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Nursing Resources : Independent Variable VS Dependent Variable

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Definitions

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

The  dependent variable  is the response that is measured.

For example:

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Nursing Experts: Translating the Evidence - Public Health Nursing

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Appraisal Concepts - Validity & Reliability

What is validity?

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

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

What is reliability?

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

Scientific Experiment Terminology

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

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

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

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

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

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

Sample Questions for Evaluating a Study

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

Standards for the Reporting of Scientific/Medical Research:

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

Online Appraisal Resources:

• NExT Appraisal Tool
• CASP Checklists Critical Appraisal Skills Programme (CASP) tools for reading research
• Centre for Evidence Based Medicine - Critical Appraisal
• EBM and Decision Tools Alan Schwartz - UIC College of Medicine
• EBM Librarian - Appraising the Evidence
• Joanna Briggs Institute - Critical Appraisal Tools
• UIC College of Nursing - Appraising your evidence guide
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• Volume 2, Issue 4
• The fundamentals of quantitative measurement
• Article Text
• Article info
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• Donna Ciliska , RN, PhD * ,
• Nicky Cullum , RN, PhD 2 ,
• Alba Dicenso , RN, PhD *
• * School of Nursing, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
• 2 Centre for Evidence Based Nursing, Department of Health Studies, University of York, York, UK

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

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

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

Types of variables

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

Issues in measurement

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

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

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

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

Are the measures reliable and valid.

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

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

IS THE MEASURE SUBJECT TO BIAS?

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

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

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

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

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

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

Read the full text or download the PDF:

The First Step: Ask; Fundamentals of Evidence-Based Nursing Practice

In this module, we will learn about identifying the problem, start the “Ask” process with developing an answerable clinical question, and learn about purpose statements and hypotheses.

Content includes:

• Identifying the problem
• Determining the Population, Intervention, Comparison, and Outcome (PICO)
• Asking a Research/Clinical Question (Based on PICO)

Statements of Purpose

Objectives:

• Describe the process of developing a research/practice problem.
• Describe the components of a PICO.
• Identify different types of PICOs.
• Distinguish function and form of statements of purpose.
• Describe the function and characteristics of hypotheses.

Development of a Research/Practice Problem

Practice questions frequently arise from day-to-day problems that are encountered by providers (Dearholt & Dang, 2012). Often, these problems are very obvious. However, sometimes we need to back up and take a close look at the status quo to see underlying issues. The basis for any research project is indeed the underlying problem or issue. A good problem statement or paragraph is a declaration of what it is that is problematic or what it is that we do not know much about (a gap in knowledge) (Polit & Beck, 2018).

The process of defining the practice/clinical problem begins by seeking answers to clinical concerns. This is the first step in the EBP process: To ask . We start by asking some broad questions to help guide the process of developing our practice problem.

• Is there evidence that the current treatment works?
• Does the current practice help the patient?
• Why are we doing the current practice?
• Should we be doing the current practice this way?
• Is there a way to do this current practice more efficiently?
• Is there a more cost-effective method to do this practice?

Problem Statements:

For our EBP Project, we will need to ask these broad questions and then develop our problem that exists. This establishes the “background” of the issue we want to know more about.

For example, if we are choosing a clinical question based on wanting to know if adjunct music therapy helps decrease postoperative pain levels than just pharmaceuticals alone, we might consider the underlying problems of:

• Postoperative pain is not adequately managed in greater than 80% of patients in the US, although rates vary depending on such factors as type of surgery performed, analgesic/anesthetic intervention used, and time elapsed after surgery (Gan, 2017).
• Poorly controlled acute postoperative pain is associated with increased morbidity, functional and quality-of-life impairment, delayed recovery time, prolonged duration of opioid use, and higher health-care costs (Gan, 2017).
• Multimodal analgesic techniques are widely used but new evidence is disappointing (Rawal, 2016).

In the above examples, we are establishing that poorly managed postoperative pain is a problem. Thus, looking at evidence about adjunctive music therapy may help to address how we might manage pain more effectively. These are our problem statements. This would be our introduction section on the EBP poster. For the sake of our EBP poster, you do not need to list these on the poster references. A heads up: The sources used to help develop our research/clinical program should not be the same resources that we use to answer our upcoming clinical question. In essence, we will be conducting two literature reviews: One, to establish the underlying problem; and, two: To find published research that helps to answer our developed clinical question.

Here is the introduction to the article titled, “The relationships among pain, depression, and physical activity in patients with heart failure” (Haedtke et al, 2017). You can read that the underlying problem is multifocal: 67% of patient with heart failure (HF) experience pain, depression is a comorbidity that affects 22% to 42% of HF patients, and that little attention has been paid to this relationship in patients with HF. The researchers have established the need for further research and why further research is needed.

Here is another example of how the clinical problem is addressed in an EBP poster that wants to appraise existing evidence related to dressing choice for decubitus ulcers.

When trying to communicate clinical problems, there are two main sources (Titler et al, 1994, 2001):

• Problem-focused triggers : These are identified by staff during routine monitoring of quality, risk, adverse events, financial, or benchmarking data.
• Knowledge-focused triggers : There are identified through reading published evidence or learning new information at conferences or other professional meetings.

Sources of Evidence-Based Clinical Problems:

Most problem statements have the following components:

• Problem identification: What is wrong with the current situation or action?
• Background: What is the nature of the problem or the context of the situation? (this helps to establish the why)
• Scope of the problem: How many people are affected? Is this a small problem? Big problem? Potential to grow quickly to a large problem? Has been increasing/decreasing recently?
• Consequences of the problem: If we do nothing or leave as the status quo, what is the cost of not  fixing the issue?
• Knowledge gaps: What information about the problem is lacking? We need to know what we do not know.
• Proposed solution: How will the information or evidence contribute to the solution of the problem?

If you are stumped on a topic, ask faculty, RNs at local facilities, colleagues, and key stakeholders at local facilities for some ideas! There is usually “something” that the nursing field is concerned about or has questions about.

Components of a PICO Question

After we have asked ourselves some background questions, we need to develop a foreground (focused) question. A thoughtful development of a well-structured foreground clinical/practice question is important because the question drives the strategies that you will use to search for the published evidence. The question needs to be very specific, non-ambiguous , and measurable in order to find the relevant evidence needed and also increased the likelihood that you will find what you are looking for.

In developing your clinical/practice question, there is a helpful format to utilize to establish the key component. This format includes the Patient/Population, Intervention/Influence/Exposure, Comparison, and Outcome (PICO) (Richardson, Wilson, Nishikawa, & Hayward, 1995).

Let’s dive into each component to better understand.

P atient, population, or problem: We want to describe the patient, the population, or the problem. Get specific. We will want to know exactly who we are wanting to know about. Consider age, gender, setting of the patient (e.g. postoperative), and/or symptoms.

I ntervention: The intervention is the action or, in other words, the treatment, process of care, education given, or assessment approaches. We will come back to this in more depth, but for now remember that the intervention is also called the “Independent Variable”.

C omparison: Here we are comparing with other interventions. A comparison can be standard of care that already exists, current practice, an opposite intervention/action, or a different intervention/action.

O utcome: What is that that we are looking at for a result or consequence of the intervention? The outcome needs to have a metric for actually measuring results. The outcome can include quality of life, patient satisfaction, cost impacts, or treatment results. The outcome is also called the “Dependent Variable”.

The PICO question is a critical aspect of the EBP project to guide the problem identification and create components that can be used to shape the literature search.  

Let’s watch a nice YouTube video, “PICO: A Model for Evidence-Based Research”:

“PICO: A Model for Evidence Based Research” by Binghamton University Libraries. Licensed CCY BY .

Great! Okay, let’s move on and discuss the various types of PICOs.

Types of PICOs

Before we start developing our clinical question, let’s go over the various types of PICOs and the clinical question that can result from the components. There are various types of PICOs but we are concerned with the therapy/treatment/intervention format of PICO for our EBP posters. 

Let’s take a look at the various types of PICOs:

The first step in developing a research or clinical practice question is developing your PICO. Well, we’ve done that above. You will select each component of your PICO and then turn that into your question. Making the EBP question as specific as possible really helps to identify specific terms and narrow the search, which will result in reducing the time it times searching for relevant evidence.

Once you have your pertinent clinical question, you will use the components to begin your search in published literature for articles that help to answer your question. In class, we will practice with various situations to develop PICOs and clinical questions.

Many articles have the researcher’s statement of purpose (sometimes referred to as “aim”, “goal”, or “objective”) for their research project. This helps to identify what the overarching direction of inquiry may be. You do not need a statement of purpose/aim/goal/objective for your EBP poster. However, knowing what a statement of purpose is will help you when appraising articles to help answer your clinical question.

The following statement of purpose was written as an aim. The population (P) was identified as patients with HF, the interventions (I) included physical activity/exercise, and the outcomes (O) included pain, depression, total activity time, and sitting time as correlated with the interventions.

In the articles above, the authors made it easy and included their statements of purpose within the abstract at the beginning of the article. Most articles do not feature this ease, and you will need to read the introduction or methodology section of the article to find the statement of purpose, much like within article 3.1.

In qualitative studies, the statement of purpose usually indicates the nature of the inquiry, the key concept, the key phenomenon, and the population.

Function and Characteristics of Hypotheses.

A hypothesis (plural: hypothes es ) is a statement of predicted outcome. Meaning, it is an educated and formulated guess as to how the intervention (independent variable – more on that soon!) impacts the outcome (dependent variable). It is not always a cause and effect. Sometimes there can be just a simple association or correlation. We will come back to that in a few modules.

In your PICO statement, you can think of the “I” as the independent variable and the “O” as the dependent variable . Variables will begin making more sense as we go. But for now, remember this:

Independent Variable (IV): This is a measure that can be manipulated by the researcher. Perhaps it is a medication, an educational program, or a survey. The independent variable enacts change (or not) onto the independent variable. 

Dependent Variable  (DV): This is the result of the independent variable. This is the variable that we utilize statistical analyses to measure. For instance, if we are intervening with a blood pressure medication (our IV), then our DV would be the measurement of the actual blood pressure.

Most of the time, a hypothesis results from a well-worded research question. Here is an example:

Research Question : “Does sexual abuse in childhood affect the development of irritable bowel syndrome in women?”

