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Online Research Guide for Nursing Students

• Conducting Online Research
• Research Tools

Evaluating Sources

• Organizing Research

Are you ready to earn your online nursing degree?

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

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

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

Conducting Online Research for Nursing Students

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

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

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

Refining Your Search Results

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

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

Google Scholar

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

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

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

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

Online Research Tools

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

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

General Academic Research Tools

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

Nursing Research Tools

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

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

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

Who Is the Author?

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

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

What Is Its Purpose?

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

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

Does It Look Professional?

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

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

Is It Objective?

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

Is It Current?

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

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

What Sites Does It Link To?

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

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

Organizing Your Research

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

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

Online Tools to Manage Your Research

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

Citing Online Resources for Nursing Students

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

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

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

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

Articles From Online Periodicals

What is a doi.

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

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

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

Without DOI

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

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

Newspaper Articles

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

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

Electronic Books

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

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

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

No Author Name Provided

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

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

Author Name Provided

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

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

Online Journal Article With Six or Fewer Authors — DOI Included

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

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

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

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

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

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The power of nurses in research: understanding what matters and driving change

The next blog in our series focussing on how research evidence can be implemented into practice, Julie Bayley, Director of the Lincoln Impact Literacy Institute writes about the power of nurses in research and how nurses can support the whole research journey. 

Research is a funny old beast isn’t it? It starts life as a glint in a researcher’s eye, then like a child needs nurturing, shuttling back and forth to events and usually requires constant checking to make sure it’s not doing something stupid.

As someone who spends the majority of their working life on impact – the provable benefits of research outside of the world of academia – it is extraordinarily clear to me how research can make the world better. And as a patient advocate – having chronically and not exactly willingly collected DVTs over the last decade – it’s even more clear how good research and good care together make a difference that matters.

Having had some AMAZING care, nursing strikes me as both an art and a science. A brilliant technical understanding of healthcare processes combined magically with kindness, compassion and care.  Having been hugged by nurses as I cried being separated from my newborn (post DVT), and watching nurses let dad happily talk them through his army photo album as they check on his dementia, I am in no doubt that such compassion is what marks the difference between not just being a patient, but being a person .

One of the oddities about research is how we can so often get the impression that only big and shiny counts. ‘Superpower’ studies such as Randomised Controlled Trials, and multi-national patient cohort studies are amazing, but can mask the breadth of the millions of questions research can explore in endless different ways. Of course we need trials to determine ‘what works’, but we also need research to unveil the stories of those who feel their rarely heard, understand how things work, and connect research to people’s lives.

Research essentially is just the act of questioning in a structured, ethical and transparent way. It might seek to understand things through numbers (quantitative) or words and experiences (qualitative), and may reveal something new or confirm something we already believe. Research is the bedrock of evidence based care, allowing us – either through new (‘primary’) or existing (‘secondary’) data – to explore, understand, confirm or disprove ways patients can be helped. Some of you reading this will be very research active, some of you might think it’s not for you, some may not know where to start, and others may hate the idea altogether. Let’s face it, healthcare is an extremely pressured environment, so why would you add research into an already busy day job? The simple truth is that research gives us a way to add to this care magic, helping to ensure care pathways are the best, safest and most appropriate in every situation.

The pace and scale of research stories can make it easy to presume research is something ‘other people’ do, and whilst there are many brilliant professionals and professions within healthcare, nurses have a unique and phenomenally important place in research in at least three key ways:

• Understanding what matters to patients. A person is far more than their illness, and being so integral to day to day care, nurses have a lens not only on patients’ conditions, but how these interweave with concerns about their life, their livelihood, their loved ones and all else. And it is in this mix that the fuller impact of research can be really understood, way beyond clinical outcome measures, and into what it what matters .
• Understanding how to mobilise and implement new knowledge. Even if new research shows promise, the act of implementing it in a pressured healthcare system can be immensely challenging. Nurses are paramount for understanding – amongst many other things – how patients will engage (or not), what can be integrated into care pathways (or can’t), what unintended consequences could be foreseen and what (if any) added pressures new processes will bring for staff. This depth of insight borne from both experience and expertise is vital to mobilising, translating and otherwise ‘converting’ research promise into reality.
• Driving research . Nurses of course also drive research of all shapes and sizes. Numerous journals, such as BMC Nursing and the Journal of Research in Nursing bear testament to the wealth of research insights driven by nurses, and shared widely to inform practice.

Research isn’t owned by any single profession, or defined by any size. Whatever methods, scale or theories we use, research is the act of understanding, and if nurses aren’t at the heart of understanding the patient experience and the healthcare system, I don’t know who is. So when it comes to research:

• Recognise the value you already bring. You are front and centre in care which gives you a perspective on patient and system need that few others have. Ask yourself, what matters?
• Recognise the sheer breadth of research possibilities, and the million questions it hasn’t yet been used to answer. Ask yourself, what needs to be understood?
• Use – or develop – your skills to do research. Connect with researchers, read up, or just get involved. Ask yourself, how can I make my research mark?

