DASS scores increased on average (i) by 6.334 units in nurses aged 20–30 years when compared to those aged 46–50 years, (ii) by 17.725 units in Saudi nationals when compared to South African nationals and (iii) by 11.699 units in nurses who worked in emergency departments when compared to those who worked in outpatient departments (Table  S1 ).

For ENSS scores, bivariate analysis showed statistically significant differences related to nationality, place of work and experience (Table  3 ). Multivariate analysis showed that the overall regression model was statistically significant ( F [5,618]  = 19.754, p  < 0.0001) with an R 2 of 37.1 (Table  S2 ). A 37% change in ENSS score was explained by nationality and place of work. The corresponding regression coefficients of these variables indicated that ENSS scores increased, on average, (i) by 5.619 units in Filipino nationals when compared to Indian nationals, (ii) by 7.987 units in Malaysian nationals when compared to Indian nationals, (iii) by 4.976 units in Saudi nationals when compared to Indian nationals and (iv) by 4.996 units in nurses who worked in emergency departments when compared to those who worked in inpatient departments (Table  S2 ).

For JSS scores, bivariate analysis showed that the mean values had statistically significant differences in relation to nationality, place of work and education level (Table  4 ). Multivariate analysis showed that the overall regression model was statistically significant ( F [3,620]  = 19.063, p  < 0.0001), with an R 2 of 29 (Table  S3 ). A 29% change in JSS score was explained by nationality and place of work. The corresponding regression coefficients of these variables indicated that JSS scores increased, on average, (i) by 13.022 units in Indian nationals when compared with Filipino nationals, (ii) by 10.017 units in Saudi nationals when compared to Filipino nationals and (iii) by 9.992 units in nurses who worked in inpatient departments when compared to those who worked in outpatient departments (Table  S3 ).

5. DISCUSSION

The present study explored the impact of COVID‐19 on nurses working in a military hospital in Saudi Arabia and identified correlations between psychological symptoms and job satisfaction. The data give a detailed understanding of specific challenges to enable the study site to give additional support where needed, as well as give the wider field with new insights that can be built upon in future research. We found that the COVID‐19 pandemic is driving frontline nursing staff in the Jeddah region of Saudi Arabia to experience severe psychological strain.

Based on mean DASS scores, stress was the highest, when compared to depression and anxiety. This result is consistent with a meta‐analysis of 93 studies in which stress was found to be the most severe psychological symptom among nurses working during the COVID‐19 pandemic (Al Maqbali et al.,  2021 ). This result itself is unsurprising, as stress is considered a normal reaction to circumstances related to the pandemic, whereas depression and anxiety are considered psychiatric disorders that should meet certain symptom criteria for a specific duration (Regier et al.,  2013 ). However, nurses in the present study, who tested positive for COVID‐19 showed symptoms of anxiety. A previous qualitative exploration with nurses who had contracted COVID‐19 revealed similar results, while also providing further context regarding the depth of anxiety, fear and psychological shock they experienced (He et al.,  2021 ). However, as that was the only qualitative study, we were able to identify on this topic to date, we highlight this as an area that would benefit from further qualitative research not only to determine lived experiences but also to identify mitigating and supporting factors.

Data collected using the ENSS and JSS indicated that the most significant sources of stress for nursing staff in the present study were those associated with their work environment, such as workload, working under pressure, short time allotted to complete tasks, unsuitable rest/work regimens, frequent night shifts and overtime work. Pre‐pandemic, unusually high workloads were countered by reductions in outpatient appointments and treatments. However, the uniquely intense and demanding nature of COVID‐19 has made that an impossibility for isolation and triage hospitals. Similar findings have been reported elsewhere, as continuous emergency COVID‐19 cases, along with sustained increases in the number of suspected and confirmed cases, are placing frontline nursing staff under intense pressure (Brahmi et al.,  2020 ; Kakar et al.,  2021 ). Moreover, the extreme nature of COVID‐19 cases and high mortality rates have also changed the challenges nurses face in their work environment. New infection control safety policies have physically separated patients and families to reduce the risk of cross‐infection (Hsu et al.,  2020 ; Jaswaney et al.,  2022 ). Nurses implementing these policies have at times faced unreasonable demands and even abuse from distressed families, which exacerbates stressors and increases the pressure on them (Abu‐Snieneh,  2021 ). We found this to be the case among our nursing participants, who reported distress at the manner and frequency of patients deteriorating and dying, regardless of all medical and nursing efforts and care. These encounters led to a sense that the pandemic cannot be overcome, causing some nurses to experience guilt and self‐blame. This phenomenon has been noted elsewhere, as nurses have responded to blaming themselves, distressed, or angry relatives and patients and cited as one of the main stressors among frontline nurses (Byrne et al.,  2021 ; Liu et al.,  2020 ). We suggest that training in end‐of‐life care processes and approaches may be beneficial to give nurses with the skills to care for patients and families and to equip them with resiliency skills for this type of care (Peters et al.,  2013 ).

