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• Published: 14 June 2021

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

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

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

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

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

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

Conclusions

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

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

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

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

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

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

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

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

Setting and participants

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

Data collection

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

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

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

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

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

Data analysis

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

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

Ethical considerations

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

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

Distinction based on complexity of care

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

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

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

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

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

Organizing hospital care

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

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

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

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

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

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

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

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

Evidence-based practices in quality improvement work

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

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

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

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

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

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

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

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

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

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

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

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

Limitations

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

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

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

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

Availability of data and materials

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

Abbreviations

Bachelor-trained nurse

Vocational-trained nurse

Evidence-based Practices

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Acknowledgements

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

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

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

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

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

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

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

What is nursing about?

Increasingly, medicine and nursing are beginning to overlap. There is much talk of interprofessional training and multidisciplinary working, and nurses have been encouraged to adopt as their own some tasks traditionally undertaken by doctors. However, in their operation, practice, and culture, nursing and medicine remain quite different. The oft quoted suggestion is that doctors “cure” or “treat” and that nurses “care”, but this is not upheld by research. In a study of professional boundaries, the management of complex wounds was perceived by nurses as firmly within their domain. 5 Nurses justified their claim to “control” wound treatment by reference to scientific knowledge and practical experience, just as medicine justifies its claim in other areas of treatment. One of the most obvious distinctions between the professions in this study was the contrast between the continual presence of the nurse as opposed to the periodic appearance of the doctor. Lawler raises the same point, and suggests that nurses and patients are “captives” together. 6 Questioning the relevance of scientific knowledge, she argues that nurses and patients are “focused on more immediate concerns and on ways in which experiences can be endured and transcended”. This highlights the particular contribution of nursing, for it is not merely concerned with the body, but is also in an “intimate” and ongoing relationship with the person within the body. Thus nursing becomes concerned with “untidy” things such as emotions and feelings, which traditional natural and social sciences have difficulty accommodating. “It is about the interface between the biological and the social, as people reconcile the lived body with the object body in the experience of illness.” 7

What sort of evidence does nursing need?

These arguments suggest that nursing, through its particular relationship with patients and their sick or well bodies, will rely on many different ways of knowing and many different kinds of knowledge. Lawler's work on how the body is managed by nurses illustrates this. 6 She explains how an understanding of the physiological body is essential, but that this must be complemented by evidence from the social sciences because “we also practice with living, breathing, speaking humans.” Moreover, this must be grounded in experiential knowledge gained from being a nurse, and doing nursing. Knowledge, or evidence, for practice thus comes to us from a variety of disciplines, from particular paradigms or ways of “looking at” the world, and from our own professional and non-professional life experiences.

Picking the research design to fit the question

Scientists believe that the social world, just like the physical world, is orderly and rational, and thus it is possible to determine universal laws which can predict outcome. They propose the idea of an objective reality independent of the researcher, which can be measured quantitatively, and they are concerned with minimising bias. The other major paradigm is interpretism/naturalism which takes another approach, suggesting that a measurable and objective reality separate from the researcher does not exist; the researcher cannot therefore be separated from the “researched”. Thus who we are, what we are, and where we are will affect the sorts of questions we pose, and the way we collect and interpret data. Furthermore, in this paradigm, social life is not thought to be orderly and rational, knowledge of the world is relative and will change with time and place. Interpretism/naturalism is concerned with understanding situations and with studying things as they are. Research approaches in this paradigm try to capture the whole picture, rather than a small part of it.

This way of approaching research is very useful, especially to a discipline concerned with trying to understand the predicaments of patients and their relatives, who find themselves ill, recovering, or facing a lifetime of chronic illness or death. Questions which arise in these areas are less concerned with causation, treatment effectiveness, and economics and more with the meaning which situations have—why has this happened to me? What is my life going to be like from now on? The focus of these questions is on the process, not the outcome. Data about such issues are best obtained by interviews or participant observation. These are aspects of nursing which are less easily measured and quantified. Moreover, some aspects of nursing cannot even be formalised within the written word because they are perceived, or experienced, in an embodied way. For example, how do you record aspects of care such as trust, empathy, or “being there”? Can such aspects be captured within the confines of research as we know it?

Questions of causation, prognosis, and effectiveness are best answered using scientific methods. For example, rates of infection and thrombophlebitis are issues which concern nurses looking after intravenous cannulas. Therefore, nurses might want access to a randomised controlled trial of various ways in which cannula sites are cleansed and dressed to determine if this affects infection rates. Similarly, some very clear economic and organisational questions might be posed by nurses working in day surgery units. Is day surgery cost effective? What are the rates of early readmission to hospital? Other questions could include: what was it like for patients who had day surgery? Did nurses find this was a satisfying way to work? These would be better answered using interpretist approaches which focus on the meaning that different situations have for people. Nurses working with patients with senile dementia might also use this approach for questions such as how to keep these patients safe and yet ensure their right to freedom, or what it is like to live with a relative with senile dementia. Thus different questions require different research designs. No single design has precedence over another, rather the design chosen must fit the particular research question.

Research designs useful to nursing

Nursing presents a vast range of questions which straddle both the major paradigms, and it has therefore embraced an eclectic range of research designs and begun to explore the value of critical approaches and feminist methods in its research. 8 The current nursing literature contains a wide spectrum of research designs exemplified in this issue, ranging from randomised controlled trials, 9 and cohort studies, 10 at the scientific end of the spectrum, through to grounded theory, 11 ethnography, 12 and phenomenology at the interpretist/naturalistic end. 13 Future issues of this journal will explore these designs in depth.

Maximising the potential of evidence-based nursing

Evidence-based care concerns the incorporation of evidence from research, clinical expertise, and patient preferences into decisions about the health care of individual patients. 14 Most professionals seek to ensure that their care is effective, compassionate, and meets the needs of their patients. Therefore sound research evidence which tells us what does and does not work, and with whom and where it works best, is good news. Maximum use must be made of scientific and economic evidence, and the products of initiatives such as the Cochrane Collaboration. However, nurses and consumers of health care clearly need other evidence, arising from questions which cannot be framed in scientific or economic terms. Nursing could spark some insightful debate concerning the nature and contribution of other types of knowledge, such as clinical intuition, which are so important to practitioners. 15

In summary, in embracing evidence-based nursing we must heed these considerations:

Nursing must discard its suspicion of scientific, quantitative evidence, gather the skills to critique it, and design imaginative trials which will assist in improving many aspects of nursing

We must promulgate naturalistic/interpretist studies by indicating their usefulness and confirming/explaining their rigour in investigating the social world of health care

More research is needed into the reality and consequences of adopting evidence-based practice. Can practitioners act on the evidence, or are they being made responsible for activities beyond their control?

It must be emphasised that those concerns which are easily measured or articulated are not the only ones of importance in health care. Space is needed to recognise and explore the knowledge which comes from doing nursing and reflecting on it, to find new channels for speaking of concepts which are not easily accommodated within the discourse of social or natural science—hope, despair, misery, love.

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Writing a Nursing Research Paper that Meets Professor's Requirements

As a nursing student, you will spend much time researching, reading, and writing papers. Many students find the entire process of writing research papers challenging.

Imagine on top of spending many hours in clinical practice shifts only to find yourself sparing more time researching and writing, not to mention the overwhelming information condensed in a few hours of in-class lecture sessions. Working shifts and studying while having family duties and obligations worsens it, and when done in a rush, you end up with subpar papers and average grades.

Even though many student nurses find writing research papers tricky and daunting, you can write a perfect paper that ticks all the checkboxes your professor uses to mark them and be sure to get an A+ grade on your nursing paper.

Our expert nursing research writers, who have written thousands of BSN, MSN, DNP, and Ph.D. papers, have compiled this comprehensive guide to help you write a strong nursing research paper that leaves a lasting impression on your professor.

Having marked many papers and supervised many theses, capstone projects, and dissertations, you can trust that the information herein is valuable and timely in your pursuit of nursing career success.

What is a Nursing Research Paper?

A nursing research paper is a scholarly and thesis-driven paper that a nursing student (at ADN, BSN, MSN, DNP, or Ph.D. level) writes to comprehensively explore a specific nursing research topic either of their choice or one that the professor assigns.

To write a perfect research paper, the student has to provide concrete, reliable, and trustworthy evidence. In most cases, even professionals such as RNs undertaking clinical practice, nursing education training, clinical studies and evaluations, and nursing research can also write research papers published in journals or conferences to advance and disseminate nursing knowledge. The typical length of most nursing papers ranges from 5 pages to 20 pages, depending mainly on the complexity of the subject, the word count limits, and the requirements. Nurses and nursing students write research papers to share their insights as they learn more about nursing processes and practices. Nursing research papers are used to: document research, organize information, advance nursing scholarship, and improve the writing skills of nurses. Students in the USA, Australia, Japan, and Canada write their research papers in the American Psychological Association (APA) format, while those in Australia and the UK write them in Harvard formats. The research papers fall under three main categories:

• Analytical research papers. These papers present an analysis of the topic using evidence, facts, and examples.
• Argumentative research papers. These research papers are analytical but with a twist where the writer uses evidence to reinforce their opinion and persuade the reader.
• Expository research papers. This category of nursing research papers explains the subject matter using credible evidence such as examples, facts, statistics, and other pieces of evidence.

Structure and Format of a Nursing Research Paper

A simple nursing research paper, especially an expository or informative type, can have 5 paragraphs, like a typical essay. However, longer research papers have additional sections.

Scientific Nursing Research Paper Structure

Here is a breakdown of how a well-formatted and scientific nursing research paper should look like.