Research is important because people are important. If you’re nearer the research-avoidant than the research-lead end of the spectrum, I’d absolutely urge you to get more involved. Whether you shine a light on problems research could address, critically inform the implementation of research, or do the research yourself….

….from this patient and research impact geek…

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Nursing, research, and the evidence

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

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

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

What is nursing about?

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

What sort of evidence does nursing need?

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

Picking the research design to fit the question

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

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

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

Research designs useful to nursing

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

Maximising the potential of evidence-based nursing

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

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

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

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

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

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

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• ↵ Gordon DR Tenacious assumptions in Western biomedicine. In: Lock M, Gordon DR , eds . Biomedicine Examined. London: Kluwer Academic Press, 1988;19–56.

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How nursing research informs nursing practice

Research can help improve patients’ outcomes as well as nurses’ professional lives, National Institute of Nursing Research director says at UND

Last Friday, a high-profile member of the nursing profession visited the UND College of Nursing & Professional Disciplines. The visitor was Shannon Zenk, director of the National Institute of Nursing Research, a part of the National Institutes of Health that conducts research and establishes a scientific basis for evolving nursing practices.

During a 45-minute fireside chat with CNPD Dean Maridee Shogren , Zenk shared her insights with the nearly 250 students in attendance. She emphasized the importance of the symbiotic relationship between nursing practice and research.

“They need to be interconnected. One informs the other,” Zenk said. “What we see in our practice informs the types of research questions we ask, and it’s really important that we take the evidence generated from research and apply it to our practice. There’s a continuum, and nurses are involved in the whole process.”

Zenk developed an interest in research after transitioning from the more traditional surgical-medical setting to one focusing on homecare. As she visited patients in their homes and interacted more directly with communities, she began to recognize common problems faced by populations with higher rates of illness — and this led to a growing interest in research.

“I was really struck by the differences in the resources people have, the differences in the communities and the implications that those factors had for people’s health,” Zenk said.

Early on in their conversation, Shogren asked Zenk what she believes to be the most urgent struggles faced in healthcare. Zenk replied that research increasingly shows a need to address gaps in health outcomes based on socioeconomic and racial differences.

“These disparities are among the biggest challenges we face, and we cannot address those challenges unless we take a big-picture approach to understanding health detriments and solutions,” Zenk said. “That means we’re looking upstream at the most fundamental drivers of what shapes our health: poverty, race, housing and food access and affordability.”

An increased focus on research regarding “upstream” contributors to overall health will equip healthcare professionals with the tools to address the root causes of illness before they manifest, Zenk said. And nurses, she said are uniquely positioned to help identify and solve these problems.

“The scope of our practice, the depth of our knowledge — from biological to societal — and our focus on individual patients, families and the community makes nursing research distinct,” she said. “Nurses have always had a really holistic perspective on health, and I think social determinants are a part of that.”

This broader approach to looking at community health outcomes has sparked an increased interest in healthcare equity, which Shogren says she’s seen flourishing in UND’s programs.

“We’ve seen a growing number of our students being especially interested in Indigenous health,” Shogren said, referencing the Recruitment & Retention of American Indians into Nursing or RAIN program. “We know that 79 percent of our nursing graduates from that program have gone on to be employees in Indigenous health centers in their home communities.”

In reply, Zenk said that that supporting a more diverse workforce is the next step toward creating a more equitable healthcare system.

“Both practice and research settings require people with diverse perspectives and diverse experiences to come together to really understand what is needed to improve people’s health,” she said. “We want to bring in people who haven’t had as much chance to have a seat at the table and give them opportunities to engage in research.”

Accordingly, Zenk hopes that as the table expands, nurses and nurse researchers will have more opportunities to improve the health of their communities.

“I’m always looking for opportunities to bring the nursing perspective — our voice, our viewpoint — to the table,” she said. “I hope that, as we move forward, we’ll apply our expertise and our experience to make a difference in reducing and eliminating health disparities.”

Following Shogren and Zenk’s discussion, the leaders opened the floor to questions from students and faculty, including questions about how students can get involved with research as undergraduates and how to find internships in the state.

A student looking ahead to graduation in May asked how she could integrate nursing research into her career when she is a practicing nurse.

“Don’t let go of those skills and the motivation you’re acquiring in class to look at and understand the research and literature,” Zenk replied. “I think it’s critically important to stay on top of the evidence and best practices to inform what you’re doing.”