Frontline nurses were further impacted by the department in which they worked. We found nurses who worked in emergency departments scored the highest on the DASS, and ENSS, which is consistent with another study showing that nurses working in high‐exposure units with suspected COVID‐19 patients had higher levels of depression than nurses working in other units (Doo et al.,  2021 ). There could be several reasons for this finding, such as an unsafe work environment, insufficient personal protective equipment and unknown patient conditions. In addition, emergency departments are known to be unpredictable work environments, which not only means nurses must be ready to respond to any potential patient need but also increases their vulnerability to unexpected events, such as workplace violence and crises (Cui et al.,  2021 ).

There were other multiple domains on the ENSS and JSS that contributed to frontline nurses experiencing occupational stress and lacking job satisfaction, respectively. Interestingly, one correlation that was found was between the level of satisfaction and the level of education. Other researchers have found that the higher the level of education, the higher the level of satisfaction (Coomber & Barriball,  2007 ). Conversely in the present study, we found that the higher the level of education, the lower the level of satisfaction. One possible explanation for this could be that during the COVID‐19 pandemic, nurses with higher levels of education are more prepared and equipped to understand evidence‐based practice and policies and guidelines, and the absence of such may have contributed towards feelings of distress and lower satisfaction than nurses who are less highly trained and may not be as aware of the lack of research underpinning rapidly developed new policies and guidelines. This finding is at odds with other studies exploring this relationship (Lorber & Skela Savič,  2012 ). Another possible reason is that “job satisfaction” has not been consistently defined across studies (Coomber & Barriball,  2007 ), and those previous studies were performed in other counties where the term's meaning may have different cultural nuances.

Another area of note was as a perceived lack of support from supervisors. Although they are generally more experienced than their subordinates, nursing supervisors have been asked to serve in their roles with greater demands on them to manage an unfamiliar scenario (Alnazly et al.,  2021 ). As such, previously developed regulations, protocols and processes have not been effective or appropriate for responding to changing patient needs or care practices for infection control management; thus, supervisors have simply not had the information needed to guide practice and support junior staff, patients and families (Buheji & Buhaid,  2020 ). We found the nature of relationships to be a consistent source of stress for nurses, with conflicts between co‐workers (nurse to nurse) and with physicians, and a sense of continuous blame directed at nurses being particularly challenging. This is not an unsubstantiated perception, as Wang et al. ( 2020 ) found that other medical professionals often treat nurses as scapegoats.

Age was of particular significance in the present study, as depression, anxiety and stress were significantly higher in nurses aged 25–30 years. This is in line with the results of other studies with nurses in Saudi Arabia (Abu‐Snieneh,  2021 ; Ghawadra et al.,  2019 ) and internationally. For example, in China, Portugal and Turkey, younger frontline nurses were found to be more likely to experience depression and worry about personal or family health during the COVID‐19 pandemic (Murat et al.,  2021 ; Sampaio et al.,  2021 ; Zheng et al.,  2021 ). Potential explanations include a lack of preparedness for the occupational role in a pandemic and less experience responding to crisis situations among younger nurses, compared with older nurses (Shahrour & Dardas,  2020 ). Within our setting, another possible explanation connects to a prevailing cultural expectation. In Arab cultures it is expected that by age 25, most people will have settled down and established a family. Thus, attempts to meet expectations, such as finding the right partner, during the pandemic while experiencing mental and physical distress is likely to increase the negative psychological impact on individuals in this age group.

Nationality was of particular interest, as although the five nationalities of nurses captured in the questionnaire (Filipino, Indian, Malaysian, Saudi and South African) were not normally distributed, Saudi nurses showed higher levels of depression, anxiety and stress than nurses of other nationalities. Similar findings were reported by Al‐Dossary et al. ( 2020 ), whose study on the effect of COVID‐19 in 500 nurses found that non‐Saudi nurses had higher self‐reported awareness, positive attitudes, optimal prevention and positive perceptions compared with Saudi nurses. A possible explanation is that many non‐Saudi nurses working in the region are away from their families, while Saudi nurses are in their usual living arrangements. Therefore, during the pandemic, Saudi nurses have an additional concern of transmitting the virus to their families, while non‐Saudi nationals may be concerned about their loved ones, but do not experience the distress of their job leading to direct risk or harm to them (Abu‐Snieneh,  2021 ). Other studies have also shown family safety to be a significant concern among frontline nursing staff during the COVID‐19 pandemic (Labrague,  2021 ).