Research Hypothesis : Women (P) who were sexually abused in childhood (I) have a higher incidence of irritable bowel syndrome (O) than women who were not abused (C).

You may note in that hypothesis that there is a predicted direction of outcome. One thing leads to something.

But, why do we need a hypothesis? First, they help to promote critical thinking. Second, it gives the researcher a way to measure a relationship. Suppose we conducted a study guided only by a research question. Take the above question, for example. Without a hypothesis, the researcher is seemingly prepared to accept any  result (Polit & Beck, 2021). The problem with that is that it is almost always possible to explain something superficially after the fact, even if the findings are inconclusive. A hypothesis reduces the possibility that spurious results will be misconstrued (Polit & Beck, 2021).

Not all research articles will list a hypothesis. This makes it more difficult to critically appraise the results. That is not to say that the results would be invalidated, but it should ignite a spirit of further inquiry as to if the results are valid.

Hypotheses (also called alternative hypothesis) can be stated as:

• Directional or nondirectional
• Simple or complex
• Research or Null

Simple hypothesis : Statement of causal (cause and effect) relationship – one independent variable (intervention) and one dependent variable (outcome).

Example : If you stay up late, then you feel tired the next day.

Complex hypothesis : Statement of causal (cause and effect) or associative (not causal) between two or more independent variables (interventions) and/or two or more dependent variables (outcomes).

Example :  Higher the poverty, higher the illiteracy in society, higher will be the rate of crime (three variables – two independent variables and one dependent variable).

Directional hypothesis : Specifies not only the existence but also the expected direction of the relationship between the dependent (outcome) and the independent (intervention) variables. You will also see this called “One-tailed hypothesis”.

Example : Depression scores will decrease  following a 6-week intervention.

Nondirectional hypothesis : Does not specify the direction of relationship between the variables. You will also see this called “Two-tailed hypothesis”.

Example : College students will perform differently from elementary school students on a memory task (without predicting which group of students will perform better). 

Null hypothesis : The null hypothesis assumes that any kind of difference between the chosen characteristics that you see in a set of data is due to chance. Now, the null hypothesis is why the plain old hypothesis is also called alternative hypothesis. We don’t just assume that the hypothesis is true. So, it is considered an alternative to something just happening by chance (null).

Example : Let’s say our research question is, “Do teens use cell phones to access the internet more than adults?” – our null hypothesis could state: Age has no effect on how cell phones are used for internet access.

And then, further develop the problem and background through finding existing literature to help answer the following questions:

• Knowledge gaps: What information about the problem is lacking? We need to know what we do not  know.

With the previous example of pain in the pediatric population, here is an example of an Introduction section from a past student poster:

• What was the research problem? Was the problem statement easy to locate and was it clearly stated? Did the problem statement build a coherent and persuasive argument for the new study?
• Does the problem have significance for nursing?
• Was there a good fit between the research problem and the paradigm (and tradition) within which the research was conducted?
• Did the report formally present a statement of purpose, research question, and/or hypotheses? Was this information communicated clearly and concisely, and was it placed in a logical and useful location?
• Were purpose statements or research questions worded appropriately (e.g., were key concepts/variables identified and the population specified?
• If there were no formal hypotheses, was their absence justified? Were statistical tests used in analyzing the data despite the absence of stated hypotheses?
• Were hypotheses (if any) properly worded—did they state a predicted relationship between two or more variables? Were they presented as research or as null hypotheses?

References & Attribution

“ Green check mark ” by rawpixel licensed CC0 .

“ Light bulb doodle ” by rawpixel licensed CC0 .

“ Magnifying glass ” by rawpixel licensed CC0

“ Orange flame ” by rawpixel licensed CC0 .

Chen, P., Nunez-Smith, M., Bernheim, S… (2010). Professional experiences of international medical graduates practicing primary care in the United States. Journal of General Internal Medicine, 25 (9), 947-53.

Dearholt, S.L., & Dang, D. (2012). Johns Hopkins nursing evidence-based practice: Model and guidelines (2nd Ed.). Indianapolis, IN: Sigma Theta Tau International. 

Gan, T. (2017). Poorly controlled postoperative pain: Prevalence, consequences, and prevention. Journal of Pain Research, 10, 2287-2298.

Genc, A., Can, G., Aydiner, A. (2012). The efficiency of the acupressure in prevention of the chemotherapy-induced nausea and vomiting. Support Care Cancer, 21 , 253-261.

Haedtke, C., Smith, M., VanBuren, J., Kein, D., Turvey, C. (2017). The relationships among pain, depression, and physical activity in patients with heart failure. Journal of Cardiovascular Nursing, 32 (5), E21-E25.

Pankong, O., Pothiban, L., Sucamvang, K., Khampolsiri, T. (2018). A randomized controlled trial of enhancing positive aspects of caregiving in Thai dementia caregivers for dementia. Pacific Rim Internal Journal of Nursing Res, 22 (2), 131-143.

Polit, D. & Beck, C. (2021).  Lippincott CoursePoint Enhanced for Polit’s Essentials of Nursing Research  (10th ed.). Wolters Kluwer Health.

Rawal, N. (2016). Current issues in postoperative pain management. European Journal of Anaesthesiology, 33 , 160-171.

Richardson, W.W., Wilson, M.C., Nishikawa, J., & Hayward, R.S. (1995). The well-built clinical question: A key to evidence-based decisions. American College of Physicians, 123 (3), A12-A13.

Titler, M. G., Kleiber, C., Steelman, V.J. Rakel, B. A. Budreau, G., Everett,…Goode, C.J. (2001). The Iowa model of evidence-based practice to promote quality care. Critical Care Nursing Clinics of North America, 13 (4), 497-509.

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• Independent vs. Dependent Variables | Definition & Examples

Independent vs. Dependent Variables | Definition & Examples

Published on February 3, 2022 by Pritha Bhandari . Revised on June 22, 2023.

In research, variables are any characteristics that can take on different values, such as height, age, temperature, or test scores.

Researchers often manipulate or measure independent and dependent variables in studies to test cause-and-effect relationships.

• The independent variable is the cause. Its value is independent of other variables in your study.
• The dependent variable is the effect. Its value depends on changes in the independent variable.

Your independent variable is the temperature of the room. You vary the room temperature by making it cooler for half the participants, and warmer for the other half.

Table of contents

What is an independent variable, types of independent variables, what is a dependent variable, identifying independent vs. dependent variables, independent and dependent variables in research, visualizing independent and dependent variables, other interesting articles, frequently asked questions about independent and dependent variables.

An independent variable is the variable you manipulate or vary in an experimental study to explore its effects. It’s called “independent” because it’s not influenced by any other variables in the study.

Independent variables are also called:

• Explanatory variables (they explain an event or outcome)
• Predictor variables (they can be used to predict the value of a dependent variable)
• Right-hand-side variables (they appear on the right-hand side of a regression equation).

These terms are especially used in statistics , where you estimate the extent to which an independent variable change can explain or predict changes in the dependent variable.

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There are two main types of independent variables.

• Experimental independent variables can be directly manipulated by researchers.
• Subject variables cannot be manipulated by researchers, but they can be used to group research subjects categorically.

Experimental variables

In experiments, you manipulate independent variables directly to see how they affect your dependent variable. The independent variable is usually applied at different levels to see how the outcomes differ.

You can apply just two levels in order to find out if an independent variable has an effect at all.

You can also apply multiple levels to find out how the independent variable affects the dependent variable.

You have three independent variable levels, and each group gets a different level of treatment.

You randomly assign your patients to one of the three groups:

• A low-dose experimental group
• A high-dose experimental group
• A placebo group (to research a possible placebo effect )

A true experiment requires you to randomly assign different levels of an independent variable to your participants.

Random assignment helps you control participant characteristics, so that they don’t affect your experimental results. This helps you to have confidence that your dependent variable results come solely from the independent variable manipulation.

Subject variables

Subject variables are characteristics that vary across participants, and they can’t be manipulated by researchers. For example, gender identity, ethnicity, race, income, and education are all important subject variables that social researchers treat as independent variables.

It’s not possible to randomly assign these to participants, since these are characteristics of already existing groups. Instead, you can create a research design where you compare the outcomes of groups of participants with characteristics. This is a quasi-experimental design because there’s no random assignment. Note that any research methods that use non-random assignment are at risk for research biases like selection bias and sampling bias .

Your independent variable is a subject variable, namely the gender identity of the participants. You have three groups: men, women and other.

Your dependent variable is the brain activity response to hearing infant cries. You record brain activity with fMRI scans when participants hear infant cries without their awareness.

A dependent variable is the variable that changes as a result of the independent variable manipulation. It’s the outcome you’re interested in measuring, and it “depends” on your independent variable.

In statistics , dependent variables are also called:

• Response variables (they respond to a change in another variable)
• Outcome variables (they represent the outcome you want to measure)
• Left-hand-side variables (they appear on the left-hand side of a regression equation)

The dependent variable is what you record after you’ve manipulated the independent variable. You use this measurement data to check whether and to what extent your independent variable influences the dependent variable by conducting statistical analyses.

Based on your findings, you can estimate the degree to which your independent variable variation drives changes in your dependent variable. You can also predict how much your dependent variable will change as a result of variation in the independent variable.

Distinguishing between independent and dependent variables can be tricky when designing a complex study or reading an academic research paper .

A dependent variable from one study can be the independent variable in another study, so it’s important to pay attention to research design .

Here are some tips for identifying each variable type.

Recognizing independent variables

Use this list of questions to check whether you’re dealing with an independent variable:

• Is the variable manipulated, controlled, or used as a subject grouping method by the researcher?
• Does this variable come before the other variable in time?
• Is the researcher trying to understand whether or how this variable affects another variable?

Recognizing dependent variables

Check whether you’re dealing with a dependent variable:

• Is this variable measured as an outcome of the study?
• Is this variable dependent on another variable in the study?
• Does this variable get measured only after other variables are altered?

Independent and dependent variables are generally used in experimental and quasi-experimental research.

Here are some examples of research questions and corresponding independent and dependent variables.

For experimental data, you analyze your results by generating descriptive statistics and visualizing your findings. Then, you select an appropriate statistical test to test your hypothesis .

The type of test is determined by:

• your variable types
• level of measurement
• number of independent variable levels.