• Title Page. The title page comprises the research paper title, details of the student or professional writer, course details, details of the school or institution, and the date. The cover page is the first contact point with the reader. It is brief.
• Abstract. The abstract summarizes the nursing research paper. It is 200-250 words long and should be focused on what the reader expects. It is a condensed version of the paper, which is critical to help professors know what your paper is about. It should not have acronyms. Note that the word count of the abstract is not considered part of the research paper.
• The Introduction. The introduction should have an attention-getter or a hook that can be a statement, statistic, or fact. It should be 10% of the entire word count. It also has background information that details the nursing issue or topic you are exploring. It also comprises a well-thought-out thesis statement related to the topic. If you have a long paper, ensure that your problem and purpose statements are part of the introduction. It should also list your PICOT question .
• Literature Review. This is a critical section of the research paper. Here, you should explore other nursing scholars' thoughts and scholarly findings. Focus on peer-reviewed scholarly articles that address the same issue as your thesis statement or topic. Explore your topic's theories, theoretical frameworks, and other facts. Do it so well that your professor marvels at your research, organization, and writing prowess. Consider the levels of evidence as you choose selection criteria for the papers to include in your nursing literature review.
• Research Methodology. This section of the research paper details the data collection methods, such as ethnographic studies, secondary data collection, literature review, quasi-experimental research, correlational studies, descriptive research, ethnography, phenomenology, grounded theory, meta-analyses, systematic reviews, or experiments. Ensure that you state and give a rationale for your research design (qualitative, quantitative, or mixed-methods). If you are writing a quantitative paper, explain how you tested the hypotheses. Also, report the sampling frame and the sampling strategy.
• Results and Discussion. This section of the paper presents the findings. You can use visual aids such as charts and graphs for a quantitative research paper. If you are writing a qualitative research paper, present the evidence chronologically. When presenting the findings, avoid making definitive facts. Instead, ensure that the results suggest something is true or false, even when testing a hypothesis.
• Conclusion and Recommendations. The conclusion should be 10% of the entire word count. You should restate the thesis and give a summary of your entire paper. Explore the recommendations for future research on the topic.
• Ensure that your reference list is arranged alphabetically. The list should adhere to the formatting requirements (Harvard, ASA, or APA formats). Only use scholarly peer-reviewed references.

Format for a General Nursing Research Paper

If you are writing a non-scientific nursing research paper, you will only have three sections as follows:

• Introduction. The introduction paragraph should introduce the topic by providing an attention-getter, background information, and a thesis statement.
• Body of the paper . The body paragraphs should have strong topic sentences, supporting details (examples, evidence, and explanation), and concluding sentences. It should also portray a good use of transition words. You should analyze the topic and use evidence to support the arguments, and give enough explanation. Use in-text citations within the body paragraphs.
• Conclusion. End the paper by recapping the main points, reasserting the thesis statement, and signaling the end of the paper to give your readers good closure.

An excellent nursing research paper follows this structure as long as it is not research-based. The three-part approach is super recommended if you did not conduct any study. In most cases, when assigned to write those 5-12 pages of nursing school research papers, you will be using this format.

So, what are the steps for writing a good nursing research paper? Let’s find out in the next section.

The 6 Main Steps for Writing a Nursing Research Paper

Writing assignments are an essential training aspect for nursing students. No wonder professors will stress that you write essays, discussion posts, responses, or proposals well. They are doing so to prepare you for research roles somewhere in your nursing career.

According to our most successful research paper writers, writing a top-grade research paper involves decoding the instructions, selecting a good topic, planning, researching, writing, and polishing the paper.

Here is a breakdown of each step for clarity and deeper understanding.

Step #1: Understand the Prompt or Instructions

You can only perfect what you know! Therefore, you can begin the research writing process by reading, analyzing, and understanding the instructions. It is an essential pre-writing stage process where you carefully read the instructions.

Although it sounds obvious, most nursing students who write off-topic and subpar research papers jump into writing without reading to understand the instructions.

You need to skim through the instructions on the first attempt, then read keenly and critically as you take note of the scope of the assignment, the topic, and other things you must fulfill in the paper. Take note of the:

• The number of words.
• Type of research paper (argumentative, analytical, exploratory, or persuasive).
• The structure of the paper (thesis-driven or research/study-based (scientific) research paper.
• The deadline.
• Whether you need to draft an outline.
• Reading materials.
• Whether you need external sources.
• Which sources to use and how many?
• The theoretical constructions or conceptual frameworks.
• The age limit of the scholarly sources.

If you need further clarification, ensure that you ask your peers, professor, or a professional writer in time.

Step #2: Select a Good Nursing Research Topic

Compared to average students, top nursing students always remember to select a research topic they are comfortable handling. When you are confident with a topic, you can develop it without procrastinating.

Sometimes you are given a list of nursing research paper topics, issues, and ideas to consider. Other times, you come up with the topic and consult your professor/educator for approval.  

Choose topics related to patient safety, nursing processes, nurse staffing, nursing policies, nurse privileges, nursing legislations, nursing ethics, mental health, health promotion, chronic disease management, healthcare systems, health informatics, changes in healthcare, and working conditions.

Choose any nursing topic that resonates with your specialization interests. It should be manageable, relevant, and explorable.

Related Readings:

• Nursing informatics research topics
• Capstone project ideas and topics for BSN, MSN, and DNP students
• Mental health nursing topics
• Epidemiology nursing topics
• List of the best nursing research paper topics
• Evidence-based nursing topics and ideas
• Nursing ethical dilemmas

Step #3: Plan your Paper

Create a thesis statement for your research paper if it is thesis-driven rather than study-based or scientific (experimental). After writing the thesis, like any of our nursing assignment slayers, write a good outline using Roman numbers and numbers.

List the ideas you wish to have in your paper in chronological order, starting with the introduction, body, and concluding paragraphs. As you outline, do some preliminary research so that you develop arguments the right way.

Include the in-text citations in your nursing research paper outline to simplify the writing process.

Step #4: Research and Organize Resources

Doing in-depth research as you refine the draft would be appropriate because you know what you want the paper to look like. Use scholarly nursing databases for research and limit yourself to topic-related scholarly articles published within the last 5 years.

You can read the abstracts of the articles to determine if they are fit to use in your paper. If you find the best articles, list them using online citation management tools such as RefWorks, Zotero, EndNote, Citefast, or any of your choice.

Ensure to list them in the most appropriate formatting styles. Take notes and list the points and ideas in your outline. Do your research meticulously and ensure that you organize the process to avoid any confusion.

Step #5: Write the First Draft

With the research, synthesis, and outline, you are now left with the chance to put rubber on the road. Use the Pomodoro technique, where you spend stretches of 25 minutes of focused work and have minor 5-minute breaks.

Ensure you cover as much ground in your research paper as possible before three-quarters of the deadline. When writing the paper, and considering that you have the outline, you can start chronologically from the introduction to the appendices.

Most research paper writing pros prefer working on the body section and conclusion before writing the introduction and finalizing the abstract. Whatever works best for you, adopt it. When writing the first draft, focus on piecing together the information rather than perfection.

Ensure you research lightly as you write and assert your voice while giving the right in-text citations for every idea you paraphrase from a source to avoid plagiarism. Each body paragraph should only have one idea.

Step #6: Edit, Proofread, and Polish the Paper

The final step towards completing your nursing research paper is ensuring everything is in its rightful place. A polished research paper scores 90% and above, which is an A. Begin by reading the paper aloud to identify areas that do not make sense.

If there is a need, do not hesitate to rewrite an entire section so that you have the right flow of information.

Check the grammatical, spelling, and syntax errors and make necessary corrections. You should also check the tenses used in the paper. If you feel like polishing the essay is too much work, you are better off hiring a nursing paper proofreader/editor.

When you receive feedback from your educator or professor, address the changes and resend the paper for grading.

Related Reading: How to write an evidence-based nursing paper.

Valuable Tips to Consider as You Write Your Nursing Research Paper

Nursing schools and educators have their standards and guidelines for writing a research paper. Therefore, ensure that before everything else, you familiarize yourself and adhere to these instructions, which include word count and citation styles.

Do not assume anything when writing a paper. You should also access and understand suggestions from your school’s writing lab. Apart from these essential tips, also ensure that you follow the insights we give below:

• Write your paper using a formal tone. Do not use passive voice when writing the paper. Instead, use active voice.
• Your paper should have a good organization from the introduction to the conclusion.
• Whenever you borrow ideas from a scholarly source, ensure you cite them correctly.
• Have a well-thought-out thesis statement that clarifies your arguments.
• Create a complete outline during the early stages of writing. It gives you a roadmap to follow as you write the paper. Organize the ideas chronologically based on their strength and weaknesses.
• Have a plan and schedule to trace your progress with the paper.
• If you have a more extended deadline, contribute to your research paper daily.
• When writing the paper, start with the body, the conclusion, and the introduction last.
• If you are writing a study-based research paper, include the literature review, methodology, discussion, and conclusion sections per the IMRAD format. A general nursing research paper follows the essay structure: introduction, body section, and conclusion.
• Use peer-reviewed scholarly sources from CINAHL, PubMed, Nursing Reference Center, Cochrane Library, MEDLINE, and other nursing research databases with peer-reviewed articles. Credible sources mean your research paper has rigor since you have strong points.
• Proofread and edit the paper thoroughly to remove any mistakes to signal your seriousness to your professor. If possible, use professional editing services.
• Have a compelling conclusion that is elaborate, clear, and concise.
• Read your paper aloud to identify mistakes.
• Revise the paper, and do not fear rewriting an entire section.