5.1. Limitations

The present study has some limitations that should be noted. Although this study provides insights into the main psychological stressors that are impacting the nursing workforce and to what degree, it would have been strengthened by including a qualitative arm to provide context and depth to our findings. This research is planned as our next phase. Survey tools were delivered in their original English language as our hospital nursing staff includes a wide range of nationalities and English is the official language of Saudi healthcare organizations. However, it may be beneficial in future research to develop alternative translations and variables that would more directly capture cultural context.

6. CONCLUSION

The present findings demonstrated a relationship between stress, psychological symptoms and job satisfaction. The main concerns were workload, work department, supervision, collegial relationships and high mortality rates in patients. More research is needed to identify what types of support are required, along with mechanisms to tailor such support to the different variables identified by the nursing participants. Based on the findings of this study, we recommend focusing efforts on raising awareness among hospital managers regarding nurses' psychological symptoms and possible support measures, which may include flexible working hours, clear communication and training in palliative and end‐of‐life care. Finally, qualitative investigation is highly recommended to explore in‐depth further context for the identified sources of stress, and psychological and emotional experiences among nurses as frontline workers facing COVID‐19. A co‐design approach may be particularly beneficial, as this will not only lead to strategies that draw from the knowledge and experience of the nursing staff but also potentially offer these nurses the opportunity to take back some control in a time of immense instability.

AUTHOR CONTRIBUTIONS

All authors listed have met all four of the following criteria: Have made substantial contributions to conception and design, or acquisition of data, or analysis and interpretation of data; Been involved in drafting the manuscript or revising it critically for important intellectual content; Given final approval of the version to be published. Agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

FUNDING INFORMATION

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

CONFLICT OF INTEREST

The authors have no conflict of interest to declare.

ETHICS STATEMENT

Ethical approval was obtained from the King Fahd Armed Forces Hospital—Jeddah Research and Ethics Committee (Ref. number: REC 398), confirming no risk to study participants via the application of an anonymous online survey. This study conforms to the recognized standards listed by the Declaration of Helsinki.

Supporting information

Sharif, L. , Almutairi, K. , Sharif, K. , Mahsoon, A. , Banakhar, M. , Albeladi, S. , Alqahtani, Y. , Attar, Z. , Abdali, F. , & Wright, R. (2023). Quantitative research on the impact of COVID‐19 on frontline nursing staff at a military hospital in Saudi Arabia . Nursing Open , 10 , 217–229. 10.1002/nop2.1297 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]