You’ll often use t tests or ANOVAs to analyze your data and answer your research questions.

In quantitative research , it’s good practice to use charts or graphs to visualize the results of studies. Generally, the independent variable goes on the x -axis (horizontal) and the dependent variable on the y -axis (vertical).

The type of visualization you use depends on the variable types in your research questions:

• A bar chart is ideal when you have a categorical independent variable.
• A scatter plot or line graph is best when your independent and dependent variables are both quantitative.

To inspect your data, you place your independent variable of treatment level on the x -axis and the dependent variable of blood pressure on the y -axis.

You plot bars for each treatment group before and after the treatment to show the difference in blood pressure.

If you want to know more about statistics , methodology , or research bias , make sure to check out some of our other articles with explanations and examples.

• Normal distribution
• Degrees of freedom
• Null hypothesis
• Discourse analysis
• Control groups
• Mixed methods research
• Non-probability sampling
• Quantitative research
• Ecological validity

Research bias

• Rosenthal effect
• Implicit bias
• Cognitive bias
• Selection bias
• Negativity bias
• Status quo bias

An independent variable is the variable you manipulate, control, or vary in an experimental study to explore its effects. It’s called “independent” because it’s not influenced by any other variables in the study.

A dependent variable is what changes as a result of the independent variable manipulation in experiments . It’s what you’re interested in measuring, and it “depends” on your independent variable.

In statistics, dependent variables are also called:

Determining cause and effect is one of the most important parts of scientific research. It’s essential to know which is the cause – the independent variable – and which is the effect – the dependent variable.

You want to find out how blood sugar levels are affected by drinking diet soda and regular soda, so you conduct an experiment .

• The type of soda – diet or regular – is the independent variable .
• The level of blood sugar that you measure is the dependent variable – it changes depending on the type of soda.

No. The value of a dependent variable depends on an independent variable, so a variable cannot be both independent and dependent at the same time. It must be either the cause or the effect, not both!

Yes, but including more than one of either type requires multiple research questions .

For example, if you are interested in the effect of a diet on health, you can use multiple measures of health: blood sugar, blood pressure, weight, pulse, and many more. Each of these is its own dependent variable with its own research question.

You could also choose to look at the effect of exercise levels as well as diet, or even the additional effect of the two combined. Each of these is a separate independent variable .

To ensure the internal validity of an experiment , you should only change one independent variable at a time.

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Independent versus Dependent Variables

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

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• Last Updated: Oct 25, 2023 3:28 PM
• URL: https://guides.library.upenn.edu/NursingResearch

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

Affiliation.

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

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

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

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

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

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

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Definitions

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

The  dependent variable  is the response that is measured.

For example:

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• Last Updated: Jan 31, 2024 10:48 AM
• URL: https://libguides.sdstate.edu/c.php?g=1177663

• Open access
• Published: 02 April 2024

Effect of evidence-based nursing practices training programme on the competency of nurses caring for mechanically ventilated patients: a randomised controlled trial

• Sameh Elhabashy 1 ,
• Michiko Moriyama 2 ,
• Eman Ibrahim El-Desoki Mahmoud 3 &
• Basem Eysa 3  

BMC Nursing volume  23 , Article number:  225 ( 2024 ) Cite this article

Metrics details

Evidence-Based Practice (EBP) has been recognised worldwide as a standardised approach for enhancing the quality of healthcare and patient outcomes. Nurses play a significant role in integrating EBP, especially in Intensive Care Unit (ICU). Consequently, this study aims to examine the effect of an adapted evidence-based nursing practices training programme on the competency level of nurses caring for mechanically ventilated patients.

A prospective open-label parallel 1:1 randomised controlled trial was conducted on 80 nurses caring for ICU patients at the National Hepatology and Tropical Medicine Research Institute, Egypt. The trial was carried out between November 2022 and February 2023 under the registration number NCT05721664. The enrolled nurses were randomly divided into intervention and control groups. The intervention group received the evidence-based nursing practice training programme (EBNPTP) in accordance with the Johns Hopkins EBP conceptional model, whereas the control group received traditional in-service education. Four assessments (one pre- and three post-assessments) were conducted to evaluate nurses’ competency level over time using the adapted evidence-based nursing competency assessment checklist. The primary endpoint was an increase the competency levels among nurses caring for mechanically ventilated patients.

The current study results revealed statistically significant differences between intervention and control groups in relation to their level of competency across the three post-assessments, with ( p  <.001). The study also demonstrated that the nurses’ competency level continued to decline significantly over time, with ( p  <.001). Additionally, a significant correlation was found between the nurses’ pre-assessment and educational level, acting as independent variables (predictors), and the third endpoint assessment ( p  <.01), indicated by multiple linear regression.

The EBP training programme demonstrated a significant increase in the nurses’ level of competency compared with traditional in-service education. This suggests that by training the nurses in various settings with the essential skills and knowledge for EBP, their competency level can be enhanced, leading to the delivery of effective care and improving patient outcomes. However, the long-term sustainability of the EBP adoptions was insufficient; further studies are needed to investigate the factors that affect the durability of EBP adoption.

Trial registration

The study was registered with Clinical Trials.gov (Registration # NCT05721664) on 10/02/2023.

Peer Review reports

Evidence-based practice (EBP) is a universal fundamental approach for delivering standardised care based on the most recent scientific evidence to enhance healthcare quality [ 1 ]. EBP is a problem-solving method for making effective, safe clinical decisions as a foundation for improving patient outcomes, as it bridges the theory-to-practice gap and delivers innovative patient care, while also reducing healthcare costs and encouraging lifelong learning [ 2 ]. Nurses play a crucial role in maximising the efficiency of healthcare services. Furthermore, they directly interact with patients, particularly in Intensive Care Units (ICUs) [ 3 ]. Therefore, healthcare organisations should always strive to make it easier for frontline nurses to use the best evidence in their everyday practices and overcome obstacles that may impede the implementation of the evidence [ 4 ]. EBP in healthcare is not a novel concept; Florence Nightingale introduced EBP to nursing in 1858 [ 5 ]. The concept of EBP changed as the nursing profession evolved and expanded significantly over the past few decades [ 6 ].

Care for critically ill patients necessitates a high level of competency [ 7 ]. In the ICU, mechanical ventilation (MV) is the most frequently utilised treatment modality [ 8 ]. Although MV aids in the survival of patients with respiratory compromise, it frequently results in a number of complications if they do not receive adequate nursing care [ 9 ]. Since the primary purpose of EBP is to address healthcare issues that contribute to higher mortality and morbidity rates, we have chosen to focus on ventilator-associated pneumonia (VAP) as it is a predominant complication among MV patients in Egypt. The incidence of VAP in Egypt ranges from 16 to 75% [ 10 , 11 ], which is a significantly higher incidence compared to other regions, as the incidence of VAP globally is 15.6%, with rates of 13.5% in the United States, 13.8% in Latin America, and 16.0% in the Asia-Pacific region [ 12 , 13 ]. Additionally, the survival rate among VAP patients in Egypt ranges from 58.3 to 31.8% [ 11 , 14 ], whereas the global survival rate of VAP typically falls between 50% and 75% [ 15 ], which is also considered greater than the rate observed in Egypt. This high incidence of VAP and low survival rates in Egypt may indicate a lack of EBP in nursing practice. Due to inadequate nursing practices, particularly in the care of patients with MV, several studies recommend extensive training for nurses [ 16 , 17 , 18 ].

Therefore, we hypothesised that nurses who received an evidence-based nursing practice training programme (EBNPTP) (μ1) demonstrate a sustainable higher increase in their level of competency than those who received the usual traditional in-service education (μ2) in caring for mechanically ventilated patients. (H1: μ1 > μ2). This study aims to examine the effect of a designed EBNPTP on the competency level of nurses caring for patients on MV in selected ICUs in Egypt.

Conceptual framework

The revised Johns Hopkins Evidence-Based Practice (JHEBP) Model [ 4 ] was selected as a systematic and efficient approach to implementing an evidence-based programme into practice in this study Fig.  1 . The JHEBP model encompasses four essential components: inquiry, practice, practice improvements, and learning. Nurse performance is considered the most typical determinant and predictor of the quality of care and patient outcomes [ 19 ]. Due to a lack of nurses’ level of competency regarding caring for MV patients, the quality of provided care and patients’ outcomes are negatively impacted [ 16 , 17 , 18 ]. As an independent variable, we designed the EBP training programme for ICU nurses based on the JHEBP method. The EBP training programme contains eight domains listed in Fig.  1 , which meet the educational needs of nurses in terms of both knowledge and practices. The ultimate objective of the training is to provide a positive, sustainable change in nurses’ level of competencies, thereby improving patient outcomes [ 20 ]. The JHEBP Model defines learning as a sustainable change in candidates’ behaviour. Therefore, the post-assessment of nurses’ competency as a dependent variable was measured three times at one-month intervals to evaluate the over-time change compared to the baseline pre-assessment and control group.

Conceptual Framework of this study

EBNCAC: Evidence-Based Nursing Competency Assessment Checklist; AARC: American Association for Respiratory Care; AACN American Association of Critical-Care Nurses; EBNPTP: Evidence-Based Nursing Practice Training Programme; MV: Mechanical Ventilator; ICU: Intensive Care Unit; EBP: Evidence-Based Practices; VAP: Ventilator-Associated Pneumonia

Trial design

The current study was a prospective open-label parallel 1:1 randomised controlled trial. This study’s protocol was developed following the Standard Protocol Items Recommendations for Interventional Trials [ 21 ]. The study was conducted between November 2022 and February 2023 at the National Hepatology and Tropical Medicine Research Institute (NHTMRI) in Cairo, Egypt, in accordance with the Consolidated Standards of Reporting Trials (CONSORT) guidelines [ 22 ].