When writing a research paper, adhere to the writing conventions. You should also read well and understand how to communicate through academic writing effectively. Your paper should document evidence that supports your arguments and topic.

Write concisely, coherently, and accurately. It is not all in vain; you are training for your future role as a nurse when you will write conference papers, white papers, essays, policy documents, letters, blog posts, and professional nursing articles.

Checklist for a Great Research Paper in Nursing

Now that you have written your paper, you must align a few things to make it the best your professor will read. Most nursing classes, especially at the graduate levels (MSN, DNP, and Ph.D. levels), have small class sizes, and the professors spend time reading the papers from start to end. This means that you should leave nothing to chance.

Nursing research asserts professional identity, ensures accountability in nursing decision-making, and expands nursing practice. You have to be meticulous when writing a research paper in nursing.

A good research paper demonstrates a complete understanding of nursing knowledge, topic exploration, advanced organization, proper formatting, and mature academic writing skills. The following checklist enlists some main aspects to countercheck before hitting the submit button.

• Have I followed all the instructions outlined in the assignment prompt or rubric?
• Does my paper have the right title page?
• Does the paper have a written title that resonates with the thesis and the research question?
• Is the introduction presenting an attention grabber, background information, and a signpost of the ideas in the paper?
• Is the thesis statement well-thought-out, clear, concise, and elaborate?
• Is the problem statement clearly stated?
• If it is a PICOT-based research paper, is the PICO question well-outlined?
• Does the paper touch well on the nursing issue that the topic needs it to address?
• Is there a logical flow of the paragraphs?
• Are the words in each paragraph balanced?
• Does the paper have correctly formatted headings and subheadings?
• Are the in-text citations done correctly and consistently?
• Does every paragraph in the body of the paper build on the thesis?
• Does the paper demonstrate a mature choice of words and uses nursing lingo?
• Is the literature review section comprehensive? Does it have a theoretical and conceptual framework or constructs?
• Are the data and information presented in the literature review current?
• Has the methodology section listed the sample, sampling strategy, data collection and analyses, and rationale for each?
• Does the discussion section interlink the concepts from the literature review with the findings?
• Does the conclusion offer good closure to the readers? Does it restate the thesis? Does it summarize the recommendations?
• Is the entire paper formatted correctly? Does it follow the formatting guidelines?
• Is the paper devoid of spelling, syntax, and mechanical mistakes?

If your answer to all these questions is a resounding YES, you are sure it will fetch your professor a good grade. Our nursing writers, most of whom are alumni from top nursing universities and colleges such as Chamberlain, Capella, Herzing, Vanderbilt, SFU, Rutgers, Yale, Duke, NYU, UCLA, University of Pennsylvania, University of Toronto, McGill, Ottawa, Queens, and other best colleges in the USA, UK, Canada, and many other places. Besides, they are nursing educators in different capacities, and a couple are nursing professors with big titles; you can trust the checklist to guarantee you an excellent grade.

Where to Get Help When Writing Research Paper

As a nursing student, writing a research paper is something you will most likely enjoy doing. However, unforeseen things happen, prompting you to search the internet for sites to help you do your nursing research paper. NurseMyGrade.com is one such place to pay a nursing writer to do your paper.

Expect a paper that meets all the requirements, is written by a human rather than AI software, and is uniquely tailored to your requirements.  Our rates are affordable, and our writers cover diverse fields. Apart from offering advice about research, writing, and formatting papers, we have resourceful writers whom we allow you to communicate directly with via our platform.

We also maintain high levels of secrecy because we care more about your privacy and confidentiality of your details. Not even your professor can tell you got help from our website because we advise on specific strategies to use the paper. We have assisted students in various levels of nursing education with their writing, and we can do yours too.

Get affordable, well-researched, formatted, and organized nursing research papers done for you today by filling out the order form. Nursing research papers are a chance to stand out. Let our professionals help you achieve your nursing school goals.

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Online Research Guide for Nursing Students

• Conducting Online Research
• Research Tools

Evaluating Sources

• Organizing Research

Are you ready to earn your online nursing degree?

Effective online nursing research skills can make a tremendous difference for your academic success in nursing school and throughout your career. Medicine and nursing change rapidly, and knowing how to conduct nursing research online keeps your skills and knowledge current.

Successful research includes both how to use nursing literature search engines and how to analyze the information you find. This helps you distinguish between reliable information that supports evidence-based nursing and misleading information that can influence your ability to care for patients.

This guide can help you find and effectively use the best nursing research websites and other research tools, whether you need a writing guide for nurses , continuing education coursework, or just hope to increase your knowledge in the field.

Conducting Online Research for Nursing Students

You can conduct most of your nursing research online, but some sources may not be available online. For example, your school library may subscribe to print journals not published on the internet. Many important books only exist in print.

Your school or hospital librarian is an invaluable resource to help you find materials online or in print. If your school or hospital doesn’t have a specific book or article, the librarian might be able to get it through an interlibrary loan service.

You can use only online nursing research tools if the most significant publications on a topic are available online. Otherwise, consider using print resources too.

Refining Your Search Results

When conducting online research, you must filter out unreliable sources and locate search results relevant to your topic. Fortunately, Google searches and other nursing literature search engines have tools to help you narrow your research to get the most reliable results.

In addition to open web searches, you can use the specialty nursing literature search engines listed below.

Google Scholar

Google Scholar has special features to make it easier to find the most relevant professional literature on a topic. Besides letting you refine your search by date, it displays related articles or other articles by the author. If the piece is available in full-text online, Google Scholar links to the page. If not, you can search to see if your library has the article or can get you a copy.

Google Scholar also tells you how many other papers cite a particular source. While this doesn’t necessarily mean that an article has reliable and current information, it does demonstrate the article’s influence.

The search engine also offers tools to help you manage your research projects and write papers. You can create a citation in several standard formats and save an article to a list. You can make as many lists as you like, such as one for different topics or assignments.

If you want to follow a specific topic, refine your search to give you preferred results, and then select “create alert.” You will then receive emails with new articles as Google Scholar indexes them.

Online Research Tools

Google reigns as the most popular search engine, but many other online resources exist. Students may use several search engines and databases geared specifically toward academic searches. Many of these sites offer free or discounted services to students. Your school’s library may also provide access.

The list below describes some of the most common resources for academic research, including some sites that focus on online research for nurses.

General Academic Research Tools

• BASE : Bielefeld Academic Search Engine offers results in a variety of academic disciplines. About 60% of the indexed documents are available for free. Results must meet BASE’s high academic standards for relevance and quality.
• CGP : The Catalog of U.S. Government Publications allows users to search official documents published by the U.S. government, including current and historical sources.
• CIA World Factbook : The Central Intelligence Agency’s World Factbook provides information on 267 countries and other entities around the world. This information includes maps and data on each entity’s history, people, geography, government, and economy.
• ERIC : The U.S. Department of Education’s Institute of Education Sciences hosts ERIC. This database uses a formal review process to decide which scholarly articles, papers, reports, and other documents to include in its index.
• iSeek Education : This resource compiles scholarly materials from noncommercial providers, including university and government sources. The searchable service allows users to bookmark items they wish to refer to later.
• National Archives : This searchable catalog includes descriptions for 85% of the National Archives’ holdings, including documents, web pages, pictures, audio files, and videos. Users can also view more than two million digitized copies of government records.
• OCLC : The OAIster catalog pools open-access resources from libraries, museums, archives, and cultural heritage organizations.
• CORE : CORE collects open-access research materials from sources around the world and indexes them in a searchable database. The public can use CORE free of charge.

Nursing Research Tools

• CINAHL Complete : The Cumulative Index of Nursing and Allied Health Literature offers a large database of research material for nurses and students. The site provides full-text access to resources, including journals, care sheets, and continuing education modules.
• MedScape : Medscape provides the latest medical news, research updates, case studies, continuing education opportunities, and disease and drug information for healthcare professionals around the world.
• National Institute of Nursing Research : Part of the National Institutes of Health, the NINR provides support for nursing research. The website hosts information on research conducted through their programs.
• Nursing Reference Center : The Nursing Reference Center features various resources for nurses, including care sheets about diseases and treatment options, drug information, information on treating patients from diverse cultural backgrounds, patient handouts, and lessons about diseases and conditions.
• PubMed : PubMed is a searchable database operated by the U.S. National Library of Medicine at the National Institutes of Health. The site provides abstracts and full-text articles from journals, books, and other publications about life science and medicine.
• Sigma Repository : The Sigma Repository boasts an open-access database of nursing research and practice materials created by nurses. Sigma Theta Tau International, the nursing honor society, sponsors this free resource.

When you conduct research on the web, you must evaluate the reliability of your sources. If your information comes from an untrustworthy source, the quality of your research will suffer and the data you gather may lead to incorrect conclusions.

When you need to determine an online information source’s reputation, you can ask yourself some questions to help evaluate its quality. The questions below include tips from Georgetown University and the University of Chicago Press.

Who Is the Author?

Find the name of the article’s author or creator. Then locate the author’s credentials to determine whether their education and experience qualifies them to speak as an authority on the topic. You also can search for the author’s other works or more information about them.

If the source does not list an author, look at the domain to see whether it belongs to a reputable entity.

What Is Its Purpose?

Look at the article and the hosting site. Who is the intended audience? Is the information for academics and experts or the general public? Why was it written and posted? Is it intended to inform or educate the reader, or does it attempt to persuade the reader to view a topic in a certain way? Is it meant to sell a product or service?

A noncommercial source that intends to educate the reader without persuasion is most likely to be reliable.

Does It Look Professional?

When you view the website and read the article, take note of any errors in grammar or spelling. The site’s content should appear clean and organized. Poorly organized content and errors in the text indicate unprofessionalism, as does the use of profanity.