DATA AVAILABILITY STATEMENT

• Abu‐Snieneh, H. M. (2021). Psychological factors associated with the spread of coronavirus disease 2019 (COVID‐19) among nurses working in health sectors in Saudi Arabia . Perspectives in Psychiatric Care , 57 ( 3 ), 1399–1408. 10.1111/ppc.12705 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Al Maqbali, M. , Al Sinani, M. , & Al‐Lenjawi, B. (2021). Prevalence of stress, depression, anxiety and sleep disturbance among nurses during the COVID‐19 pandemic: A systematic review and meta‐analysis . Journal of Psychosomatic Research , 141 , 110343. 10.1016/j.jpsychores.2020.110343 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Al‐Dossary, R. , Alamri, M. , Albaqawi, H. , Al Hosis, K. , Aljeldah, M. , Aljohan, M. , Aljohani, K. , Almadani, N. , Alrasheadi, B. , Falatah, R. , & Almazan, J. (2020). Awareness, attitudes, prevention, and perceptions of COVID‐19 outbreak among nurses in Saudi Arabia . International Journal of Environmental Research and Public Health , 17 ( 21 ), 8269. 10.3390/ijerph17218269 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Almalki, M. , Fitzgerald, G. , & Clark, M. (2011). The nursing profession in Saudi Arabia: An overview . International Nursing Review , 58 , 304–311. [ PubMed ] [ Google Scholar ]
• Alnazly, E. , Khraisat, O. M. , Al‐Bashaireh, A. M. , & Bryant, C. L. (2021). Anxiety, depression, stress, fear and social support during COVID‐19 pandemic among Jordanian healthcare workers . PLoS One , 16 ( 3 ), e0247679. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Alsharif, F. (2021). Nurses' Knowledge and Anxiety Levels toward COVID‐19 in Saudi Arabia . Nursing Reports , 11 ( 2 ), 356–363. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Bandyopadhyay, S. , Baticulon, R. E. , Kadhum, M. , Alser, M. , Ojuka, D. K. , Badereddin, Y. , Kamath, A. , Parepalli, S. A. , Brown, G. , Iharchane, S. , & Gandino, S. (2020). Infection and mortality of healthcare workers worldwide from COVID‐19: A systematic review . BMJ Global Health , 5 ( 12 ), e003097. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Brahmi, N. , Singh, P. , Sohal, M. , & Sawhney, R. S. (2020). Psychological trauma among the healthcare professionals dealing with COVID‐19 . Asian Journal of Psychiatry , 54 , 102241. 10.1016/j.ajp.2020.102241 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Buheji, M. , & Buhaid, N. (2020). Nursing human factor during COVID‐19 pandemic . International Journal of Nursing Science , 10 ( 1 ), 12–24. 10.5923/j.nursing.20201001.02 [ CrossRef ] [ Google Scholar ]
• Byrne, A. , Barber, R. , & Lim, C. H. (2021). Impact of the COVID‐19 pandemic–a mental health service perspective . Progress in Neurology and Psychiatry , 25 ( 2 ), 27–33b. [ Google Scholar ]
• Coomber, B. , & Barriball, K. L. (2007). Impact of job satisfaction components on intent to leave and turnover for hospital‐based nurses: A review of the research literature . International Journal of Nursing Studies , 44 ( 2 ), 297–314. 10.1016/j.ijnurstu.2006.02.004 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Cui, S. , Jiang, Y. , Shi, Q. , Zhang, L. , Kong, D. , Qian, M. , & Chu, J. (2021). Impact of COVID‐19 on anxiety, stress, and coping styles in nurses in emergency departments and fever clinics: A cross‐sectional survey . Risk Management and Healthcare Policy , 14 , 585–594. 10.2147/RMHP.S289782 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Del Carmen Giménez‐Espert, M. , Prado‐Gascó, V. , & Soto‐Rubio, A. (2020). Psychosocial risks, work engagement, and job satisfaction of nurses during COVID‐19 pandemic . Frontiers in Public Health , 8 , 566896. 10.3389/fpubh.2020.566896 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Doo, E. Y. , Kim, M. , Lee, S. , Lee, S. Y. , & Lee, K. Y. (2021). Influence of anxiety and resilience on depression among hospital nurses: A comparison of nurses working with confirmed and suspected patients in the COVID‐19 and non‐COVID‐19 units . Journal of Clinical Nursing , 30 ( 13–14 ), 1990–2000. 10.1111/jocn.15752 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• French, S. E. , Lenton, R. , Walters, V. , & Eyles, J. (2000). An empirical evaluation of an expanded Nursing Stress Scale . Journal of Nursing Measurement , 8 ( 2 ), 161–178. [ PubMed ] [ Google Scholar ]