Another student, interested in a research career, asked what being a nurse researcher is like. Zenk replied that while research roles and career paths are varied, the most fulfilling part of her work is the ability to connect with patients and the community.

“The most enjoyable part in my role is getting to talk with people and engage with communities to learn what’s important to them and what they think will work to improve their health,” she said. “Just like in practice, you’re getting to spend time with patients, families and communities. In research, that just looks a little different.”

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The primary purpose of nursing research is to create science that informs nursing practice, allowing nurses to provide the best care to their patients. Nurse scientists can help ensure that findings from nursing research studies are adapted into everyday patient care. They stay involved in practice and share findings with nurses engaged in direct patient care, and with those who have input into the development of clinical practice guidelines and standards.

Including direct care nurses in the design and implementation of studies ensures clinical relevance and feasibility and helps facilitate rapid integration of nursing research findings into clinical practice.

Related publication

A practice-based model to guide nursing science and improve the health and well-being of patients and caregivers.

Mayo Clinic nurse scientists seek solutions to complex healthcare needs among patients and their caregivers. Research falls into three broad categories:

• Caregiving science.
• Self-management science.
• Symptom science.

Research findings are used to improve the health and well-being of patients. The Mayo Clinic nursing research model serves as a guide for the conduct of clinical research in these three distinct scientific areas in a practice-based setting.

Caregiving science

Care interventions for caregivers.

Lead researcher: Sherry S. Chesak, Ph.D., M.S., R.N.

Clinicians are at high risk of experiencing stress and burnout, which has consequences at both the personal and professional levels, including a negative impact on patient care. In addition, care partners — family, friends, others — take on major responsibilities in patient care. The latter, often thrust into their roles unexpectedly, tend to experience high levels of care burden.

Research on care for the caregiver is particularly focused on investigating resilience-promoting interventions for both professional caregivers and care partners. It also involved developing and evaluating methods to instill a sense of belonging among healthcare workers.

Self-management science

Using technology to support patient healthcare choices.

Lead researcher: Elizabeth E. Umberfield, Ph.D., R.N.

Every day, people make choices about the care they receive. These choices can include decisions about how they allow healthcare teams to handle personal biospecimens and health information. Dr. Umberfield's research program centers on making these choices discoverable, interpretable, actionable and interoperable throughout the digital health information ecosystem. Her research prioritizes patient agency — often defined as a patient's ability to act — and patient-centered systems.

Symptom self-management in adults with inflammatory bowel disease

Lead researcher: Samantha Conley, Ph.D., R.N.

People with many chronic conditions face a high symptom burden, and the daily management of their symptoms is challenging. Symptom self-management research aims to better understand how symptoms co-occur in people with chronic conditions. Researchers also study how people living with chronic conditions can better self-manage their symptoms using behavioral interventions to improve their daily functioning and quality of life.

Toxicities of cancer therapies and psychosocial concerns and decision-making at end of life

Lead researcher: Cindy Tofthagen, Ph.D., ARNP, AOCNP, FAANP, FAAN

Cancer treatments have side effects that create significant physical, emotional and financial burdens for patients as well as their families. The goal of this research is to find effective ways to prevent or treat these side effects and help patients better manage side effects at home. This includes specific emphasis on:

• Chemotherapy-induced peripheral neuropathy.
• Psychological distress associated with cancer.
• Pain related to cancer treatment.

Symptom science

Delirium prevention and symptom management in older adults.

Lead researcher: Heidi L. Lindroth, Ph.D., R.N.

Nurse scientists improve patient outcomes through holistic scientific discovery that considers the whole healthcare team, including the patient and family, as part of the discovery-translation-application cycle.

Gut microbiome link to chemotherapy-induced nausea

Lead researcher: Komal P. Singh, Ph.D., R.N.

People with cancer experience several neuropsychological and gastrointestinal symptoms during and after treatment. Debilitating symptoms include:

• Depression.
• Cognitive changes.
• Sleep disturbance.
• Lack of appetite.
• Change in taste.

Investigating patient risk factors associated with these symptom experiences can help identify people at high risk for symptom burden. In addition, omics-based methodologies can help pinpoint underlying biological mechanisms associated with patient symptoms.

A multidisciplinary team at Mayo Clinic is collaborating with additional world-renowned academic institutions to investigate associations between oncology patient symptom experiences and chemotherapy-induced changes in the microbiome-gut-brain axis. Identifying precise changes in patients most at risk of experiencing debilitating symptoms after chemotherapy can help in developing targeted interventions to alleviate the adverse side effects of oncology treatments.

Symptom management for patients on mechanical ventilators in the ICU

Lead researcher: Linda L. Chlan, Ph.D., R.N., ATSF, FAAN

Research in this area develops and tests interventions to help patients manage feelings of anxiety. Patients often feel anxiety when receiving mechanical ventilatory support in the intensive care unit (ICU). Our research team seeks solutions for how to best assess and empower patients to co-manage or self-manage symptoms safely while in the ICU .