Participants sampling and study setting

The study was conducted in adult ICUs at the NHTMRI, Cairo, Egypt. The total capacity of the ICU is 14 beds, divided into two sections. One section was allocated for nurses who were assigned as an intervention group, while the other section was allocated for nurses who served as a control group. By randomly assigning nurses to each group and ensuring they work in separate ICU sections, the risk of contamination bias is reduced. These sections are comparable in terms of patient flow, equipment availability, and the number of working nurses. The total number of nurses in the selected setting is 94. All selected nurses met specific inclusion criteria: Willing to participate in this research, hold the existing position for at least three months; this criterion ensures that participants have had sufficient time to become familiar with their roles and responsibilities, allowing for a more accurate assessment of any changes or improvements in competency resulting from the EBP training programme. Additionally, participants were required to have at least two years of critical care experience, ensuring they possess a solid foundation of knowledge and skills necessary for caring for MV patients. This experience enhances the credibility of their feedback on the training programme’s effectiveness. Nurses intending to leave their jobs within the study period (four months) were excluded.

Sample size calculation

The sample size of 80 nurses was estimated by G power software V.3.1.9.4 (Psychonomic Society, Madison, Wisconsin, USA) with α = 0.05, power (1-β err prob) = 0.80, effect size = 0.56, and confidence level of 0.95. In terms of statistical power and effect size, the sample size chosen for our study was deemed adequate based on the previous study that studied the impact of an education programme on the performance of nurses providing care for patients on MV [ 23 ].

Randomisation and allocation

After verifying the eligibility criteria, the enrolled nurses were randomly divided into intervention and control groups. A simple random sample was generated by a lottery method. The eligible nurses were assigned a number, and each number was written and placed in a small opaque envelope. Then random selection and allocation were performed sequentially for the intervention and control groups. Randomisation and allocation were conducted by an unaffiliated third party.

The primary endpoint

The primary outcome was an ‘increase in the competency level’ of nurses caring for MV patients, measured by the Evidence-Based Nursing Competency Assessment Checklist (EBNCAC) over three months after receiving EBNPT, aiming to comprehensively evaluate the effectiveness and durability of the provided EBNPTP and to ensure the stability of results.

Measurement tools

EBNCAC is a structured observational checklist assessing nurses’ competency developed by the researcher and compiled from evidence-based clinical guidelines listed in Fig.  1 . Encompassing 74 items, the checklist covers eight domains addressed in the Evidence-Based Nursing Practice Training Programme (EBNPTP). The tool was structured based on various sources, including the American Association of Critical-Care Nurses (AACN), the American Association for Respiratory Care (AARC), the National Institutes of Health (NIH), and the Cochrane Library [ 24 , 25 , 26 , 27 ]. The responses of nurses to each item were graded on a scale of 2 to 0. “2 = performed correctly and satisfactory”, “1 = performed but unsatisfactory,” and “0 = not performed”. The total score ranged from 0 (lowest) to 148 (highest). Assessors were the charge nurses in the selected ICUs; they directly observed the nurses’ performance while participants cared for the MV patients. Based on the total score of 148, the scoring level was divided into three categories: High (> 120 / >80%), Moderate (74–120 / 50–80%), and Low (74 / 50%).

Validity and reliability

Content and scope validity for EBNCAC were determined utilising the Lawshe method [ 28 ]. The tool was revised by five experts in critical care medicine and nursing. Following the Subject Matter Expert (SME) ratings, the content validity ratio (CVR) was calculated for each item using the formula (ne–N/2)/(N/2), where ne represents the number of SMEs indicating “essential” and N denotes the total number of SMEs. The Content Validity Index (CVI) was then calculated by averaging the CVRs across all items, resulting in a value of 0.98 (72.57/74). The scale’s reliability was assessed using internal consistency (Cronbach’s alpha) for all items in the EBNCAC. The calculated Cronbach’s alpha for the EBNCAC was 0.721.

Evidence-based nursing practices training programme (EBNPTP) for the intervention group

BNPTP pertains to the care of MV patients. This is an integrated theoretical and clinical course for one week (30 h) designed by the researchers. To ensure the validity and reliability of the provided EBNPTP, it was formulated based on the latest research findings in the relevant areas of this study, such as those from the AACN and Cochrane Library [ 24 , 27 ]. Furthermore, it underwent review by three professional experts in critical care nursing and medicine to ascertain content validity. Also, three ICU nurses were enlisted to conduct a pre-test assessing the feasibility and acceptability of the training programme and the tool. Necessary revisions were made based on their feedback, and these nurses were excluded from the sample frame for enrollment. We standardised the delivery of the EBNPTP to enhance reliability by providing clear instructions to facilitators and conducting training sessions in a controlled and consistent manner. Finally, setting amenities and nurses’ and patients’ preferences were considered as it is a necessity of EBP. During the training week, the nurses in the intervention group ( n  = 40) were divided into two equal groups. They were scheduled to exchange their working days in the ICU with their training times to prevent any interruption of workflow in the ICU. The nurses’ considerable clinical experience enabled them to effectively fulfil the objectives of the condensed course.

Control group

The control group received traditional in-service education on a regular basis from the quality management department and nursing office. Usually, the educational content was provided in accordance with the educational needs of nurses. Routine clinical guidance was usually provided in real clinical settings. Additionally, periodic supplementary sessions were organised to address significant incidental clinical issues encountered by nurses.

Data collection procedure

After obtaining the informed consent, recruitment started in November 2022, and baseline pre-assessment was conducted in November 2022 using the EBNCAC. It serves as the initial assessment before the EBNPTP intervention, which was provided in one week at the end of November 2022. The first post-assessment was conducted immediately after the EBNPTP at the beginning of December 2022. It measures the immediate impact of the EBNPTP using the EBNCAC. The second post-assessment took place one month after the first assessment in January 2023. The Third Post-assessment occurred in the second half of February 2023, one month after the second post-assessment and three months after the EBNPTP, serving as the endpoint assessment. Considering that each assessment was held within one week, the interval between the four assessments was one month.

Data analysis

This study utilized a per-protocol analysis. Statistical Package for Social Sciences (SPSS) V.23.0 (IBM, New York) was used for analysis. Data were expressed using mean and standard deviation (SD). The normal data distribution was examined using Shapiro-Wilk’s test, histograms, box plots, and normal Q-Q plots for both the control and intervention groups with ( p  >.05). The two groups were compared by a two-way repeated measure of ANOVA. Multiple linear regression was applied as a regression model to test the effect of the study predictors on the endpoint third post-assessment. Finally, the effects of demographic characteristics on the baseline pre-assessment and endpoint of the third post-assessment were determined utilising a t-test and one-way ANOVA. The significance level was set at ( p  <.05).

Out of 94 nurses, 14 were excluded as they did not meet the eligibility criteria. Eighty nurses were equally allocated into the intervention group and control group. Ultimately, the third post-assessment data was carried out for 71 nurses (intervention, n  = 37; control, n  = 34). The reasons for dropout throughout the follow-up using three post-assessments are reported in Fig.  2 . The scores for nurses’ competency subscales across the control and intervention groups at the four observation times are depicted in supplementary material 1 .

CONSORT flow diagram shows the participation in this study

At baseline, there were no significant differences between the groups in regard to their demographic characteristics Table  1 . Most participants were female (78.8%), and more than half were diploma nurses (57.5%). Their mean age and length of experience at the ICU were 33.2 years old and 10.3 years, respectively.

Comparison between nurses’ level of competency over the four times of measurements

* P  <.001

The stacked line chart in Fig.  3 depicts the chronological change in nurses’ competency level measured by EBNCAC among the two groups, revealing a low level of competency at the baseline with no significant difference between the two groups ( p  =.81). The highest level of competency was at the first post-assessment score among the interventional group, with a mean score of (90.4 ± 11.55). The mean score declined steadily until the third post-assessment reaching a mean score of (65.6 ± 26.70). The control group demonstrated a low level of competency along with the four-time assessments, with mean scores ranging from 31.5 to 33.67 out of 148. Statistically significant differences were observed between the groups among the three post-assessments, with ( p  <.001).

According to Table  2 , there is a statistically significant difference within groups in terms of pre, first, second, and third assessments in relation to the nurses’ competency level ( p  <.001). In addition, there is a statistically significant difference between groups regarding the nurses’ competency level ( p  <.001), specifically in the three post-assessment phases. with a considerable high estimated effect size (η2 = 0.699). Finally, there is an interaction effect between the measurements in time and group ( p  <.001). Therefore, the result of the Two-way repeated measures ANOVA supported our hypothesis that the EBNPTP significantly increased nurses’ level of competency.

Table  3 presents the results of multiple linear regression models, which reveal the effect of these independent variables on the endpoint observation. The study revealed that pre-assessment (B = 0.53, p  =.002), educational level (B = 14.12, p  <.001), and control-intervention groups strongly predicted improvement of the third post-assessment (Endpoint) (B = 35.69, p  <.001). The adjusted R square was (0.667), indicating that the model could account for approximately 66.7% of third post assessment improvement.

Table  4 indicates significant differences between nurses’ level of education and the scores of the third post-assessment (F = 9.41, p  <.01). The 3rd post assessment score was significantly higher for bachelor’s degree nurses than for diploma ( p  <.001) and technical institute nurses ( p  <.05), while no significant differences between nurses’ pre / third post-assessments related scores in term of their gender, age, and years of experience.

To the of our knowledge, this is the first randomised controlled trial (RCT) in Egypt and the Middle East that aimed to quantitatively examine the effect of the EBNPTP caring for MV patients and assess the sustainability effect over time. The current study showed that the nurses who received the EBNPTP demonstrated a higher level of competency than those who did not. Congruently, several studies revealed that nurses’ level of competency was significantly improved by attending an EBP educational programme [ 29 , 30 , 31 , 32 ]. These findings strongly advocate for the widespread adoption of EBP utilisation to enhance nurses’ competency levels. Conversely, previous research has suggested that although EBP enhances nurses’ practices, it does not have a significant impact on their knowledge and attitude [ 33 ].

The improvement in nurses’ level of competency after receiving the EBNPTP can be attributed to a number of factors, including an increase in their job satisfaction, a sense of confidence, and an increase in their knowledge and skills, which provides them with a rationale for each specific task they perform. These provided justifications align with previous research [ 4 , 31 ]. From another point of view, this finding underscores deficiencies in baseline nurses’ understanding of EBP and its inadequate integration into their clinical practices. Moreover, the findings hint at the ineffectiveness of traditional in-service education delivered to nurses. Indicates the importance of substituting traditional in-service education with EBP training programmes and wide use of such programmes across different nursing domains.