• Ghawadra, S. F. , Abdullah, K. L. , Choo, W. Y. , & Phang, C. K. (2019). Psychological distress and its association with job satisfaction among nurses in a teaching hospital . Journal of Clinical Nursing , 28 ( 21–22 ), 4087–4097. 10.1111/jocn.14993 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Harper, L. , Kalfa, N. , Beckers, G. M. A. , Kaefer, M. , Nieuwhof‐Leppink, A. J. , Fossum, M. , Herbst, K. W. , Bagli, D. , & ESPU Research Committee . (2020). The impact of COVID‐19 on research . Journal of Pediatric Urology , 16 ( 5 ), 715–716. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• He, J. , Liu, L. , Chen, X. , Qi, B. , Liu, Y. , Zhang, Y. , & Bai, J. (2021). The experiences of nurses infected with COVID‐19 in Wuhan, China: A qualitative study . Journal of Nursing Management , 29 ( 5 ), 1180–1188. 10.1111/jonm.13256 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Hernandez, S. H. A. , Bedrick, E. J. , & Parshall, M. B. (2014). Stigma and barriers to accessing mental health services perceived by Air Force nursing personnel . Military Medicine , 179 ( 11 ), 1354–1360. 10.7205/MILMED-D-14-00114 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Hsu, S. T. , Chou, L. S. , Chou, F. H. C. , Hsieh, K. Y. , Chen, C. L. , Lu, W. C. , Kao, W. T. , Li, D. J. , Huang, J. J. , Chen, W. J. , & Tsai, K. Y. (2020). Challenge and strategies of infection control in psychiatric hospitals during biological disasters—From SARS to COVID‐19 in Taiwan . Asian Journal of Psychiatry , 54 , 102270. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Hu, D. , Kong, Y. , Li, W. , Han, Q. , Zhang, X. , Zhu, L. X. , Wan, S. W. , Liu, Z. , Shen, Q. , Yang, J. , & He, H. G. (2020). Frontline nurses' burnout, anxiety, depression, and fear statuses and their associated factors during the COVID‐19 outbreak in Wuhan, China: A big‐scale cross‐sectional study . EClinical Medicine , 24 ( 2 ), 100424. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Jaswaney, R. , Davis, A. , Cadigan, R. J. , Waltz, M. , Brassfield, E. R. , Forcier, B. , & Joyner, B. L., Jr. (2022). Hospital policies during COVID‐19: An analysis of visitor restrictions . Journal of Public Health Management and Practice , 28 ( 1 ), E299–E306. [ PubMed ] [ Google Scholar ]
• Jones, S. , Agud, K. , & McSweeney, J. (2020). Barriers and facilitators to seeking mental health care among first responders: “Removing the darkness” . Journal of the American Psychiatric Nurses Association , 26 ( 1 ), 43–54. 10.1177/1078390319871997 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Kakar, M. S. , Rauf, S. , Jalal, U. , Khan, W. A. , & Gul, I. (2021). The emotional burden of COVID 19 in frontline health care workers at a tertiary care hospital in Pakistan . Journal of Bahria University Medical and Dental College , 11 ( 2 ), 60–64. [ Google Scholar ]
• King Fahad Armed Forces Hospital . (2020). Nurse‐driven quality improvement intervention to reduce the hospital acquired community infection rate among health care workers . Internal report: Unpublished.
• Knaak, S. , Mantler, E. , & Szeto, A. (2017). Mental illness‐related stigma in healthcare: Barriers to access and care and evidence‐based solutions . Healthcare Management Forum , 30 ( 2 ), 111–116. 10.1177/0840470416679413 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Kursumovic, E. , Lennane, S. , & Cook, T. M. (2020). Deaths in healthcare workers due to COVID‐19: The need for robust data and analysis . Anesthesia , 1 ( 1 ), 1–10. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Labrague, L. J. (2021). Psychological resilience, coping behaviours and social support among health care workers during the COVID‐19 pandemic: A systematic review of quantitative studies . Journal of Nursing Management , 29 ( 7 ), 1893–1905. 10.1111/jonm.13336 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Liu, M. , He, P. , Liu, H. G. , Wang, X. J. , Li, F. J. , Chen, S. , Lin, J. , Chen, P. , Liu, J. H. , & Li, C. H. (2020). Clinical characteristics of 30 medical workers infected with new coronavirus pneumonia . Chinese Journal of Tuberculosis and Respiratory Diseases , 43 ( 3 ), 209–214. [ PubMed ] [ Google Scholar ]
• Lorber, M. , & Skela Savič, B. (2012). Job satisfaction of nurses and identifying factors of job satisfaction in Slovenian hospitals . Croatian Medical Journal , 53 ( 3 ), 263–270. 10.3325/cmj.2012.53.263 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Lovibond, P. F. , & Lovibond, S. H. (1995). The structure of negative emotional states: Comparison of the Depression Anxiety Stress Scales (DASS) with the Beck Depression and Anxiety Inventories . Behaviour Research and Therapy , 33 ( 3 ), 335–343. [ PubMed ] [ Google Scholar ]