Nursing research model

Nursing research is centered on the health and well-being of patients with complex care needs. Research in caregiving science, symptom science and self-management science is conducted through team science using big data, technology and innovation. Discoveries are translated to patient care and applied in the clinical setting to transform the practice.

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Nursing Research

Research mindset, pico: patient (problem), intervention, comparison, outcome, steps in library research, search tips, limits or filters, subject headings.

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Between clinical practice, care coordination, and study management, research is now vital to nurses’ career success. However, most clinical nurses are not properly prepared to undertake the responsibility of research. It is important to be able to know how to

• Develop a research question and complete a literature review
• Be able to synthesize knowledge and write abstracts
• Understand elements of a well designed study

Other opportunities in research include securing grant funding for clinical research projects, and teaching staff how to conduct clinical research projects and how to present and publish their work. Nursing research focuses on four key areas that concentrate on optimizing health across the spectrum, from discovery to translation:

Health Innovation : Advancing approaches using ideas, processes, products, procedures or interventions and health system changes to benefit the health of individuals, groups and populations.

Population Health : Improving health outcomes of groups of individuals, including families and communities, and reducing health disparities within and between groups.

Precision Health : Customizing evidence-based approaches to health that incorporates genomics, environment and lifestyle.

Data Science : Facilitating knowledge discovery in biomedicine by applying contemporary analytics to large data to inform decision making in healthcare.

• AACN Position Statement on Nursing Research
• National Institute of Nursing Research (NINR)

Develop a research mindset. Understand research as a process of asking questions and exploring. 

The quality of your research depends largely on the questions you ask. Practice asking a lot of them. Adopt the mindset of an explorer or investigator. What qualities and characteristics do successful explorers and investigators have?  Develop a plan; where will you start?  As you begin to explore, you will discover that research can be messy. Expect and welcome twists and turns, keep an open mind, and keep asking questions throughout the process. Use many different kinds of search tools and resources, and conduct many different kinds of searches. 

Research takes time and patience; it can also be fun and has value.

Developing your research skills will enable you to identify a problem, collect informational resources that can help address the problem, evaluate these resources for quality and relevance, and come up with an effective solution to a problem. Research skills develop critical thinking and equip you to write better research papers and craft better speeches. You will also improve problem solving skills required to tackle issues in your personal life and in the workplace. 

• Structured Searching PICO Helpful grid from Ovid; can be used with any database. (Link to PDF on website)
• Structured Searching PICO Helpful grid from Ovid; can be used with any database. (Stored PDF for download)
• PICO Handout from EbscoHost This two-page PDF handout includes a description of the PICO process and examples of PICO topics for nursing research.
• PICO: Research Questions for Health Sciences A tutorial from Arizona Statue University Library.

Follow these steps.

Keep an open mind. You may need to refine your topic, ask new questions, and repeat steps as you go along.

Identify and define your topic. Put your research topic into a question such as, "What is the debate surrounding vaccination refusal?" Now you can identify the main concepts and keywords, including alternate terms, for your topic.

Background reading will deepen your understanding and vocabulary around the topic, which will help you identify search terms and develop an effective research question. Subject encyclopedias (in print or in Credo Reference)   are excellent resources. 

Use ArcherSearch or the library catalog to find books . 

Use ArcherSearch or individual databases to find articles from magazines, journals and newspapers . Choose appropriate databases for your topic.

Search for credible website resources. Try the librarian-recommended websites on this guide.

Always evaluate what you find. Consider timeliness, relevance, authority, accuracy, and purpose.

Cite your sources . Citing gives proper credit to the authors of materials you use and allows your professors to verify your conclusions. 

Keyword Searching

Keyword searching is used by internet search engines, databases, and the library catalog. Keep in mind that the search will find matches for specific words, not concepts. The default in the library catalog (and most databases) is to find results that include every word in your search. Think of this as using AND between the words: 

• nursing AND careers AND education
• nursing careers education

The two searches above are the same, and will find all books in the library catalog that have all three words in the description of the book. 

If you want to find a specific phrase, with the words next to each other in order, use double quotation marks around the phrase:

• "nursing care plans" 

You might want to broaden your search to include synonyms or other related words. To find either of two words or phrases, use OR between them:

•  nutrition OR diet
• (nutrition OR diet) AND diabetes

You can also use truncation to search for different forms of a word. The asterisk * is used in the library catalog and many databases for this. 

• patient AND educat*
• (patient OR consumer) AND educat*

In the above searches, educat*  will find the words educate, educated, education,  etc. 

When combining searches, use parentheses () around different parts of the search, as in the examples above. 