In terms of the sustainability effect of EBNPTP among the intervention group, this study demonstrated that the mean scores of the nurses who received EBNPTP decreased significantly over time, indicating a lack of sustainability in the nurses’ level of competency. Even though the third post-assessment score for the intervention group was the lowest, it was still significantly two times higher than the baseline per-assessment score for the same group and the average scores of the control group. Similarly, Chu et al. (2019) [ 34 ] found that the experimental group’s scores substantially improved more than the control group one month after the training. However, both groups’ results declined; still, the experimental group performed better than the control group, indicating the effectiveness of the EBNPTP. Short-term initiatives of EBP education are likely to be successful. Nevertheless, there is little evidence regarding these initiatives’ sustainability [ 34 , 35 ]. Conversely, other studies confirmed that the participants’ EBP competencies were significantly improved and maintained over time [ 36 , 37 ].

The rationale for the lack of sustainability of nurses’ competencies can be attributed to nurses’ attitudes, resistance to change, lack of motivation, inadequate commitment, insufficient clinical supervision, stressful work environment, and workload. This finding is consistent with previous studies [ 31 , 36 ]. The lack of sustainability may also result from insufficient availability of essential equipment and supplies required for conducting EBP. Hence, it is strongly advised to provide effective clinical supervision for nurses in parallel with implementing EBP and to encourage nurses to adopt EBP consistently. Also, ensuring the constant availability of the necessary equipment.

Regarding the variables that affect the competency level of the nurses, multi-linear regression analysis revealed that a higher educational level was associated with a higher level of nurses’ competency. This result could be attributed to the higher level of skills and knowledge that baccalaureate-educated nurses possess; they are also more confident and take the initiative to update their knowledge, which makes them more capable of performing competently. On the same line, Hashish et al. (2020) [ 38 ] illustrated that experienced and baccalaureate nurses are more likely to access more resources, power, and knowledge that enable them to undertake autonomous and EBP than diploma programmes. Notably, the majority (approximately 90%) of nurses in Egypt hold diplomas, while only 6–8% hold bachelor’s degrees [ 39 ].

Furthermore, the study found that the baseline pre-assessment was an independent predictor and showed a significant relationship with the third assessment. This may be due to the fact that those who demonstrated in a particular way will continue to do so, and the nurses’ performance depends on their previous accumulated knowledge. This finding aligns with previous research which stated that nurses with a higher baseline competency level are likely to be more confident in implementing EBP [ 40 ]. However, the study revealed that nurses’ gender, age, and years of experience did not significantly affect their competency level before and after EBNPTP. This finding may be due to the reliability and accessibility of the provided EBNPTP, which was available to all nurses irrespective of these demographic variations, thus suggesting that EBNPTP implementation in the future could be beneficial for all nurses, regardless of these demographic characteristics. Consistently, Stokke et al. (2014) stated that none of the nurses’ demographic characteristics were found to be correlated with the implementation of EBP [ 41 ]. Since nurses’ attitude and motivation reflect their professional values and performance, prior research emphasises the importance of enhancing these factors when encouraging nurses to adopt EBP into their practices [ 42 ].

The current RCT is the first in Egypt and the Middle East to investigate the effect of an EBP training programme on the competency of nurses caring for MV patients and to assess the effect’s sustainability over time. In accordance with the research hypothesis, the EBP training programme demonstrated a significant increase in the nurses’ level of competency compared with traditional in-service education. This highlights the potential for widespread adoption of EBP across various areas of nursing to enhance the quality of care provided. However, the efficacy of the EBP training programme was found to be unsustainable over time. Addressing this challenge requires integrating the EBP training programme as material for job development and remuneration training for nurses to enhance its long-term effectiveness, ongoing monitoring of nurses’ performance, and further assessment of the contributing factors. The baseline competency and educational level of nurses correlate significantly with their performance. Consequently, the difficulties in dealing with nurses with varying levels of education and diminishing competencies persisted. This suggests the need for customised training programmes based on nurses’ baseline competency levels and educational backgrounds, as well as facilitating peer support and mentorship.

Limitations of the study

The enrolled participants were selected from a limited number of nurses. In addition, when the researchers estimated the sample size, the dropout rate was not considered, which may affect the power of the sample size; the dropout rate was 11%. The study included a small number of allocated bachelor nurses. Another limitation is that only three months were the duration to assess the sustainability effect of EBNPTP over time, which may be a short period. Additionally, data was collected from only one hospital.

Recommendations

According to the current study’s findings, we strongly suggest implementing EBP in nursing practices through elevating awareness and delivering extensive training for nurses across different settings. By equipping nurses with the necessary skills and knowledge for EBP, their competency can be enhanced, thus contributing to improved patient outcomes. Additionally, assign highly educated nurses to critical care settings requiring advanced care. Also, to sustain the implementation of EBP, we recommend providing effective clinical supervision. Furthermore, we propose a larger-scale evaluation of the impact of EBP implications in a variety of nursing specialisations. We therefore strongly advise evaluating the effects of EBP on patient outcomes. In addition, it is important to assess the factors or obstacles that may affect the application of EBP in nursing and to maintain its sustainability, as well as to identify the gap between education and practice using qualitative and quantitative research methods.

Data availability

The generated tool of data collection EBNCAC, intervention training programme EBNPTP and raw data of this study are available from the corresponding author upon request.

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Acknowledgements

We would like to express our gratitude to all nurses who participated in this study. We thank Mrs. Samar Hashem for the assistance in data collection.

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Open access funding provided by The Science, Technology & Innovation Funding Authority (STDF) in cooperation with The Egyptian Knowledge Bank (EKB).

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Conceptualization, S.E., and M.M.; methodology, S.E., M.M., E.E., and B.E.; Data collection, E.E., B.E., and S.E. investigation and formal analysis, S.E. and M.M.; writing—review and editing, S.E., M.M., E.E., and B.E.; All authors read and approved the final manuscript.

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Correspondence to Sameh Elhabashy .

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Ethics approval and informed consent to participate.

This study was registered with Clinical Trials.gov (Registration # NCT05721664) on 10/02/2023 and approved by the Research Ethics Committee for Human Subject Research at NHTMRI-IRB, Egypt (approval # 33/22). Participation in this study was entirely voluntary, and a written informed consent was obtained before the commencement of the study, the authors are attesting that all participants were aware of the study’s purpose, risks, and potential benefits before providing written consent. Participants had the right to withdraw from the study at any time without any repercussions on their professional evaluations, while still receiving the traditional routine education as usual. Even though the control group did not receive the intervention being studied, they still received equitable education to ensure fairness, and no expected harm was verified. Also, we intend to provide the EBP training programme to the control group if the intervention proves to be effective, thus ensuring equal treatment for all participants in the study. The study was conducted with the participants’ rights and safety protected by adhering to local Egypt laws and all methods were carried out in accordance with relevant guidelines and regulations of the Declaration of Helsinki. Every participant received a unique identification number, which protected their anonymity. Confidentiality was also confirmed.

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Elhabashy, S., Moriyama, M., Mahmoud, ED. et al. Effect of evidence-based nursing practices training programme on the competency of nurses caring for mechanically ventilated patients: a randomised controlled trial. BMC Nurs 23 , 225 (2024). https://doi.org/10.1186/s12912-024-01869-1

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• http://orcid.org/0000-0001-8401-4976 Majd T Mrayyan 1 ,
• http://orcid.org/0000-0002-6393-3022 Abdullah Algunmeeyn 2 ,
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Background Research shows a significant growth in clinical leadership from a nursing perspective; however, clinical leadership is still misunderstood in all clinical environments. Until now, clinical leaders were rarely seen in hospitals’ top management and leadership roles.

Purpose This study surveyed the attributes and skills of clinical nursing leadership and the actions that effective clinical nursing leaders can do.

Methods In 2020, a cross-sectional design was used in the current study using an online survey, with a non-random purposive sample of 296 registered nurses from teaching, public and private hospitals and areas of work in Jordan, yielding a 66% response rate. Data were analysed using descriptive analysis of frequency and central tendency measures, and comparisons were performed using independent t-tests.

Results The sample consists mostly of junior nurses. The ‘most common’ attributes associated with clinical nursing leadership were effective communication, clinical competence, approachability, role model and support. The ‘least common’ attribute associated with clinical nursing leadership was ‘controlling’. The top-rated skills of clinical leaders were having a strong moral character, knowing right and wrong and acting appropriately. Leading change and service improvement were clinical leaders’ top-rated actions. An independent t-test on key variables revealed substantial differences between male and female nurses regarding the actions and skills of effective clinical nursing leadership.

Conclusions The current study looked at clinical leadership in Jordan’s healthcare system, focusing on the role of gender in clinical nursing leadership. The findings advocate for clinical leadership by nurses as an essential element of value-based practice, and they influence innovation and change. As clinical leaders in various hospitals and healthcare settings, more empirical work is needed to build on clinical nursing in general and the attributes, skills and actions of clinical nursing leadership of nursing leaders and nurses.

• clinical leadership
• health system
• leadership assessment

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WHAT IS ALREADY KNOWN ON THIS TOPIC

Clinical leadership was limited to service managers; however, currently, all clinicians are invited to participate in leadership practices. Clinical leaders are needed in various healthcare settings to produce positive outcomes.

WHAT THIS STUDY ADDS

This study outlined clinical leadership attributes, skills and actions to understand clinical nursing leadership better. The current study highlighted the role of gender in clinical nursing leadership, and it asserts that effective clinical nursing leadership is warranted to improve the efficiency and effectiveness of care. The results call for nurses’ clinical leadership as essential in today’s turbulent work environment.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

Nurses and clinical leaders need additional attributes, skills and actions. Clinical nursing leaders should use innovative interventions and have skills or actions to manage current work environments. Further work is needed to build on clinical nursing in general and the attributes, skills and actions of clinical nursing leadership. Clinical leadership programmes must be integrated into the nursing curricula.

Introduction

Clinical leadership is a matter of global importance. Currently, all clinicians are invited to participate in leadership practices. 1 This invitation is based on the fact that people deliver healthcare within complex systems. Effective clinicians must understand systems of care to function effectively. 1 2 Engaging in clinical leadership is an obligation, not a choice, for all clinicians at all levels. This obligation is more critical in nursing with many e merging global health issues , 2 such as the COVID-19 pandemic.