If the site emphasizes images over text or appears to focus on selling products or services, it may not be a reliable source for scholarly information.

Is It Objective?

Academic sources should show objectivity and must not present opinions as hard data. Consider whether the information is fact or opinion. Does the author show any bias? Is the information officially endorsed or approved by an organization? If so, determine whether the organization takes an official position on the issue at hand.

Is It Current?

When researching science and medical topics, students must find the most current information. Scientific knowledge progresses rapidly, and new research appears frequently.

Check the publishing date listed on your source. If it is more than a few years old, look for more current sources on the same topic. If a website has not been updated recently, this also may indicate information is outdated.

What Sites Does It Link To?

The links featured in your source may provide clues about the information’s reliability. The links should relate to the site’s purpose or the topic at hand. In most cases, a source should link back to research which supports the text. Students may find this information within the text or in a references list.

Test the links to make sure they work. If the links are broken, the information may be old or outdated.

Organizing Your Research

You will most likely browse a large amount of information as you conduct research online. To avoid becoming overwhelmed, you must remain organized before, during, and after your search. Remember that you must cite all your sources accurately.

If you develop a consistent system for locating and organizing your information, your research efforts will be more efficient and accurate. Below are a few basic tips to help you manage and organize your online research.

Online Tools to Manage Your Research

• EasyBib : This tool helps you improve your writing, take notes, avoid unintentional plagiarism, and add citations in your choice of style. Options include MLA, APA, and Chicago. EasyBib offers basic services and MLA citations for free. Users pay a monthly fee for additional access.
• Endnote : This software package manages references and bibliographies. EndNote provides research tools and allows teams to share documents, files, and other materials. The software offers student pricing.
• Mendeley : Designed for science and technology research, Mendeley helps store and organize research documents and files. Mendeley manages citations and lets users connect with others in a research network.
• RefWorks : This web-based reference management tool stores the user’s reference database in an online portal. Some universities grant their students free access to RefWorks.
• Zotero : This free, open-source software helps users find research materials and organize their information. Zotero manages citations, documents, and other research materials.

Citing Online Resources for Nursing Students

When you write a research paper or create a research presentation, you must follow a consistent format and include a bibliography of all the sources you used. Several popular editorial styles exist. Science and social science disciplines, including nursing, most frequently use the Publication Manual of the American Psychological Association, commonly known as APA style .

Alternatively, some institutions require AMA style , created by the American Medical Association. The style you use depends on the institution you attend. These editorial styles establish a consistent format for researchers to follow when publishing their work. They cover aspects of writing, such as punctuation, accepted abbreviations, headings, and formatting for statistics and tables.

Style also dictates a specific format for listing citations, including the order in which the information must appear and the punctuation required. This formatting makes it easy for readers to retrieve sources that may interest them.

Several examples of APA style from the Purdue Online Writing Lab appear below. You can find an expanded list of such examples on the Purdue website.

Articles From Online Periodicals

What is a doi.

When an article is published electronically, the publisher assigns a unique digital object identifier (DOI) to it. The DOI provides a permanent identification code and internet link for the article. APA style recommends that you include the DOI in any citation for which it is available. See the examples below.

Author, A. A., & Author, B. B. (Date of publication). Title of article. Title of Journal, volume number , page range. doi:0000000/000000000000 or http://doi.org/10.0000/0000

Brownlie, D. (2007). Toward effective poster presentations: An annotated bibliography. European Journal of Marketing, 41 , 1245-1283. doi:10.1108/03090560710821161

Without DOI

Author, A. A., & Author, B. B. (Date of publication). Title of article. Title of Journal, volume number . Retrieved from https://www.journalhomepage.com/full/url/

Kenneth, I. A. (2000). A Buddhist response to the nature of human rights. Journal of Buddhist Ethics, 8 . Retrieved from https://www.cac.psu.edu/jbe/twocont.html

Newspaper Articles

Author, A. A. (Year, Month Day). Title of article. Title of Newspaper . Retrieved from https://www.homeaddress.com/

Parker-Pope, T. (2008, May 6). Psychiatry handbook linked to drug industry. The New York Times . Retrieved from https://well.blogs.nytimes.com/

Electronic Books

Last name, A. A. (n.d.). Title . Available from https://www.urlofebook.com/full/url/

Davis, J. (n.d.). Familiar birdsongs of the Northwest . Available from https://www.powells.com/cgi-bin/biblio? inkey=1-9780931686108-0

The AMA Manual of Style details official guidelines for writing and citing medical research. The style is maintained by the American Medical Association. The examples below originate from the Arizona Health Sciences Library website and the USciences website .

No Author Name Provided

Name of organization. Title of specific item cited. URL. Accessed date.

International Society for Infectious Diseases. ProMED-mail Website. https://www.promedmail.org. Accessed April 29, 2004.

Author Name Provided

Author A. Title. Name of website. URL. Updated date. Accessed date.

Sullivan D. Major search engines and directories. SearchEngineWatch Website. https://www.searchenginewatch.com/links/article.php/2156221. Updated April 28, 2004. Accessed December 6, 2005.

Online Journal Article With Six or Fewer Authors — DOI Included

Author A. Title. Name of online journal. URL. Publication year;volume(issue):page numbers. doi.

Florez H, Martinez R, Chakra W, Strickman-Stein M, Levis S. Outdoor exercise reduces the risk of hypovitaminosis D in the obese. J Steroid Biochem Mol Bio . 2007;103(3-5):679-681. doi:10.1016 /j.jsbmb.2006.12.032.

Online Journal Article With Six or More Authors — DOI Not Included

Author A. Title. Name of online journal. URL. Publication year;volume(issue):page numbers. Access date.

Siris ES, Miller PD, Barrett-Connor E, et al. Identification and fracture outcomes of undiagnosed low bone mineral density in postmenopausal women: results from the National Osteoporosis Risk Assessment. JAMA. 2001;286(22):2815-2822. https://jama.ama-assn.org/cgi/reprint/286/22 /2815. Accessed April 4, 2007.

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Best Nursing Research Topics for Students

What is a nursing research paper.

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

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

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

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

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

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

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

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

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

About Nursing Research Papers

When do nursing students write research papers.

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

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

Do Nursing Students Conduct Original Research?

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

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

Example Research Project Scenario:

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

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

What Does a Nursing Research Paper Include?

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

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

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

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

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

How to Choose a Nursing Research Topic

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

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

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

The Best Research Topics for Nursing Students

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

1. Clinical Nursing Research Topics

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

2. Community Health Nursing Research Topics

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

3. Nurse Education Research Topics

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

4. Mental Health Nursing Research Topics

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

5. Pediatric Nursing Research Topics

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

6. The Nursing Profession Research Topics

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

Tips for Writing a Nursing Research Paper

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

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

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

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

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

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

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

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

Helpful Nursing Research Writing Resources:

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

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

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

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

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

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

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Nursing Research

Nursing research worldwide is committed to rigorous scientific inquiry that provides a significant body of knowledge to advance nursing practice, shape health policy, and impact the health of people in all countries. The vision for nursing research is driven by the profession's mandate to society to optimize the health and well-being of populations (American Nurses Association, 2003; International Council of Nurses, 1999). Nurse researchers bring a holistic perspective to studying individuals, families, and communities involving a biobehavioral, interdisciplinary, and translational approach to science. The priorities for nursing research reflect nursing's commitment to the promotion of health and healthy lifestyles, the advancement of quality and excellence in health care, and the critical importance of basing professional nursing practice on research.

As one of the world leaders in nursing research, it is important to delineate the position of the academic leaders in the U.S. on research advancement and facilitation, as signified by the membership of the American Association of Colleges of Nursing (AACN). In order to enhance the science of the discipline and facilitate nursing research, several factors need to be understood separately and in interaction: the vision and importance of nursing research as a scientific basis for the health of the public; the scope of nursing research; the cultural environment and workforce required for cutting edge and high-impact nursing research; the importance of a research intensive environment for faculty and students; and the challenges and opportunities impacting the research mission of the discipline and profession.

Approved by AACN Membership: October 26, 1998 Revisions Approved by the Membership: March 15, 1999 and March 13, 2006

• Introduction
• Conclusions
• Article Information

A, Nursing homes (NHs) with a high proportion of vaccinated staff were in the top quartile (highest 25%) of staff vaccination rates; NHs with a low proportion of vaccinated staff were in the bottom quartile (lowest 25%) of staff vaccination rates. B, Quartiles of staff vaccination rates are calculated for each week and thereby vary for each week. C and D, Data represent facility-weeks between May 30 and December 5, 2021.

A, Regressions controlled for facility and week fixed effects and adjust for resident, staff vaccination rates, county-level COVID-19 prevalence per 1000 population, and direct care staff hours per resident day. B and C, Data represent facility-weeks between May 30 and December 5, 2021.

eFigure 1. Timeline of COVID-19 Vaccination Policies in Nursing Homes

eFigure 2. Construction of Analytic Sample

eFigure 3. Unadjusted Associations Between Staff Vaccination Rates and COVID-19 Outcomes in Nursing Homes (May 30, 2021, to January 23, 2022)

eTable 1. COVID-19 Outcomes Across Nursing Homes in the Top and Bottom Quartiles of Staff Vaccination Rates

eTable 2. Effect of Staff Vaccination Rates (SVR) on COVID-19 Outcomes in Nursing Homes: Results From Negative Binomial Regression Models

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Sinha S , Konetzka RT. Association of COVID-19 Vaccination Rates of Staff and COVID-19 Illness and Death Among Residents and Staff in US Nursing Homes. JAMA Netw Open. 2022;5(12):e2249002. doi:10.1001/jamanetworkopen.2022.49002

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Association of COVID-19 Vaccination Rates of Staff and COVID-19 Illness and Death Among Residents and Staff in US Nursing Homes

• 1 Department of Public Health Sciences, Biological Sciences Division, University of Chicago, Chicago, Illinois
• 2 Department of Medicine, Biological Sciences Division, University of Chicago, Chicago, Illinois

Question   Are higher staff vaccination rates associated with lower adverse outcomes of COVID-19 in nursing homes?