• Pediatric nursing
• Nursing care plans
• Nursing ethics
• Alzheimer's disease
• Communicable diseases
• Heart -- Diseases
• Evidence-based nursing

Use the filters or limits to see just a subset of your search results. Depending on the tool you are using, search limits may show up in the left margin, at the top of the results, or below the search box. 

Date limits are especially useful to filter out older, outdated material. You can usually choose a preset limit such as "current 5 years," or set a custom range of publication dates. 

Scholarly/Peer-Reviewed Journals

This will limit to only journals that publish articles that have undergone a rigorous peer-review process. These are usually articles that report on a specific study, analysis, experiment, or other piece of the research. Some scholarly/peer-reviewed articles are systematic reviews  which survey a wide range of published peer-reviewed articles to give an overview of the current state of knowledge on the topic.

The Subject limit will help you narrow your results by subject terms. These are like tags or labels; they indicate that the book, article, or other source focuses on the subject of interest. Without this limit, you may find items that include your search words but are not about your topic. Keep in mind that different databases may use different subject terms.  

The Full-text limit is already applied for most searches. It is very useful to filter out articles where you only have access to a citation or a description of an article, not the full the full article. Unless you are required to find everything out there is published on a given subject, this limit should be applied every time you search. If you do find resources that are not full text but would be useful to you, STLCC Libraries may be able provide them. See the Borrowing from Other Libraries page for details and the form for requests. 

• Borrowing from Other Libraries

Subject Heading Searching

Think of subject headings as labels or tags that someone has used to identify the subject of a book or article. The subject headings are standardized so that only one term is used for a specific subject. For example, following the Library of Congress Subject Headings standard, we use Cerebrovascular disease instead of  S troke  in the STLCC Library Catalog. You can search directly by subject, or click on a subject heading in the description of a book you find by keyword searching. Instead of a list of search results, you'll get a list of subject headings to choose from.  Here are a few examples:

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Introduction to qualitative nursing research

This type of research can reveal important information that quantitative research can’t.

• Qualitative research is valuable because it approaches a phenomenon, such as a clinical problem, about which little is known by trying to understand its many facets.
• Most qualitative research is emergent, holistic, detailed, and uses many strategies to collect data.
• Qualitative research generates evidence and helps nurses determine patient preferences.

Research 101: Descriptive statistics

Differentiating research, evidence-based practice, and quality improvement

How to appraise quantitative research articles

All nurses are expected to understand and apply evidence to their professional practice. Some of the evidence should be in the form of research, which fills gaps in knowledge, developing and expanding on current understanding. Both quantitative and qualitative research methods inform nursing practice, but quantitative research tends to be more emphasized. In addition, many nurses don’t feel comfortable conducting or evaluating qualitative research. But once you understand qualitative research, you can more easily apply it to your nursing practice.

What is qualitative research?

Defining qualitative research can be challenging. In fact, some authors suggest that providing a simple definition is contrary to the method’s philosophy. Qualitative research approaches a phenomenon, such as a clinical problem, from a place of unknowing and attempts to understand its many facets. This makes qualitative research particularly useful when little is known about a phenomenon because the research helps identify key concepts and constructs. Qualitative research sets the foundation for future quantitative or qualitative research. Qualitative research also can stand alone without quantitative research.

Although qualitative research is diverse, certain characteristics—holism, subjectivity, intersubjectivity, and situated contexts—guide its methodology. This type of research stresses the importance of studying each individual as a holistic system (holism) influenced by surroundings (situated contexts); each person develops his or her own subjective world (subjectivity) that’s influenced by interactions with others (intersubjectivity) and surroundings (situated contexts). Think of it this way: Each person experiences and interprets the world differently based on many factors, including his or her history and interactions. The truth is a composite of realities.

Qualitative research designs

Because qualitative research explores diverse topics and examines phenomena where little is known, designs and methodologies vary. Despite this variation, most qualitative research designs are emergent and holistic. In addition, they require merging data collection strategies and an intensely involved researcher. (See Research design characteristics .)

Although qualitative research designs are emergent, advanced planning and careful consideration should include identifying a phenomenon of interest, selecting a research design, indicating broad data collection strategies and opportunities to enhance study quality, and considering and/or setting aside (bracketing) personal biases, views, and assumptions.

Many qualitative research designs are used in nursing. Most originated in other disciplines, while some claim no link to a particular disciplinary tradition. Designs that aren’t linked to a discipline, such as descriptive designs, may borrow techniques from other methodologies; some authors don’t consider them to be rigorous (high-quality and trustworthy). (See Common qualitative research designs .)