The systematic literature review of Cummings et al 3 shows the differences in leadership literature. In early 2000, clinical leadership emerged in scientific literature. 4 It is about having the knowledge, skills and competencies needed to effectively balance the needs of patients and team members within resource constraints. 4 Clinical leadership is vital in nursing as nurses face complex challenges in clinical settings, especially in acute care settings. 4 Although developed from the management domain, leadership and management are two concepts used interchangeably, 5–9 leading to further misunderstanding of the relationship between clinical leadership and management. While different types of leadership have been evident in nursing and health industry literature, clinical leadership is still misunderstood in clinical environments. 8 Clinical leadership is not fully understood among health professionals trained to care for patients, as clinical leadership is a management concept, leaving the concept open to different interpretations. 10 For example, Gauld 10 reported that clinical leaders might be professionals (such as doctors and nurses) who are no longer clinically active, mandating that clinical leaders should also be involved in delivering care. 10

There is no clear definition of ‘clinical leadership’. However, effective clinical leadership involves individuals with the appropriate clinical leadership skills and attributes at different levels of an organisation, focusing on multidisciplinary and interdisciplinary work. 10 The main skills associated with clinical leadership were having values and beliefs consistent with their actions and interventions, being supportive of colleagues, communicating effectively, serving as a role model and engaging in reflective practice. 4–9 The main attributes associated with clinical leadership were using effective communication, clinical competence, being a role model, supportive and approachability. 4–9 Stanley and colleagues reported that clinical leaders are found across health organisations and are presented in all clinical environments. Clinical leaders are often found at the highest level for clinical interaction but not commonly found at the highest management level in wards or units. 4–9

With the increasing urgency to improve the efficiency and effectiveness of care, effective nursing leadership is warranted. 4 11–17 Clinical leaders can be found in various healthcare settings, 4 most often at the highest clinical level, but they are uncommon at the top executive level. 6–9 18–24 In the UK, the National Health Service (NHS) 25 empowers clinicians and front-line staff to build their decision-making capabilities, which is required for clinical leadership. This empowerment encourages a broader practice of clinical leadership without being limited to top executives alone. 25 26

Purpose and significance

This study assesses clinical nursing leadership in Jordan. More specifically, it answers the following research questions: (1) What attributes are associated with clinical nursing leadership in Jordanian hospitals? (2) What skills are important for effective clinical nursing leadership? (3) What actions are important for effective clinical nursing leadership? (4) What are the differences in skills critical to effective clinical nursing leadership based on the sample’s characteristics? (5) What are the differences in effective clinical nursing leaders’ actions based on the sample’s characteristics?

Nursing leadership studies are abundant; however, clinical leadership research is not well established. 8 27 Until fairly recently, clinical leadership in nursing has tended to focus on nursing leaders in senior leadership positions, ignoring nurse managers in clinical positions. 8 There has been significant growth in research exploring clinical leadership from a nursing perspective. 4 8 9 14–17 24 26–32 A new leadership theory, ‘congruent leadership’, has emerged, claiming that clinical leaders acted on their values and beliefs about care and thus were followed. 6–9 20 This study is the first in Jordan’s nursing and health-related research about clinical leadership. Clarifying this concept from nurses’ perspectives will support greater healthcare delivery efficiencies.

Search methods

The initial search was done using ‘clinical nursing leadership’ at the Clarivate database and Google Scholar database from 2017 to 2021, yielded 35 studies, of which, after abstracting, 14 studies were selected. However, Stanley’s work (12 studies), including those before 2017, was included because we followed the researcher’s passion and methodology of studying clinical leadership; also, some classical models of clinical leadership because they were essential for the conceptualisation of the study as well as the discussion, such as the NHS Leadership Academy (three studies; ref 25 33 34 ).

Another search was run using the words ‘attributes’, ‘skills’ or ‘actions’ using the same time frame; most of the yielded studies were not relevant, this search year was expanded to 2013–2021 because the years 2013–2015 were the glorious time of studying these concepts. Using ‘clinical leadership’ rather than ‘leadership studies’, 15 studies were yielded; however, Stanley’s above work was excluded to avoid repetition, resulting in using three studies (ref 29 30 35 ). A relevant reference of 2022 similar to our study (ref 36 ) was added at the stages of revisions. The remaining 16 of 49 references were related to the methodology and explanation of some results, such as those related to gender differences in leadership. The following limits were set: the language was English; and the year of publication was basically the last 5 years to ensure that the search was current.

Clinical leadership

Clinical leadership ensures quality patient care by providing safe and efficient care and creating a healthy clinical work environment. 4 10–17 27 31 32 It also decreases the high costs of clinical litigation settlements and improves the safety of service delivery to consumers. 4 11–17 32 For these reasons, healthcare organisations should initiate interventions to develop clinical leadership among front-line clinicians, including nurses. 8 9

Literature was scarce on clinical leadership in nursing. 4 8–10 14–17 27 28 31 Stanley and Stanley 8 defined clinical leadership as developing a culture and leading a set of tasks to improve the quality and safety of service delivery to consumers.

Clinical leadership is about focusing on direct patient care, delivering high-quality direct patient care, motivating members of the team to provide effective, safe and satisfying care, promoting staff retention, providing organisational support and improving patient outcomes. 31 Clinical leadership roles include providing the vision, setting the direction, promoting professionalism, teamwork, interprofessional collaborations, good practice and continued medical education, contributing to patient care and performing tasks effectively. 31 Moreover, the researchers added that clinical leadership is having the approachability and the ability to communicate effectively, the ability to gain support and influence others, role modelling, visibility and availability to support, the ability to promote change, advise and guide. 31 Clinical leadership competencies include demonstrating clinical expertise, remaining clinically focused and engaged and comprehending clinical leadership roles and decision-making. In addition, clinical leadership was not associated with a position within the management and organisational structure, unlike health service management. 31 33

Clinical leadership is hindered by many barriers that include the lack of time and the high clinical/client demand on their time. 8 9 Clinical leadership is limited because of the deficit in intrapersonal and interpersonal capabilities among team members and interdisciplinary and organisational factors, such as a lack of influence in interdisciplinary care planning and policy. 37 Other barriers include limited organisational leadership opportunities, the perceived need for leadership development before serving in leadership roles and a lack of funding for advancement. 38

This paper aligns with the theory of congruent leadership proposed by Stanley. 19 This theory is best suited for understanding clinical leadership because it defines leadership as a congruence between the activities and actions of the leader and the leader’s values, beliefs and principles, and those of the organisation and team.

Attributes of clinical leadership

The clinical leadership attributes needed for nurses 8 28 to perform their roles effectively are: (1) personal attributes: nurses are confident in their abilities to provide best practice, communicate effectively and have emotional intelligence; (2) team attributes: encouraging trust and commitment to others, team focus and valuing others’ skills and expertise; and (3) capabilities: encouraging contribution from others, building and maintaining relationships, creating clear direction and being a role model. 8 28 Clinical leadership attributes are linked to communicating effectively, role modelling, promoting change, providing advice and guidance, gaining support and influencing others. 28–30 Other attributes to include are clinical leaders’ engagement in reflective practice, 29 provision of the vision; setting direction, having the resources to perform tasks effectively and promoting professionalism, teamwork, interprofessional collaborations, effective practice and continued education. 27 28 31

Skills of clinical leadership

Clinical leadership skills include (1) a ‘clinical focus’: being expert knowledge, providing evidence-based rationale and systematic thinking, understanding clinical leadership, understanding clinical decision-making, being clinically focused, remaining clinically engaged and demonstrating clinical expertise; (2) a ‘follower/team focus’: being supportive of colleagues, effectively communicating communication skills, serving as a role model and empowering the team; and (3) a ‘personal qualities focus’: engaging in reflective practice, initiating change and challenging the status quo. 17 30 32 Clinical leaders have advocacy skills, facilitate and maintain healthier workplaces by driving changes in cultural issues among all health professionals. 17 29 Moreover, the overlap between the attributes and skills of clinical leaders includes being credible to colleagues because of clinical competence and the skills and capacity to support multidisciplinary teams effectively. 17 29 32

Actions of clinical leadership

A clinical leader is anyone in a clinical position exercising leadership. 26 The clinical leader’s role is to continuously instil in clinicians the capability to improve healthcare on small and large scales. 26 Furthermore, Stanley et al 9 demonstrated that clinical leaders are not always managers or higher-ups in organisations. Clinical leaders act following their values and beliefs, are approachable and provide superior service to their clients. 9 Clinical leaders define and delegate safety and quality responsibilities and roles. 14 32 39 They also ensure safety and quality of care, manage the operation of the clinical governance system, implement strategic plans and implement the organisation’s safety culture. 14 32 39 The Australian Commission on Safety and Quality in Health Care 39 also reported that clinical leaders might support other clinicians by reviewing safety and quality performance data, supervising the clinical workforce, conducting performance appraisals and ensuring that the team understands the clinical governance system.

In summary, clinical leadership attributes, skills and actions were outlined to understand clinical nursing leadership. The literature shows limited nursing research on clinical leadership, calling for clinical leadership that paves the road for nurses in the current turbulent work environment.

Study design

A descriptive quantitative analysis was developed to collect data about the attributes and skills of clinical nursing leadership and the actions that effective nursing clinical leaders can take. A cross-sectional design was employed to measure clinical leadership using an online survey in 2020. This design was appropriate for such a study as it allows the researchers to measure the outcome and the exposures of the study participants at the same time. 40

Sample and settings

The general population was registered nurses in medical centres in Jordan. The target population was registered nurses in teaching, public and private hospitals. Most nurses in Jordan are females working at different shifts on a full-time basis in different types of healthcare services. The baccalaureate degree is the minimum entry into the clinical practice of registered nurses. As previous nurses, we would like to attest that nurses in Jordanian hospitals commonly use team nursing care delivery models with different decision-making styles. The size of the sample was calculated by using Thorndike’s rule as follows: N≥10(k)+50 (where N was the sample size, k is the number of independent variables) (attributes, skills, actions), the minimum sample size should be 80 participants. 40 From experience, the researcher considers the sample’s demographics and subscales as independent variables (k=17); the overall sample should not be less than 220.