Findings   This cohort study of 15 042 nursing homes found that, holding everything else constant prior to the Omicron variant wave, an increase in staff vaccination rates of 10 percentage points was associated with fewer weekly COVID-19 cases among residents, fewer weekly COVID-19 deaths among residents, and fewer weekly COVID-19 cases among staff. During the Omicron wave, increased staff vaccination rates were not associated with lower adverse COVID-19 outcomes.

Meaning   These findings suggest that before the Omicron wave, increasing nursing home staff vaccination rates was associated with fewer COVID-19 cases and deaths among residents and fewer COVID-19 cases among staff.

Importance   It is important to understand the association between staff vaccination rates and adverse COVID-19 outcomes in nursing homes.

Objective   To assess the extent to which staff vaccination was associated with preventing COVID-19 cases and deaths among residents and staff in nursing homes.

Design, Setting, and Participants   This longitudinal cohort study used data on COVID-19 outcomes in Medicare- and Medicaid-certified nursing homes in the US between May 30, 2021, and January 30, 2022. Participants included the residents of 15 042 US nursing homes that reported COVID-19 data to the Centers for Disease Control and Prevention and passed Centers for Medicare & Medicaid Services data quality checks in the National Healthcare Safety Network.

Exposures   Weekly staff vaccination rates.

Main Outcomes and Measures   Main outcomes are weekly COVID-19 cases and deaths among residents and weekly COVID-19 cases among staff. The treatment variable is the primary 2-dose staff vaccination rate in each facility each week.

Results   In the primary analysis of 15 042 nursing homes before the Omicron variant wave (May 30 to December 5, 2021) using fixed effects of facility and week, increasing weekly staff vaccination rates by 10 percentage points was associated with 0.13 (95% CI, −0.20 to −0.10) fewer weekly COVID-19 cases per 1000 residents, 0.02 (95% CI, −0.03 to −0.01) fewer weekly COVID-19 deaths per 1000 residents, and 0.03 (95% CI, −0.04 to −0.02) fewer weekly COVID-19 staff cases. In the secondary analysis of the Omicron wave (December 5, 2021, to January 30, 2022), increasing staff vaccination rates were not associated with lower rates of adverse COVID-19 outcomes in nursing homes.

Conclusions and Relevance   The findings of this cohort study suggest that before the Omicron variant wave, increasing staff vaccination rates was associated with lower incidence of COVID-19 cases and deaths among residents and staff in US nursing homes. However, as newer, more infectious and transmissible variants of the virus emerged, the original 2-dose regimen of the COVID-19 vaccine as recommended in December 2020 was no longer associated with lower rates of adverse COVID-19 outcomes in nursing homes. Policy makers may want to consider longer-term policy options to increase the uptake of booster doses among staff in nursing homes.

The tragic effects of the COVID-19 pandemic in nursing homes have been well established. To date, residents and staff in nursing homes have accounted for approximately 2.16 million cases and close to 155 000 deaths from COVID-19 in the US. 1 Staff in nursing homes, often risking their own health during the pandemic, provide hours of hands-on care per day and are responsible for maintaining the physical, mental, and psychosocial well-being of residents. Research has shown that higher staffing ratios were helpful in containing outbreaks in nursing homes. 2 However, studies have also found that more staff traffic between facilities and in and out of areas with high virus prevalence was associated with more cases and deaths in the nursing homes where the staff worked. 3 , 4 To mitigate this risk, when vaccines became available in December 2020, staff and residents in nursing homes were among the first to be deemed eligible for vaccination. 5

States began vaccinating nursing home staff and residents as early as December 14, 2020, and facilities were mandated to report data on vaccination rates from May 23, 2021. The initial data indicated that while the uptake of vaccinations among nursing home residents was in the range of 71.4% to 85.7%, uptake of vaccinations among staff in nursing homes varied substantially, between 31.0% and 82.0%. 6 Given the wide variation in staff vaccination rates in nursing homes and low rates on average, and given convincing evidence that staff were a primary, if inadvertent, source of COVID-19 outbreaks, a federal mandate requiring vaccinations for all health care workers, including health care workers in nursing homes, was issued on November 5, 2021 7 (a timeline of vaccination policies is provided in eFigure 1 in Supplement 1 ).

The evidence base on the effectiveness of the mandate in preventing COVID-19 cases among nursing home residents is weak. One cross-sectional study 6 in December 2021 found lower levels of COVID-19 cases and deaths among residents in facilities with higher levels of staff vaccination rates during the Delta wave. However, that study was subject to confounding by facility characteristics and could not inform the extent to which increases in vaccination rates over time would lead to improvements in COVID-19 outcomes. 6 Thus, ongoing policy around staff vaccinations has been made in the absence of a robust evidence base. The present study fills a key gap in the literature by providing estimates on the magnitude to which increasing staff vaccination rates over time were associated with mitigating adverse COVID-19 outcomes among staff and residents in nursing homes in the United States. We also examined the extent to which the 2-dose vaccine regimen for staff in nursing homes continued to be associated with lower adverse COVID-19 outcomes during the Omicron wave of the COVID-19 pandemic.

In this cohort study, we derived data on weekly staff vaccination rates and weekly COVID-19 cases and deaths among residents and staff from the National Healthcare Safety Network (NHSN). This study was determined to be exempt from review by the Biological Sciences Division of the University of Chicago Institutional Review Board owing to the use of publicly available data. The study followed the Strengthening the Reporting of Observational Studies in Epidemiology ( STROBE ) reporting guideline.

Although the NHSN now includes data on booster shots, these data are highly incomplete and therefore unusable for our purposes; thus, by vaccination rates , we mean only the original COVID-19 vaccination regimens. Using the facility provider identification number from the NHSN files, we merged these data with 3 sources of facility-level data: the Payroll Based Journal, 8 LTCFocus (Long-term Care Focus), 9 and Nursing Home Compare archives. The Payroll Based Journal provided data on direct care staff hours per resident day during the study period; LTCFocus provided data on aggregated resident characteristics as of 2018; and the Nursing Home Compare archives provided data on nursing home characteristics as of the last quarter of 2021.

We used county-level identifiers from the NHSN to merge our COVID-19 facility-level data sets with 3 sources of county-level data: County Health Rankings, 10 the US Census Bureau, and USAfacts.org. 11 County Health Rankings provided county-level estimates of Black and Hispanic populations in the community and the percentage of the population living without insurance; the US Census Bureau provided county-level estimates of the percentage of the population living in poverty and with Medicaid. USAFacts.org provided data on the prevalence of COVID-19 in the community over time.

For our primary analysis, we restricted our sample to the period after Centers for Medicare & Medicaid Services (CMS) started reporting data on COVID-19 vaccinations in nursing homes (May 30, 2021) and before the Omicron wave of the COVID-19 pandemic (December 5, 2021). To capture the association of staff vaccination rates on COVID-19 outcomes during the Omicron wave of the COVID-19 pandemic, for our secondary analysis we restricted the sample to the period between December 5, 2021, and January 30, 2022. We consider these 2 periods separately because the hypothesized effects of vaccination may differ. Prior to the Omicron wave, the original vaccination regimen (2 doses of BNT162b2 or mRNA-1273 vaccine or 1 dose of JNJ-78436735 vaccine) was shown to be highly effective in reducing risk of infection or adverse outcomes; this same regimen proved to be less effective against the Omicron variant and led to the use of booster shots. 12 , 13 For both sets of analyses, we restricted our sample to facilities that reported complete data on staff vaccination rates, COVID-19 cases, and deaths among residents and staff to the Centers for Disease Control and Prevention for all reporting weeks and that passed the CMS data quality assurance checks. Our final analytic samples consisted of 15 042 nursing homes for the primary analysis and 14 879 nursing homes for our secondary analysis (see eFigure 2 in Supplement 1 ).

We examined the association of weekly staff vaccination rates with 3 outcomes: weekly COVID-19 cases per 1000 residents, weekly COVID-19 deaths per 1000 residents, and weekly staff COVID-19 cases. Estimation of total residents for resident cases and deaths from COVID-19 was based on the study by Miller et al, 14 and staff COVID-19 cases were measured as the aggregate number of cases per facility per week. We excluded weekly staff deaths because it was a rare outcome and lacked adequate statistical power for analysis.

First, we examined unadjusted associations between weekly staff vaccination rates and weekly COVID-19 outcomes in nursing homes in the top and bottom quartile of staff vaccinations. Next, we used multivariable regression models with facility and week fixed effects to determine the adjusted associations between staff vaccination rates and COVID-19 outcomes. Facility fixed effects controlled for all measured and unmeasured time-invariant facility characteristics; by using the fixed-effects design, we essentially used each facility as its own control. Since COVID-19 vaccinations take at least 2 weeks to confer adequate protection against COVID-19 15 and transmission to residents is likely to take additional time, we estimated lagged effects. For weekly staff COVID-19 cases, we lagged the outcome by 1 week; for weekly COVID-19 cases per 1000 residents, we lagged the outcome by 2 weeks; and for weekly COVID-19 deaths per 1000 residents, we lagged the outcome by 3 weeks in our respective regression models.