Sampling approaches

Sampling approaches depend on the qualitative research design selected. However, in general, qualitative samples are small, nonrandom, emergently selected, and intensely studied. Qualitative research sampling is concerned with accurately representing and discovering meaning in experience, rather than generalizability. For this reason, researchers tend to look for participants or informants who are considered “information rich” because they maximize understanding by representing varying demographics and/or ranges of experiences. As a study progresses, researchers look for participants who confirm, challenge, modify, or enrich understanding of the phenomenon of interest. Many authors argue that the concepts and constructs discovered in qualitative research transcend a particular study, however, and find applicability to others. For example, consider a qualitative study about the lived experience of minority nursing faculty and the incivility they endure. The concepts learned in this study may transcend nursing or minority faculty members and also apply to other populations, such as foreign-born students, nurses, or faculty.

Qualitative nursing research can take many forms. The design you choose will depend on the question you’re trying to answer.

A sample size is estimated before a qualitative study begins, but the final sample size depends on the study scope, data quality, sensitivity of the research topic or phenomenon of interest, and researchers’ skills. For example, a study with a narrow scope, skilled researchers, and a nonsensitive topic likely will require a smaller sample. Data saturation frequently is a key consideration in final sample size. When no new insights or information are obtained, data saturation is attained and sampling stops, although researchers may analyze one or two more cases to be certain. (See Sampling types .)

Some controversy exists around the concept of saturation in qualitative nursing research. Thorne argues that saturation is a concept appropriate for grounded theory studies and not other study types. She suggests that “information power” is perhaps more appropriate terminology for qualitative nursing research sampling and sample size.

Data collection and analysis

Researchers are guided by their study design when choosing data collection and analysis methods. Common types of data collection include interviews (unstructured, semistructured, focus groups); observations of people, environments, or contexts; documents; records; artifacts; photographs; or journals. When collecting data, researchers must be mindful of gaining participant trust while also guarding against too much emotional involvement, ensuring comprehensive data collection and analysis, conducting appropriate data management, and engaging in reflexivity.

Data usually are recorded in detailed notes, memos, and audio or visual recordings, which frequently are transcribed verbatim and analyzed manually or using software programs, such as ATLAS.ti, HyperRESEARCH, MAXQDA, or NVivo. Analyzing qualitative data is complex work. Researchers act as reductionists, distilling enormous amounts of data into concise yet rich and valuable knowledge. They code or identify themes, translating abstract ideas into meaningful information. The good news is that qualitative research typically is easy to understand because it’s reported in stories told in everyday language.

Evaluating a qualitative study

Evaluating qualitative research studies can be challenging. Many terms—rigor, validity, integrity, and trustworthiness—can describe study quality, but in the end you want to know whether the study’s findings accurately and comprehensively represent the phenomenon of interest. Many researchers identify a quality framework when discussing quality-enhancement strategies. Example frameworks include:

• Trustworthiness criteria framework, which enhances credibility, dependability, confirmability, transferability, and authenticity
• Validity in qualitative research framework, which enhances credibility, authenticity, criticality, integrity, explicitness, vividness, creativity, thoroughness, congruence, and sensitivity.

With all frameworks, many strategies can be used to help meet identified criteria and enhance quality. (See Research quality enhancement ). And considering the study as a whole is important to evaluating its quality and rigor. For example, when looking for evidence of rigor, look for a clear and concise report title that describes the research topic and design and an abstract that summarizes key points (background, purpose, methods, results, conclusions).

Application to nursing practice

Qualitative research not only generates evidence but also can help nurses determine patient preferences. Without qualitative research, we can’t truly understand others, including their interpretations, meanings, needs, and wants. Qualitative research isn’t generalizable in the traditional sense, but it helps nurses open their minds to others’ experiences. For example, nurses can protect patient autonomy by understanding them and not reducing them to universal protocols or plans. As Munhall states, “Each person we encounter help[s] us discover what is best for [him or her]. The other person, not us, is truly the expert knower of [him- or herself].” Qualitative nursing research helps us understand the complexity and many facets of a problem and gives us insights as we encourage others’ voices and searches for meaning.

When paired with clinical judgment and other evidence, qualitative research helps us implement evidence-based practice successfully. For example, a phenomenological inquiry into the lived experience of disaster workers might help expose strengths and weaknesses of individuals, populations, and systems, providing areas of focused intervention. Or a phenomenological study of the lived experience of critical-care patients might expose factors (such dark rooms or no visible clocks) that contribute to delirium.

Successful implementation

Qualitative nursing research guides understanding in practice and sets the foundation for future quantitative and qualitative research. Knowing how to conduct and evaluate qualitative research can help nurses implement evidence-based practice successfully.

When evaluating a qualitative study, you should consider it as a whole. The following questions to consider when examining study quality and evidence of rigor are adapted from the Standards for Reporting Qualitative Research.