Research participants were recruited through a ‘direct recruitment strategy’ from the hospitals where the nursing students were trained. A survey was used to collect data using non-random purposive sampling; of possible 450 Jordanian nurses, 296 were recruited from different types of hospitals: teaching (51 of possible 120 nurses), public (180 of possible 210 nurses) and private (65 of possible 120 nurses), with a response rate of 66%, which is adequate for an online survey. The inclusion criteria were that nurses should work in hospital settings, and any nurses who work in non-hospital settings were excluded. No incentives were applied.

Using a direct measurement method, Stanley’s Clinical Leadership Scale ( online supplemental file 1 ) was used to collect the data using the English version of the scale because English is the official education language of nursing in Jordan. 8 9 The original questionnaire consists of 24 questions: 12 quantitative and qualitative questions relevant to clinical leadership, and 12 related to the sample’s demographics. Several studies about clinical leadership among nurses and paramedics in the UK and Australia used modified versions of a survey tool 5 8 9 18–24 ; construct validity was ensured using exploratory factor analysis or triangulation of validation. Cronbach’s alpha measures the homogeneity in the survey, and it was reported to be 0.87 8 9 and 0.88 in the current study.

Supplemental material

Several questions were measured on a 5-point Likert scale in the original scale, and others were qualitative. The survey for the current study consists of 12 quantitative and qualitative questions related to clinical leadership and 14 questions related to the sample’s demographics. However, the qualitative data obtained were scattered and incomplete; thus, only the quantitative questions were analysed and reported, and another qualitative study about clinical leadership was planned. For the current study, three quantitative questions only focused on clinical leadership, leadership skills and the actions of clinical leaders, and 14 questions focused on the sample’s characteristics relevant to the Jordanian healthcare system developed by the first author. The sample characteristics were gender, marital status, shift worked, time commitment, level of education, age, years of experience in nursing, years of experience in leadership and the number of employees directly supervised. Other characteristics include the type of unit/ward, model of nursing care, ward/unit’s decision-making style, formal leadership-related education (yes/no) and formal management-related education (yes/no). Before data collection, permission to use the tool was granted.

Ethical considerations

Nurses were invited to answer the survey while assuring the voluntary nature of their participation. The participants were told that their participation in the survey was their consent form. Participants’ anonymity and confidentiality of information were assured; all questionnaires were numerically coded, and the overall results were shared with nursing and hospital administrators. 40

Patient and public involvement

There was no patient or public involvement in this research’s design, conduct, reporting or dissemination.

Data collection procedures

After a pilot study on 12 December 2020, which checked for the suitability of the questionnaire for the Jordanian healthcare settings, data were collected over a month on 23 December 2020. Data were collected through Google Forms; the survey was posted on various WhatsApp groups and Facebook pages. Using purposive snowball sampling, nurses were asked to invite their contacts and to submit the survey once. To assure one submission, the Google Forms was designed to allow for one submission only.

No problem was encountered during data collection. The two attrition prevention techniques used were effective communication and asserting to the participants that the study was relevant to them.

The researchers controlled for all possible extraneous and confounding variables by including them in the study. A possible non-accounted extraneous variable is the organisational structure; a centralised organisational structure may hinder the use of clinical nursing leadership.

Data analyses

After data cleaning and checking wild codes and outliers, all coded variables were entered into the Statistical Package for Social Sciences (SPSS) (V.25), 35 which was used to generate statistics according to the level of measurement. A descriptive analysis focused on frequency and central tendency measures. 40 Part 1 of the scale comprises 54 qualities or characteristics to answer the first research question. Responses related to skills were measured on a 1–5 Likert scale; thus, means and SDs were reported to answer the second research question. Eight actions were rated on a 1–5 Likert scale; thus, means and SDs were reported to answer the third research question. Independent t-tests using all sample characteristics were performed to answer the fourth and fifth research questions.

The preanalysis phase of data analysis was performed; data were eligible and complete as few missing data were found; thus, they were left without intervention. The assumption of normality was met; both samples are approximately normally distributed, and there were no extreme differences in the sample’s SDs.

Characteristics of the sample

There were 296 nurses in the current study from different types of hospitals: teaching (51 nurses), public (180 nurses) and private (65 nurses), with a response rate of 66%. Most nurses were females (209, 70.6%), single (87, 29.4%), working a day shift (143, 48.3%) or rotating shifts (92, 31.1%), on a full-time basis (218, 73.6%), with a baccalaureate degree (236, 79.7%), aged less than 25 years (229, 77.4%) and 25–34 years (45, 15.2%), respectively. Also, 65.1% (166) of nurses reported having less than 1 year of experience in nursing; thus, they have few nurses under them to supervise (145, 49% supervise one to two nurses), and 23.3% (69) of nurses reported having 1–9 years of experience in leadership. Nurses reported that their unit or ward has a primary (81, 27.4%) or team nursing care delivery model (162, 54.7%), with a mixed (94, 31.8%) or participatory decision-making style (113, 38.2%), and had formal leadership-related education (191, 64.5%), and had no formal management-related education (210, 70.9%) ( table 1 ).

• View inline

Sample’s characteristics (N=296*)

Attributes of clinical nursing leadership

Nurses were asked to think about the attributes and features of clinical leadership. Based on Stanley’s Clinical Leadership Scale, 8 9 nurses were given a list of 54 qualities and characteristics and asked to select the most strongly associated with clinical leadership, followed by those least strongly associated with clinical leadership. Table 2 shows the respondents’ ‘top ten’ selected qualities in ranked order.

'Most’ and ‘Least’ important attributes associated with clinical nursing leadership (N=296)

Skills of effective clinical nursing leaders

On a Likert scale of 1–5, respondents were asked to rank the skills of effective clinical leaders from ‘not relevant’ or ‘not important’ to 5=‘very relevant’ or ‘very important’. The top skills were having a strong moral character, knowing right and wrong and acting appropriately which received a high rating, with a mean of 4.17 out of 5 (0.92). Being in a management position to be effective was ranked as the least skill of an effective leader, with a mean value of 3.78 out of 5 (1.00). As indicated by respondents, other skills of effective clinical leaders are shown in table 3 .

Skills of effective clinical nursing leaders (N=296)

Actions of effective clinical nursing leaders

On a Likert scale of 1–5, respondents were asked to rank the actions of effective clinical leaders. Leading change and service management achieved a high rating of 4.07 out of 5 points (0.90). Influencing organisational policy was rated last, with a mean score of 3.95 out of 5 (1.01), which may reflect the very junior nature of the majority of the sample. As described by respondents, some of the other actions of effective leaders are shown in table 4 .

Actions effective clinical nursing leaders can do (N=296)

Significant differences in skills of effective clinical nursing leaders based on gender

Independent t-tests using all sample’s characteristics were performed to answer the fourth research question. Gender was the only characteristic variable that differentiated clinical leadership skills. An independent t-test demonstrates that males and females have distinct perspectives on 3 out of 10 items measuring clinical leadership skills. Female participants outperform male participants in terms of ‘working within the team (p value=0.021)’, ‘being visible in the clinical environment (p value=0.004)’ and ‘recognizing optimal performance and expressing appreciation promptly (p value=0.042) ( table 5 )’.

Significant differences in skills and actions of effective clinical nursing leaders based on gender (n=296)

Significant differences in actions of effective clinical nursing leaders based on gender

Independent t-tests using all sample’s characteristics were performed to answer the fifth research question. Gender was the only characteristic variable that differentiated clinical leadership actions, and it was discovered that five of the eight propositions varied in their actions: the way clinical care is administered (p=0.010); participating in staff development education (p=0.006); providing valuable staff support (p=0.033); leading change and service improvement (p=0.014); and encouraging and leading service management (p=0.019). The independent t-test results revealed that female participants scored higher in those acts, corresponding to effective leaders’ competencies. The mean values of participants’ responses to the actions of effective clinical leaders are shown in table 5 .

The characteristics of the current sample are similar to those of the structure of the task force in Jordan. The remaining question is how men in Jordan be supported in nursing to develop clinical leadership skills on par with females. Al-Motlaq et al 41 proposed using a part-time nurses policy to address nurses’ gender imbalances. Although this is necessary for both genders, we propose to develop a clinical leadership training package to promote working male nurses’ clinical leadership. In Jordan, we apply the modern trend of using leadership in nursing rather than management. About 65% of the nurses reported having formal leadership-related education, while around 71% reported no formal management-related education.

The findings clearly showed what nurses seek in a clinical leader. They appear to refer to a good communicator who values relationships and encouragement, is flexible, approachable and compassionate, can set goals and plans, resource allocation, is clinically competent and visible and has integrity. They necessitate clinical nursing leaders who can be role models for others in practice and deal with change. They should be supportive decision-makers, mentors and motivators. They should be emphatic; otherwise, they should not be in a position of control. These findings align with other research on clinical leadership. 7–9 21 Clinical leaders should be visible and participate in team activities. They should be highly skilled clinicians who instil trust and set an example, and their values should guide them in providing excellent patient care. 8 9

Participants chose other terms or functions associated with leadership roles less frequently or perceived as unrelated to clinical leadership functions. Management, creativity and vision were among the terms and functions mentioned. The absence of the word ‘visionary’ from the list of the most important characteristics suggests that traditional leadership theories, as transformational leadership and situational leadership, do not provide a solid foundation for understanding clinical leadership approaches in the clinical setting. This result can also be influenced by the junior level of the majority of the sample.

Skills of clinical nursing leadership

Numerous studies have documented the characteristics and skills of clinical leaders. 27 29 31 Clinical leaders’ skills include advocacy, facilitation and healthier workplaces. 27 29 31 Our participants were rated as having high morals (similar to other studies) 27 29 31 and worked within teams. 29 In turn, they were flexible and expressed appreciation promptly. 7–9 21 They were clinically competent; thus, they improvised and responded to various situations with appropriate skills and interventions. They recognised optimal performance, initiated interventions, led actions and procedures and had the skills and resources necessary to perform their tasks.