We conducted 2 sets of ordinary least-squares regressions for each outcome, 1 with weekly staff vaccination rates measured as a continuous variable, and 1 using quartiles of staff vaccination coverage as a categorical variable, with nursing homes in the lowest 25% of staff vaccination rates as the reference category. In all models, in addition to facility and week fixed effects, we controlled for weekly resident vaccination rates, direct care staff hours per resident day, and county-level prevalence of COVID-19 per 1000 population. Other facility characteristics were absorbed in the fixed effects.

Finally, to explore whether increasing a facility’s vaccination rate was dependent on the absolute level of vaccination and to look for threshold effects, we next used cubic spline regressions with knots at different levels of staff vaccination rates. Cubic splines reflect piecewise linear-adjusted associations between levels of weekly staff vaccination rates and weekly COVID-19 outcomes; that is, they allow the association of additional vaccinations to vary over the distribution of vaccination rates.

As a sensitivity analysis, we used negative binomial regressions to assess the robustness of our results relative to our main approach using ordinary least-squares models. All analyses were performed using Stata, version 17.1 (StataCorp LLC), and statistical significance was determined at 2-sided P  < .05. Unless otherwise indicated, data are expressed as mean (SD).

Across our national sample of 15 042 nursing homes, the mean (SD) staff vaccination rate per nursing home during the primary study period between May 30 and December 5, 2021, was 66.05% (20.36%). Among these nursing homes, 9311 (61.9%) were for-profit institutions. The facilities had a mean (SD) of 106.35 (58.85) beds, a mean (SD) of 58.71% (24.13%) residents insured by Medicaid, and a mean (SD) of 17.54% (21.74%) Black residents. Nursing homes had a mean (SD) Nursing Home Care Compare star rating of 3.26 (1.36) stars (range, 1-5, with higher ratings indicating better care). Adjusted mean (SD) total nurse staffing hours per resident-day was 3.98 (0.92). Last, facilities were located in counties with a mean (SD) weekly prevalence of 0.25 (0.49) cases per 1000 population. These counties had a mean (SD) Black population of 11.36% (12.38%) and a mean (SD) Hispanic population of 14.72% (15.42%). Further, sample facilities were located in counties where a mean (SD) 20.13% (6.97%) of the population was covered by Medicaid, 11.35% (5.35%) lacked insurance, and 12.02% (4.28%) lived in poverty (see Table 1 ).

We stratified our results across quartiles of staff vaccination coverage and found that across the study period, staff vaccination rates increased across all facilities in the country. At the start and end of the study period, mean staff vaccination rate for facilities was 32.28% (8.75%) in the lowest quartile of staff vaccination rates and 82.67% (7.70%) in the highest quartile. By the end of the study period, the mean staff vaccination rate was 53.78% (10.06%) in the lowest quartile and 97.98% (1.93%) in the highest quartile. In other words, vaccination rates increased on average, but substantial variation remained. We also found that compared with facilities in the lowest quartile of staff vaccination rates, facilities in the highest quartile experienced lower levels of weekly COVID-19 cases and deaths among residents and a lower level of weekly COVID-19 cases among staff ( Figure 1 ).

At the onset of the Omicron wave, nursing homes across the US witnessed sharp increases in cases and deaths from COVID-19 among both residents and staff. Facilities across the 2 quartiles of staff vaccination coverage exhibited little to no difference in COVID-19 cases and deaths. However, as the Omicron wave progressed, the differences in cases and deaths (especially among residents) eventually widened between nursing homes across the top and bottom quartiles of staff vaccination rates (eFigure 3 in Supplement 1 ).

Regression-adjusted results from our primary analysis are presented in Table 2 . In our first set of regressions—using staff vaccination rates as a continuous variable and controlling for facility fixed effects, week fixed effects, county-level COVID-19 prevalence per 1000 population, resident vaccination rates, and direct care staff hours per resident day—we found that a 10–percentage point increase in the weekly staff vaccination rate on average was associated with 0.13 (95% CI, −0.20 to −0.10) fewer weekly cases per 1000 residents ( P  = .002), 0.02 (95% CI, −0.03 to −0.01) fewer weekly deaths per 1000 residents ( P  = .003), and 0.03 (95% CI, −0.04 to −0.02) fewer weekly staff cases ( P  < .001).

In our second set of regressions with quartiles of staff vaccination rate as categorical variables, we found that staff vaccination rates exhibited a dose-response association with cases and deaths. Using the same set of controls and the 2-way fixed effects, we found that compared with facilities in the lowest quartile of staff vaccination rates, facilities in the highest quartile of staff vaccinations reported fewer cases and deaths among both residents and staff ( Table 2 ). Across all models, the effects were found to be statistically significant.

We also found that county-level COVID-19 prevalence per 1000 population was positively associated with all our outcomes, and direct care hours per resident day and resident vaccination rates were negatively associated with our outcome variables. While the association of county-level COVID-19 prevalence per 1000 population and resident vaccination rate was statistically significant across all the models, the association of hours per resident day was found to be statistically significant only with weekly cases and deaths per 1000 residents ( Table 2 ). All the aforementioned results were found to be in line with the regression models in our sensitivity analysis using negative binomial models (eTable 2 in Supplement 1 ). In our secondary analysis, we found that during the Omicron wave, staff vaccination rates—both as a continuous variable and using quartiles of staff vaccination coverage—were not associated with COVID-19 cases and deaths in nursing homes ( Table 3 ).

We used the distribution of weekly staff vaccination rates across the nursing homes in our sample to identify knots for our spline regressions at 30%, 60%, and 80% of staff vaccination rates. Adjusting for facility and week fixed effects, prevalence of COVID-19 in the community, direct care staff hours per resident day, and resident vaccination rates, we again found that lower staff vaccination rates were associated with higher levels of cases and deaths among both staff and residents, but threshold effects emerged ( Figure 2 ).

Up to a staff vaccination rate of 30%, increases in staff vaccination were associated with worse COVID-19 outcomes ( Figure 2 ). After this point, the direction of the slope changed across all COVID-19 outcomes, indicating benefits of vaccination. The size of the beneficial association then increased with higher vaccination rates. Steeper decreases for COVID-19 cases and deaths among residents and COVID-19 cases among staff were observed at higher staff vaccination levels of 60% and 80%. Compared with weekly resident cases, the threshold effects were more pronounced for weekly resident deaths and weekly staff cases ( Figure 2 ).

We conducted a national examination of the association between staff vaccination rates and COVID-19 outcomes among staff and residents in nursing homes. In line with the findings of previous studies, 6 the results from our unadjusted analysis showed that COVID-19 cases and deaths were highest among nursing homes with a lower level of staff vaccination rates. Our primary, adjusted analysis found that when controlling for 2-way fixed effects, county-level COVID-19 prevalence, resident vaccination rates, and staffing hours, higher levels of staff vaccination were associated with lower adverse COVID-19 outcomes among staff and residents in nursing homes. Control variables were also significantly associated with the outcomes. The results show a dose-response pattern and an association with lower adverse COVID-19 outcomes at the highest rates of vaccination. Our primary analysis found that highest rates of staff vaccinations were associated with protection to residents and staff amidst both a surging prevalence of virus in the community and a changing landscape of COVID-19–safe practices in nursing homes.

Between May 30 and December 5, 2021, nursing homes across the country on average recorded 27.7 weekly COVID-19 cases per 1000 residents, 3.01 weekly COVID-19 deaths per 1000 residents, and 3760.5 weekly staff COVID-19 cases per week. Per the estimates from our fixed-effects models (see Table 2 ), a back-of-the-envelope calculation suggests that increasing weekly staff vaccinations in nursing homes on average by even 10 percentage points resulted in 1.98 fewer weekly COVID-19 cases per 1000 residents, 0.3 fewer weekly COVID-19 deaths per 1000 residents, and 401.6 total fewer weekly COVID-19 staff cases.

If we extrapolate to 1 year, our estimates imply that on average, a 10–percentage point increase in staff vaccination rates would have prevented 102.9 COVID-19 cases per 1000 residents, 15.6 COVID-19 deaths per 1000 residents, and approximately 21 000 staff cases nationwide. At the same time, our estimates of the association of staff vaccinations may or may not be generalizable moving forward as new variants of COVID-19 emerge. Our analysis of the beginning of the Omicron wave is consistent with a changing landscape of vaccination effectiveness. Specifically, we found that the original COVID-19 vaccination regimen did not suffice to effectively mitigate adverse COVID-19 outcomes in nursing homes during the Omicron wave of the pandemic. Newer strains of the COVID-19 virus such as Omicron and its subvariants have been found to be more transmissible than the previous strains of the virus. This suggests that going forward, additional booster doses for staff may be needed to effectively manage the pandemic in nursing homes. Although the original vaccination campaign in nursing homes was highly successful in bringing down case and death rates, and mandates led to staff vaccination rates exceeding the thresholds we found for high effectiveness, these policies cannot remain stagnant. As the pandemic evolves, staff vaccination mandates need to evolve as well.

Despite the controversy and debates, COVID-19 vaccinations—as documented herein and in previous studies 6 —seem to have provided some relief for nursing home residents. The introduction of the vaccines was associated with a decline in deaths and cases and made possible new CDC and CMS recommendations that nursing homes fully open to visitors, which provided physical and emotional benefits for nursing home residents. 16 At the same time, uptake of booster doses among staff in nursing homes is low on average, and there remains substantial variation in the uptake of booster doses across states. 17 Going forward, policy makers should take note of the existing evidence base on the association of staff vaccination rates with COVID-19 outcomes in nursing homes and use that to guide efforts to optimize policy. Evolving evidence-based policy will be critical.