Jennifer Chicca is a PhD candidate at the Indiana University of Pennsylvania in Indiana, Pennsylvania, and a part-time faculty member at the University of North Carolina Wilmington.

Amankwaa L. Creating protocols for trustworthiness in qualitative research. J Cult Divers. 2016;23(3):121-7.

Cuthbert CA, Moules N. The application of qualitative research findings to oncology nursing practice. Oncol Nurs Forum . 2014;41(6):683-5.

Guba E, Lincoln Y. Competing paradigms in qualitative research . In: Denzin NK, Lincoln YS, eds. Handbook of Qualitative Research. Thousand Oaks, CA: SAGE Publications, Inc.;1994: 105-17.

Lincoln YS, Guba EG. Naturalistic Inquiry . Thousand Oaks, CA: SAGE Publications, Inc.; 1985.

Munhall PL. Nursing Research: A Qualitative Perspective . 5th ed. Sudbury, MA: Jones & Bartlett Learning; 2012.

Nicholls D. Qualitative research. Part 1: Philosophies. Int J Ther Rehabil . 2017;24(1):26-33.

Nicholls D. Qualitative research. Part 2: Methodology. Int J Ther Rehabil . 2017;24(2):71-7.

Nicholls D. Qualitative research. Part 3: Methods. Int J Ther Rehabil . 2017;24(3):114-21.

O’Brien BC, Harris IB, Beckman TJ, Reed DA, Cook DA. Standards for reporting qualitative research: A synthesis of recommendations. Acad Med . 2014;89(9):1245-51.

Polit DF, Beck CT. Nursing Research: Generating and Assessing Evidence for Nursing Practice . 10th ed. Philadelphia, PA: Wolters Kluwer; 2017.

Thorne S. Saturation in qualitative nursing studies: Untangling the misleading message around saturation in qualitative nursing studies. Nurse Auth Ed. 2020;30(1):5. naepub.com/reporting-research/2020-30-1-5

Whittemore R, Chase SK, Mandle CL. Validity in qualitative research. Qual Health Res . 2001;11(4):522-37.

Williams B. Understanding qualitative research. Am Nurse Today . 2015;10(7):40-2.

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How a better understanding of nursing research roles may help to embed research into clinical structures

Affiliations.

• 1 Research Matron, The Royal Wolverhampton NHS Trust, and Visiting Fellow, Staffordshire University, Stoke-on-Trent.
• 2 Trust Practice Education Facilitator for Research, The Royal Wolverhampton NHS Trust and PhD Candidate, Staffordshire University, Stoke-on-Trent.
• 3 Research Fellow (Clinical and Medical Statistics) and Doctoral Student, Staffordshire University, Stoke-on-Trent.
• 4 Chief Nursing Officer, The Royal Wolverhampton NHS Trust and Walsall Healthcare NHS Trust, Wolverhampton.
• PMID: 36149424
• DOI: 10.12968/bjon.2022.31.17.902

Background: Despite efforts to build research capacity within nursing there are growing concerns about the lack of funding and support for nurses who wish to pursue a career in research.

Aim: To explore how research capacity within the nursing profession can be increased.

Discussion: The disparity in opportunity and support for such roles is a barrier to the growth of nursing research. This article examines the nomenclature that exists around nursing roles in research, including those of clinical research nurse, nurse researcher and clinical nurse academic, and the challenges associated with each of these roles. The authors reflect on their career paths, specifically the transition from clinical research nurse to nurse researcher.

Conclusion: To grow research capacity within the nursing discipline, organisations must provide opportunities for research at all career stages, promote the fundamental role that research plays in the quality of patient care and highlight career pathways and roles in nursing research.

Keywords: Career pathways; Evidence-based practice; Nursing roles; Research.

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Search Tips: Finding Evidence Based Articles

• Databases / Articles
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• Analysis (SWOT / Lewin's Model)
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• EBA in CINAHL
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To search for evidence-based articles on CINAHL:

• Click on the link below to go to CINAHL .
• Below the search boxes, there is a list of "search options." Scroll down the list of limiters. (Look at the other choices on the way. You may find others that will come in handy in the future.) 
• In the right column, find one that says "Evidence-based practice."  Check this box.
• Go back up to the search boxes at the top, enter your search terms and click the search button. The results the search returns will be evidence-based.
• CINAHL Plus with Full Text This link opens in a new window Index, abstracts, and full text of the literature of nursing and allied health.

To search for evidence-based articles in the Nursing and Allied Health database:

• Click on the link below to go to the Nursing and Allied Health Database.
• Click on the "advanced search" link.
• Put your search terms in the search box.
• Scroll down the page to see the limiters. Under "document type", select "evidence based healthcare"
• Nursing & Allied Health This link opens in a new window Mix of scholarly literature, clinical training videos, reference materials, and evidence-based resources, including dissertations and systematic reviews which takes a holistic and interdisciplinary approach.