The lowest mean was ‘ being in a management position to be effective ’. This lowest meaning ‘ somehow ’ makes sense; all nurses can be effective leaders rather than managers, assuming effective clinical leadership roles without having management positions. 28 42

Actions of clinical nursing leadership

Influential nursing leaders are clinically competent and can initiate interventions and lead actions; these skills translate to actions. Clinical leaders are qualified to lead and manage the service improvement change (similar to Major). 42 This role will not suddenly happen; it requires clinical nursing leaders who encourage and participate in staff development education (consistent with Major). 42 This is an essential milestone and an example of providing valuable staff support. As these were the lowest reported actions, clinical nursing leaders should initiate and lead improvement initiatives in their clinical settings, 42 resulting in service improvement. They also have to influence evidence-based policies to improve work–life integration 43 and enhance patients, nurses and organisational outcomes. These outcomes include quality of care, nurses’ empowerment, job satisfaction, quality of life and work engagement. 4 11–17 32

Female nurses had more clinical leadership skills. Because the findings of this study have never been reported in the previous clinical leadership research literature, they are considered novel. This finding indicates that one possible explanation is that the overwhelming majority of respondents were females, with the proportion of females in favour (70.6%) exceeding that of males (29.4%). Furthermore, the current findings could be explained because the study was conducted in Jordan, a traditionally female-dominated gender nursing career.

This study discovered that there are gender differences in the characteristics of nurses and their clinical leadership skills, with female clinical nursing leaders scoring higher on the t-test than male clinical nursing leaders in the following areas: this is contrary to Masanotti et al , 43 who reported that male nurses have a greater sense of coherence and, in turn, more teamwork than female nurses, who commonly have job dissatisfaction and less teamwork. These could apply to female clinical nursing leaders. These female nurses had more ‘visibility in the clinical environment’, as expected in female-dominated gender nursing careers. As they were commonly dissatisfied as nurses, 43 clinical nursing leaders would be competent in caring for their nurses’ psychological status. These leaders know that even ‘thank you’ is the simplest way to show appreciation and recognition; however, this should be given promptly.

In Arab and developing countries, the perception that females have more skills with effective clinical leadership characteristics than males is consistent with Alghamdi et al 44 and Yaseen. 45 They found that females outperform males on leadership scales, which may also apply to clinical leadership. This study shows consistency between female and male clinical nursing leaders’ general perceptions of clinical leadership skills in female-dominated gender nursing careers but not in male-dominated, gender-segregated countries, including Jordan.

Female nurses had more clinical leadership actions, which differed in five out of eight actions. Female clinical nursing leaders were better at impacting clinical care delivery, participating in staff development education, providing valuable staff support, leading change and improving service.

It is aware that the nursing profession has a difficult context in some Arab and developing countries. For example, a study conducted in Saudi Arabia could explain the current findings that male nurses face various challenges, including a lack of respect and discrimination, resulting in fewer opportunities for professional growth and development. 46 The researchers reported that female clinical nursing leaders are preferred over male nurses because nursing is a nurturing and caring profession; it has been dubbed a ‘female profession’. 46 Additionally, this study corroborates a study that found many males avoid the nursing profession entirely due to its negative connotations 47 ; the profession is geared towards females. These and other stereotypes have influenced male nurses to pursue masculine nursing roles.

The study’s findings are unique because they have never been published in the previous clinical leadership research literature. However, these results can be explained indirectly based on non-clinical leadership literature. Consistent with Khammar et al , 48 as it is a female-dominated profession, it is apparent that female clinical nursing leaders are better at delivering clinical care. This result could also be related to female clinical nursing leaders having a better attitude towards clinical conditions and managing different conditions. 48 Female clinical nursing leaders, in turn, are better at influencing patient care and improving patient safety 36 and overall care and services. This improvement will not happen suddenly; it should be accompanied by paying more attention to providing continuous support, especially during induced change.

The current study reported that female clinical nursing leaders supported staff development and education because it is a female-oriented sample. Yet, Khammar et al 48 reported that men had more opportunities to educate themselves in nursing; this is true in a male-dominated country like Jordan. They also noted that males could communicate better during nursing duties. Regardless of gender, all of us should pay attention to our staff’s working environment and related issues, including promoting open communication, providing support, encouraging continuing education, managing change and improving the overall outcomes.

Limitations

Even though the study’s findings are intriguing, further investigation is needed to comprehend them. Because of the cross-sectional design used in the current study, we cannot establish causality. For this reason, the results should be interpreted with caution. Also, the purposive sample limits the generalisability; thus, this research should be carried out again with a broader selection of nursing candidates and clinical settings. Moreover, the sample consists mostly of nurses with minimal experience compared with nurses in other international countries such as Canada, the UK and the USA. 5 The current study also included nurses in their 40s and above, with male nurses less represented, and this causes misunderstanding of the true clinical leadership in nursing.

Implications

For practice, our sample consists of nurses with minimal experience compared with nurses in other developed counties. Our sample reported ‘influencing organizational policy’ as the last clinical leadership skill, which reflects the very junior nature of the sample. Unlike our study, in their systematic review, Guibert-Lacasa and Vázquez-Calatayud 36 reported that the profiles of the care clinical nurses’ experience usually varied, ranging from recent graduates to senior nurses. If our nurses were more experienced, it might lead to different results. More nurses’ clinical experience would increase nurses’ abilities at the bedside, especially in areas related to reasoning and problem solving. 36 More experienced nurses tend to work collaboratively within the team with greater competency and autonomy. 36 More experienced nurses would provide high-quality care, 36 resulting in patient satisfaction. To generate positive outcomes of clinical nursing leadership, such early-career nurses should be qualified. Guibert-Lacasa and Vázquez-Calatayud 36 suggested using the nursing clinical leadership programme based on the American Organization for Nursing Leadership 34 competency model, pending the presence of organisational support for such an initiative. 36

‘Most’ important clinical nursing leadership attributes should be promoted at all organisational and clinical levels. Clinical nursing leadership’s ‘least’ important attributes should be defeated to achieve better outcomes. Clinical nursing leaders should use innovative interventions and have skills or actions conducive to a healthy work environment. These interventions include being approachable to enable their staff to cope with change, 28 using open and consistent communication, 28–30 being visible and consistently available as role models and mentors and taking risks. 28 Hospital administrators must help their clinical leaders, including nursing leaders, to effectively use their authority, responsibility and accountability; clinical leadership is not only about complying with the job description. A good intervention to start with to promote the culture of clinical leadership is setting an award for the ‘ideal nursing leaders’. This award will bring innovative attributes, skills and actions.

Moreover, as they are in the front line of communication, nurses and clinical nursing leaders should be involved in policy-related matters and committees. 49 An interventional programme that gives nurses more autonomy in making decisions is warranted. In turn, various patient, nurse and organisational outcomes will be improved. 13–17 32

The study’s findings revealed statistically significant differences in the skills and actions of effective clinical leaders, with female nurses scoring higher in many skills and actions. Hence, healthcare organisations must re-evaluate current leadership and staff development policies and prioritise professional development for nurses while also introducing new modes of evaluation and assessment that are explicitly geared at improving clinical leadership among nurses, particularly males.

For education, this study outlined clinical leadership attributes, skills and actions to understand clinical nursing leadership in Jordan better. Nevertheless, nurses and clinical leaders need additional attributes, skills and actions. Consequently, undergraduate nursing students might benefit from clinical leadership programmes integrated into the academic curriculum to teach them the fundamentals of clinical leadership. A master’s degree programme in ‘Clinical Nursing Leadership’ would prepare nurses for this pioneering role and today and tomorrow’s clinical nursing leaders. However, all nurses are clinical leaders regardless of their degrees and experience. Conducting presentations, convening meetings, overseeing organisational transformation and settling disagreements are common ways to hone these abilities.

For research purposes, it is worth exploring the concept of clinical leadership from a practice nurse’s perspective to provide insight into practice nurses’ feelings and perceptions. Thus, a longitudinal quantitative design or a phenomenological qualitative design might be adopted to assess the subjective experience of the nurses involved. It is better in future research to focus on both young and veteran clinical leaders; some of our nurses were aged 45 years and above, and those nurses may not be clinically focused.

Summary and conclusion

The current study put clinical leadership into the context of the healthcare system in Jordan. This study highlighted the role of gender in clinical nursing leadership. Nurses’ clinical leadership is a milestone for influencing innovation and change. The current study identified the ‘most’ and ‘least’ important attributes, skills and actions associated with clinical leadership. However, the male and female nurses found substantial differences in effective clinical nursing leadership skills and actions. This study is unique; little is known about the collective concepts of attributes, skills and actions necessary for clinical nursing leadership.

Nurses need leadership attributes, skills and actions to influence policy development and change in their work environments. Leadership attributes can help develop programmes that give nurses more autonomy in making decisions. As a result, nurses will be more active as clinical leaders.

Ethics statements

Patient consent for publication.

Not applicable.

Ethics approval

This study involves human participants and was approved by The Hashemite University, Jordan (IRB number: 1/1/2020/2021) on 18 October 2020. Participants gave informed consent to participate in the study before taking part.

Acknowledgments

The researchers thank the subjects who participated in the study, and Mrs Othman and Mr Sayaheen who collected the data.

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Supplementary materials

Supplementary data.

This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.

• Data supplement 1

Contributors MTM developed the study conception, abstract, introduction, literature review and methods; collected the data and wrote the first draft of this research paper and the final proofreading. HAN analysed the data and wrote the results. AA wrote the discussion and updated the literature review. OK wrote the limitations, implications, and summary and conclusion. IAF and AAK did the critical revisions and the final proofreading. All authors contributed to the current work.

Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Competing interests None declared.

Provenance and peer review Not commissioned; externally peer reviewed.

Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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

Loujain sharif.

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

Khalid Almutairi

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

Khalid Sharif

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

3 Johns Hopkins School of Nursing, Baltimore Maryland, USA

Associated Data

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

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

Descriptive cross‐sectional study.

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

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

1. INTRODUCTION

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

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

2. BACKGROUND

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

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

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

3.1. Design

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

3.2. Method

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

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

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

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

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

3.3. Data collection process

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

3.4. Analysis

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

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

3.5. Ethics

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

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

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

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

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

Note : Bolded text denotes p value of <0.05.

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

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

4.1. Bivariate and multivariate analyses

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

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

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

5. DISCUSSION

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

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

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

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

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

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

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

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

5.1. Limitations

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

6. CONCLUSION

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

AUTHOR CONTRIBUTIONS

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

FUNDING INFORMATION

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

CONFLICT OF INTEREST

The authors have no conflict of interest to declare.

ETHICS STATEMENT

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

Supporting information

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

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