• Murat, M. , Köse, S. , & Savaşer, S. (2021). Determination of stress, depression and burnout levels of front‐line nurses during the COVID‐19 pandemic . International Journal of Mental Health Nursing , 30 ( 2 ), 533–543. 10.1111/inm.12818 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Olenick, M. , Flowers, M. , & Diaz, V. J. (2015). US veterans and their unique issues: enhancing health care professional awareness . Advances in Medical Education and Practice , 6 , 635–639. 10.2147/AMEP.S89479 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Peters, L. , Cant, R. , Payne, S. , O'Connor, M. , McDermott, F. , Hood, K. , Morphet, J. , & Shimoinaba, K. (2013). How death anxiety impacts nurses' caring for patients at the end of life: A review of literature . The Open Nursing Journal , 7 , 14–21. 10.2174/1874434601307010014 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Regier, D. A. , Kuhl, E. A. , & Kupfer, D. J. (2013). The DSM‐5: Classification and criteria changes . World Psychiatry , 12 ( 2 ), 92–98. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Reuters Staff . (2020). Saudi Arabia announces first case of coronavirus . Reuters. https://www.reuters.com/article/us‐health‐coronavirus‐saudi/saudi‐arabia‐announces‐first‐case‐of‐coronavirus‐idUSKBN20P2FK Accessed 5 April 2021. [ Google Scholar ]
• Sampaio, F. , Sequeira, C. , & Teixeira, L. (2021). Impact of COVID‐19 outbreak on nurses' mental health: A prospective cohort study . Environmental Research , 194 , 110620. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Sasangohar, F. , Jones, S. L. , Masud, F. N. , Vahidy, F. S. , & Kash, B. A. (2020). Provider burnout and fatigue during the COVID‐19 pandemic: Lessons learned from a high‐volume intensive care unit . Anesthesia and Analgesia , 131 , 106–111. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Sataloff, R. T. , & Vontela, S. (2021). Response rates in survey research . Journal of Voice , 35 ( 3 ), 683–684. 10.1016/j.jvoice.2020.12.043 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Shahrour, G. , & Dardas, L. (2020). Acute stress disorder, coping self‐efficacy and subsequent psychological distress among nurses amid COVID‐19 . Journal of Nursing Management , 28 ( 7 ), 1686–1695. 10.1111/jonm.13124 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Shaukat, N. , Ali, D. M. , & Razzak, J. (2020). Physical and mental health impacts of COVID‐19 on healthcare workers: A scoping review . International Journal of Emergency Medicine , 13 ( 1 ), 1–8. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Spector, P. (1985). Measurement of human service staff satisfaction: Development of the Job Satisfaction Survey . American Journal of Community Psychology , 13 ( 6 ), 693–713. [ PubMed ] [ Google Scholar ]
• Spector, P. (1994). Job satisfaction survey , copyright Paul E . Spector . http://shell.cas.usf.edu/~pspector/scales/jssinterpretation.html
• Tayyib, N. A. , & Alsolami, F. J. (2020). Measuring the extent of stress and fear among Registered Nurses in KSA during the COVID‐19 Outbreak . Journal of Taibah University Medical Sciences , 15 ( 5 ), 410–416. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Tukey, J. (1953). Multiple comparisons . Journal of the American Statistical Association , 48 ( 263 ), 624–625. [ Google Scholar ]
• Walston, S. , Al‐Harbi, Y. , & Al‐Omar, B. (2008). The changing face of healthcare in Saudi Arabia . Annals of Saudi Medicine , 28 ( 4 ), 243–250. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Wang, W. , Song, W. , Xia, Z. , He, Y. , Tang, L. , Hou, J. , & Lei, S. (2020). Sleep disturbance and psychological profiles of medical staff and non‐medical staff during the early outbreak of COVID‐19 in Hubei Province, China . Frontiers in Psychiatry , 11 , 733. 10.3389/fpsyt.2020.00733 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• World Health Organization . (2020). Rolling updates on coronavirus disease . (COVID‐19 ) . https://www.who.int/emergencies/diseases/novel‐coronavirus‐2019/events‐as‐they‐happen . Accessed 5 April 2021.
• Zheng, R. , Zhou, Y. , Fu, Y. , Xiang, Q. , Cheng, F. , Chen, H. , Xu, H. , Fu, L. , Wu, X. , Feng, M. , Ye, L. , Tian, Y. , Deng, R. , Liu, S. , Jiang, Y. , Yu, C. , & Li, J. (2021). Prevalence and associated factors of depression and anxiety among nurses during the outbreak of COVID‐19 in China: A cross‐sectional study . International Journal of Nursing Studies , 114 , 103809. 10.1016/j.ijnurstu.2020.103809 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Zu, Z. Y. , Jiang, M. D. , Xu, P. P. , Chen, W. , Ni, Q. Q. , Lu, G. M. , & Zhang, L. J. (2020). Coronavirus disease 2019 (COVID‐19): A perspective from China . Radiology , 296 ( 2 ), E15–E25. [ PMC free article ] [ PubMed ] [ Google Scholar ]