The study has several limitations. First, we cannot provide a causal estimate of the impact of staff vaccination rates on COVID-19 outcomes among staff and residents. Second, while our study design controlled for time-invariant facility-level factors, we cannot account for potential confounders such as rates of booster shots and adherence to COVID-19–safe practices (eg, handwashing, masking, and social distancing). Third, the CMS started reporting data on staff vaccinations only toward the end of May 2021; therefore, data points from December 2020 to the beginning of May 2021 were excluded from our analysis.

The findings of this cohort study suggest that increasing staff vaccination rates in US nursing homes was associated with lower adverse COVID-19 outcomes among residents and staff. However, with unpredictable outbreaks of new, more infectious, and transmissible strains of the COVID-19 virus, evolving policy, potentially including mandates for additional booster doses for staff, may be needed to confer adequate protection against adverse outcomes of COVID-19 in nursing homes.

Accepted for Publication: November 10, 2022.

Published: December 29, 2022. doi:10.1001/jamanetworkopen.2022.49002

Open Access: This is an open access article distributed under the terms of the CC-BY License . © 2022 Sinha S et al. JAMA Network Open .

Corresponding Author: Soham Sinha, MS, Department of Public Health Sciences, The University of Chicago Biological Sciences, 5841 S Maryland Ave, Room 214, Chicago, IL 60637 ( [email protected] ).

Author Contributions: Both authors had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Both authors.

Acquisition, analysis, or interpretation of data: Sinha.

Drafting of the manuscript: Sinha.

Critical revision of the manuscript for important intellectual content: Both authors.

Statistical analysis: Both authors.

Supervision: Konetzka.

Conflict of Interest Disclosures: None reported.

Data Sharing Statement: See Supplement 2 .

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From the Bedside to Research: Navigating Change in Nursing

As we celebrate National Nurses Week, the AcademyHealth Interdisciplinary Research Group on Nursing Issues shines a spotlight on the indispensable contributions of nurses to the health care sector. Amid evolving challenges, these frontline professionals continue to lead with resilience and innovation, driving significant changes across the industry.

National Nurses Week is a time to celebrate and reflect on the evolving role of nurses and their significant impact on the health care system. As frontline caregivers, nurses face a myriad of challenges, yet they continue to lead and innovate, shaping the future of health care with their resilience and pioneering spirit.

Addressing Nurse Compensation

The establishment of the  Commission for Nurse Reimbursement in 2023 marks a significant shift in the financial recognition of nurses within the health care system. Historically, nursing services have been bundled into the general costs of health care, much like hospital supplies, leading to undervaluation and lack of visibility in the billing process. This commission, led by co-chairs Rebecca Love, RN, BS, MSN, FIEL, and Sharon Pearce, DNP, CRNA, FAANA, FAAN, was formed in response to a critical staffing shortage and aims to transform nursing care into a billable service. By advocating for changes in how Medicare and other entities reimburse for nursing services, the commission seeks to elevate the financial stature of nursing, enhancing job satisfaction, and retention, and ultimately stabilizing health care services. This initiative not only acknowledges the indispensable role of nurses but also strives to create a sustainable work environment that attracts and retains skilled professionals

Combating Workplace Violence

Workplace safety is another critical issue in the nursing sector, particularly the rising incidents of violence that nurses face. On average,  two nurses per hour are assaulted in acute care settings, underscoring the urgent need for better protection. Strategies to combat this include training staff in de-escalation techniques, implementing stricter security protocols, and establishing support systems for those affected by violence. Ensuring the safety of nurses is crucial for allowing them to provide the best possible care to their patients.

Policy Engagement: Amplifying Nurses' Voices

Nurses play a vital role in health care policymaking, given their direct patient care experience and patient-centered perspectives. Their active participation in legislative discussions helps ensure that health policies are practical and effectively implemented. Nurses advocate for policies that reflect the realities of patient care, steering the health care system toward more effective and humane outcomes.

Nurse Researchers: Pioneers of Innovation

Nurse researchers are at the forefront of refining nursing practices and introducing innovations that improve patient outcomes. Their work in 2024 is particularly vital as they research staffing models, patient care techniques, and the integration of new technologies such as digital health records and predictive analytics tools. These innovations are transforming everyday nursing practices, making health care more effective and responsive.

Embracing Technological Innovations

The integration of Artificial Intelligence (AI) and Telehealth has been a game-changer in health care delivery,  spearheaded by nurses . AI enhances diagnostic accuracy and treatment protocols by analyzing vast amounts of patient data. Telehealth, on the other hand, expands access to medical services, especially in remote or underserved areas, ensuring timely and efficient care. These technologies provide nurses with tools that augment their clinical skills and allow for better care across various settings.

As we observe National Nurses Week, it is essential to acknowledge the adaptability and innovative spirit of nurses globally. Despite numerous challenges, they continue to lead in the health care sector. With initiatives like the Commission for Nurse Reimbursement and the adoption of new technologies like AI, nurses are setting new standards in health care delivery. This week, and every week, we reaffirm our commitment to supporting and empowering the nursing profession as it continues to navigate these transformative times. From bedside care to research labs, nurses play an indispensable role in enhancing our health care system.

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Nurses’ and nursing students’ reasons for entering the profession: content analysis of open-ended questions

Lisa mckenna.

1 La Trobe University, Melbourne, Australia

Ian Ruddy Mambu

2 Universitas Pelita Harapan, Tangerang, Indonesia

Christine L. Sommers

Sonia reisenhofer.

3 Bairnsdale Regional Health Service, Bairnsdale, Australia

Julie McCaughan

4 Siloam Hospitals, Tangerang, Indonesia

Associated Data

The datasets generated and/or analysed during the current study are not publicly available due to ethical approval conditions but are available from the corresponding author on reasonable request.

Global nursing shortages require effective recruitment strategies and understanding of individuals’ motivations to enter the profession. These can be complex and bound by numerous factors such as gender and culture. While much research around this has been conducted, little has been undertaken in non-Western cultures where motivations could be different.

To explore Indonesian nurses’ and nursing students’ motivations for entering the nursing profession.

Online survey with closed and open-ended questions drawn from two different studies. This paper reports findings from one similar open-ended question.

As part of two larger surveys, nurses from 13 hospitals across one private health care group and nursing students with clinical experienced enrolled in a baccalaureate nursing program in Indonesia were asked the question, Why do you want to be a nurse? Responses were translated into English and back-translated into Indonesian prior to being subjected to summative content analysis.

In total, 1351 nurses and 400 students provided responses to the question, representing 98.72% and 99.70% respectively of those completing the survey. Both groups were primarily influenced by desire to serve others and God, personal calling and influence of family members and others. Nurses identified a desire to work in the health field and with the sick, in a noble and caring profession.

Conclusions

Nurses and nursing students were motivated by traditional perspectives on nursing. These should be considered in future recruitment activities. However, more research is needed to understand how these factors influence career choice.

Nurses have been identified as crucial to global achievement of Sustainable Development Goals (SDGs) and play a strong role in health policy, achievement of health targets [ 1 ]. However, global workforce shortages, along with an ageing nursing population [ 1 ] and COVID-19 related burnout further impacting retention [ 2 ], mean that strategies for recruitment into the nursing profession are paramount to meet community health care needs. While more than sufficient numbers of graduate nurses are being produced in Indonesia, 54.1% of nurses are located in urban areas, mostly in Java Island, while the other 45.9% are in rural areas with reported chronic shortages in some areas of the country, especially among communities in Eastern Indonesia [ 3 ]. The need for public education to improve the professional image of nursing has been advocated as one means for promoting recruitment of new nurses into the profession [ 4 ].

Understanding why individuals seek a career in nursing is important in facilitating the targeting of recruitment strategies. Some studies have reported on individual motivations to enter nursing courses, largely from western countries. In Italy, Messineo et al. [ 5 ] found that first year nursing students entered their courses with high levels of empathy and altruistic and prosocial motivations. However, there is also evidence that this declines over the duration of nursing studies [ 6 ]. Crick et al. [ 7 ] found that new nursing students in the United Kingdom were motivated to enter the course due to a desire to care for others. In a study of graduate entry nursing students in Australia, McKenna et al. [ 8 ] identified that previous exposure to nurses, either personally or family, played an important role in their decisions to enter the course, along with desire to care for others.

In a systematic review of 29 papers, Wu et al. [ 9 ] examined motivations of healthcare students influencing career choice, identifying a range of both intrinsic and extrinsic factors. They found that altruism through a desire to help others was strong among nursing students, particularly for those who were sick and in need of care. Job security and social status of nursing were considered important, while financial remuneration was not considered as important as for other health professions. Influence of family was mixed in nursing, with some families seeing nursing as having low pay and status, while having family members in the profession was positively influential.

The introduction of the Indonesian Nursing Act in 2014 saw rapid development in the nurse education system and nursing practice with introduction of curriculum standards and accreditation, national competency examination, and nurse registration across the country [ 10 ]. Four-year bachelor or three-year diploma courses can be undertaken to become professional or vocational nurses respectively. Furthermore, there has been recent growth in postgraduate and doctoral programs across the country [ 11 ]. Few previous studies could be sourced exploring why individuals are motivated (seek) to enter the nursing profession in Indonesia. In one study, 20 nursing diploma students participated in focus groups exploring their reasons for choosing to study nursing. Findings identified wanting to help family and others, being inspired by nurses, wanting to improve the image of nursing, influence of family and parents, and work opportunities all influenced choices [ 12 ]. In another study of 57 students in a bachelor degree nursing program, the majority entered the program because they were interested in the nursing profession or wanted to become nurses [ 13 ]. Around a third of students were motivated by their parents to enter the program. Previous studies regarding motivation among existing qualified nurses could not be sourced. Hence, this study sought to explore why Indonesian nurses and nursing students pursued nursing careers.

Data were drawn from two concurrent studies involving online questionnaires, the first focusing on Indonesian registered nurses’ training needs [ 14 ] and the second, on Indonesian nursing students’ experiences of their clinical learning environment [ 15 ]. In each study, participants were asked the same open-ended question: Why do you want to be a nurse? The responses to that question comprise the focus of this paper. Prior to commencement of data collection, approvals were obtained from ethics committees at La Trobe University (ID: S17-155) and Universitas Pelita Harapan (No.005/MRIN-EC/ECL/III/2018). In the original studies, inclusion criteria for the nurses were currently working at the private hospital with a 3-year nursing diploma level qualification or above. Inclusion criteria for nursing students were those who had completed a clinical placement in the private hospital, were enrolled as a nursing student in the university, and were 18 years of age or older. There were no specific exclusion criteria.

Links to the online Qualtrics surveys were provided in participant information materials. These were circulated via internal email and WhatsApp groups to a convenience sample of 2093 eligible registered nurses from 13 sites of an Indonesian private health care group across Jakarta, Sumatra, Sulawesi and Bali and Nusa Tenggara Timur and 796 students from one nursing degree program. Participants provided informed consent using a survey link in the study information provided and participation was voluntary and anonymous. In total, 406 s- and third-year students and 1355 nurses completed the open-ended question forming the basis of this paper.

Responses to the question from both datasets were translated from Indonesian into English and back-translated by two researchers to ensure original meanings were retained [ 16 ]. Data were then subjected to summative content analysis [ 17 ]. Key words were initially identified and coded within Microsoft Excel by two members of the research team. Codes were then manually collated into categories of like terms, quantified utilising frequency counts. Overarching themes were then identified from categories.

In total, 400 students and 1351 nurses provided responses to the question, representing response rates of 98.52% and 99.70% respectively. Among the student group, the average age was 20 years and 84% were female. In the registered nurse group, 80.8% were female and years of experience were relatively evenly distributed from less than one to more than 10 years. Of these, 39% had been in the profession for longer than five years, that is, before introduction of the Indonesian Nursing Act. From the analysis, seven categories and five themes emerged from the student data (Table  1 ) and eight categories and four themes from the nurse data (Table  2 ). Substantial overlap was evident across the two groups and rankings.

Student data (n = 400)

Nurse data (n = 1351)

Overwhelmingly, having an impact on others’ lives was key to both groups through helping or serving others or own family ranked highest for both groups, reported by 50.00% of students and 44.93% of nurses. Students also wanted to be a blessing to others , while nurses valued the interaction with people that is a fundamental part of nursing practice.

For both groups, factors around decision to enter nursing ranked second. Many described having a calling to nursing, while others described this in terms of a ‘childhood dream’, or for ‘personal reward or satisfaction’. Influence of family, others or circumstances played an important part for students and nurses, while a number of nurses described having no reason or choice around entering nursing. Service to God/religious response was also noted to have been the motivation for some students (9.50%); however, it is important to note that these students were enrolled in a faith-based university, so this could be expected. Attraction to the Profession of nursing was also identified as an important factor for both groups. Students expressed a desire to be a part of, or improve, the profession, while many nurses identified a desire to work in the health field or with the sick. For nurses, the status of the profession as noble and caring was a strong factor.

Finally, financial reasons were identified by a small number of participants in both groups who identified commencing their nursing education as they received an offer of a scholarship.

With a predicted continued global nursing shortage, targeted successful strategies need to be introduced to recruit into the profession. Understanding motivations for entering nursing courses can assist with the development of appropriate recruitment strategies and may also inform future retention strategies to keep nurses within the profession. Hence, this study sought to understand why nurses and nursing students in Indonesia chose to enter the profession. Prior to this study, little was known about such motivations in Indonesia, and outside of western countries.

A desire to impact others’ lives was the strongest reported influence for both nurses and nursing students in this study. This was seen as wanting to serve others, and desire to work with the sick. Altruism has long been identified as a reason why individuals choose nursing careers. However, Carter [ 18 ] cautions against simplifying such motivations just to this aspect, where “gender, culture and class and individual dispositions” (p.703) play an important role in the complex make-up of a nursing professional. These views may also change as students progress in their courses. A longitudinal study of nursing students in The Netherlands found that even though many students entered their courses with altruistic and empathic predispositions, their perceptions towards nursing changed to being more professional and focused on their role, knowledge and skills [ 6 ]. Conversely, this was not reflected in the current study where nurses still displayed strong altruistic characteristics beyond graduation from their nursing courses. This suggests that the caring aspect of nursing and ability to make a difference to people’s lives should be emphasised in recruitment to the profession. Additional research in the Indonesian context is needed to better understand the influences on nurses’ personal dispositions and whether these change over time.

Nurses and nursing students in this study both described a personal calling into nursing. Calling, itself, has been described as complex in nursing, and having changed from a traditional perspective based in religion and femininity, to a more contemporary conceptualisation focused on care provision, the profession and self-fulfilment [ 19 ]. In this study, a more traditional focus emerged with both focus on serving community and service to God. This may be, in part, related to the fact that the study was undertaken in a faith-based university and health care group. Being a strong faith-based country, this may be a particularly important consideration in Indonesia and would benefit from further research with other groups across the country. The importance of inclusion of this concept in recruitment into nursing in the country could be further explored. In a recent study in Indonesia, the concept of calling and reason for entering nursing played a role in student success in a nursing program [ 20 ]. The importance of understanding values is particularly pertinent in nursing recruitment strategies with a recent mandate in the United Kingdom for values-based recruitment of healthcare students aligning with those of the National Health Service [ 21 ].

The influence of families and others was a factor in this study for pursuing a nursing career. In Indonesia, families have been shown to play an important role in career pathways, particularly in family businesses [ 22 ]. However, the literature is mixed on whether this is an important factor for nursing. In their review, Wu et al. [ 9 ] identified that some studies identified parents as not being supportive of their children entering the nursing profession because of low pay and status, a view reflected elsewhere [ 23 ]. Despite this, families have been found to be a strong influencing factor influencing choice of nursing career in some studies [ 8 , 24 , 25 ]. Having family members or friends who are nurses or had experienced time in hospitals were identified as influencing factors in one study [ 8 ]. In a study conducted in the United States, Woods-Giscombe et al. [ 25 ] recommended including family members into recruitment processes into nursing, particularly for recruitment of students from underrepresented groups. This suggests that recruitment strategies should not only be directed towards potential students, but their families as well.

While career stability and vocational reasons have been identified by other researchers as guiding factors in pursuing nursing careers [ 8 , 18 ], these aspects were not identified by nurses and nursing students in this study. It is possible that cultural aspects may play a role. In a Norwegian study, nursing students from immigrant backgrounds were found to be more motivated by salary, status, and work flexibility than non-immigrants [ 26 ]. Findings from the current study suggest that such considerations might not be primary considerations for Indonesian nurses and students and that more research is needed to explore this aspect further.

Media representations have been identified in a number of studies as influencing decisions to pursue nursing careers. In one Australian study, hospital dramas on television as well as print and television news played a role in influencing graduate entry students to pursue nursing education [ 8 ]. In another Australian study focused on television representation of the nursing profession, nursing students perceived nurses to be negatively represented in comparison to doctors who were positively portrayed. They recognised that medical programs could provide some recruitment value [ 27 ]. However, a role of media influencing career choice was not identified in this study. Whether or not this plays some role in assisting career decisions for Indonesian students could also be examined further.

There are some acknowledged limitations to this study. The sample was drawn from one faith-based university and hospital group. While the study population was large and drawn from a number of locations, findings may be different in other Indonesian nurse populations across the diverse cultural groups in the country. Furthermore, data were only collected using one open-ended survey question. Further research that explores these concepts in greater depth would be highly valuable.

With global nursing shortages, there is an ongoing need for effective recruitment strategies into the profession. This makes it vital to understand motivations of those entering the profession to facilitate recruitment approaches. However, motivations may vary according to a wide range of intrinsic and extrinsic factors. This study identified that Indonesian nurses and nursing students were largely motivated by a need to serve others and God, personal calling, and the influence of family. As a strong faith-based country, this is likely to be an important consideration in future nursing recruitment. However, further research is needed across more communities to ensure that other motivating factors can be identified and incorporated into successful recruitment strategies. Further research is also needed to understand if these concepts play a role in nursing students successfully completing a program and entering the nursing profession.

Acknowledgements

The authors are grateful to all the nurses and nursing students for their contributions to the study.

Author Contribution

All authors have agreed on the final version and meet at least one of the following criteria (recommended by the ICMJE): (1) substantial contributions to conception and design (LM, CS, SR, IM, JC), acquisition of data, or analysis (LM, CS, IM) and interpretation (LM, CS, IM) of data; (2) drafting the article or revising it critically for important intellectual content (LM, CS).

This study was supported by a La Trobe Asia Research Grant Program grant and the Universitas Pelita Harapan Research and Community Service Grant Program.

Data Availability

Declarations.

The study was approved by Human Research Ethics Committees at La Trobe University (ID: S17-155) and Universitas Pelita Harapan (No.005/MRIN-EC/ECL/III/2018). All data collection was in accordance with relevant guidelines and regulations. Participants provided informed consent for this study using the survey link in study information provided.

Not applicable.

The authors have no competing interests to declare.

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