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• Published: 17 April 2024

Deciphering the influence: academic stress and its role in shaping learning approaches among nursing students: a cross-sectional study

• Rawhia Salah Dogham 1 ,
• Heba Fakieh Mansy Ali 1 ,
• Asmaa Saber Ghaly 3 ,
• Nermine M. Elcokany 2 ,
• Mohamed Mahmoud Seweid 4 &
• Ayman Mohamed El-Ashry   ORCID: orcid.org/0000-0001-7718-4942 5  

BMC Nursing volume  23 , Article number:  249 ( 2024 ) Cite this article

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Metrics details

Nursing education presents unique challenges, including high levels of academic stress and varied learning approaches among students. Understanding the relationship between academic stress and learning approaches is crucial for enhancing nursing education effectiveness and student well-being.

This study aimed to investigate the prevalence of academic stress and its correlation with learning approaches among nursing students.

Design and Method

A cross-sectional descriptive correlation research design was employed. A convenient sample of 1010 nursing students participated, completing socio-demographic data, the Perceived Stress Scale (PSS), and the Revised Study Process Questionnaire (R-SPQ-2 F).

Most nursing students experienced moderate academic stress (56.3%) and exhibited moderate levels of deep learning approaches (55.0%). Stress from a lack of professional knowledge and skills negatively correlates with deep learning approaches (r = -0.392) and positively correlates with surface learning approaches (r = 0.365). Female students showed higher deep learning approach scores, while male students exhibited higher surface learning approach scores. Age, gender, educational level, and academic stress significantly influenced learning approaches.

Academic stress significantly impacts learning approaches among nursing students. Strategies addressing stressors and promoting healthy learning approaches are essential for enhancing nursing education and student well-being.

Nursing implication

Understanding academic stress’s impact on nursing students’ learning approaches enables tailored interventions. Recognizing stressors informs strategies for promoting adaptive coping, fostering deep learning, and creating supportive environments. Integrating stress management, mentorship, and counseling enhances student well-being and nursing education quality.

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Introduction

Nursing education is a demanding field that requires students to acquire extensive knowledge and skills to provide competent and compassionate care. Nursing education curriculum involves high-stress environments that can significantly impact students’ learning approaches and academic performance [ 1 , 2 ]. Numerous studies have investigated learning approaches in nursing education, highlighting the importance of identifying individual students’ preferred approaches. The most studied learning approaches include deep, surface, and strategic approaches. Deep learning approaches involve students actively seeking meaning, making connections, and critically analyzing information. Surface learning approaches focus on memorization and reproducing information without a more profound understanding. Strategic learning approaches aim to achieve high grades by adopting specific strategies, such as memorization techniques or time management skills [ 3 , 4 , 5 ].

Nursing education stands out due to its focus on practical training, where the blend of academic and clinical coursework becomes a significant stressor for students, despite academic stress being shared among all university students [ 6 , 7 , 8 ]. Consequently, nursing students are recognized as prone to high-stress levels. Stress is the physiological and psychological response that occurs when a biological control system identifies a deviation between the desired (target) state and the actual state of a fitness-critical variable, whether that discrepancy arises internally or externally to the human [ 9 ]. Stress levels can vary from objective threats to subjective appraisals, making it a highly personalized response to circumstances. Failure to manage these demands leads to stress imbalance [ 10 ].

Nursing students face three primary stressors during their education: academic, clinical, and personal/social stress. Academic stress is caused by the fear of failure in exams, assessments, and training, as well as workload concerns [ 11 ]. Clinical stress, on the other hand, arises from work-related difficulties such as coping with death, fear of failure, and interpersonal dynamics within the organization. Personal and social stressors are caused by an imbalance between home and school, financial hardships, and other factors. Throughout their education, nursing students have to deal with heavy workloads, time constraints, clinical placements, and high academic expectations. Multiple studies have shown that nursing students experience higher stress levels compared to students in other fields [ 12 , 13 , 14 ].

Research has examined the relationship between academic stress and coping strategies among nursing students, but no studies focus specifically on the learning approach and academic stress. However, existing literature suggests that students interested in nursing tend to experience lower levels of academic stress [ 7 ]. Therefore, interest in nursing can lead to deep learning approaches, which promote a comprehensive understanding of the subject matter, allowing students to feel more confident and less overwhelmed by coursework and exams. Conversely, students employing surface learning approaches may experience higher stress levels due to the reliance on memorization [ 3 ].

Understanding the interplay between academic stress and learning approaches among nursing students is essential for designing effective educational interventions. Nursing educators can foster deep learning approaches by incorporating active learning strategies, critical thinking exercises, and reflection activities into the curriculum [ 15 ]. Creating supportive learning environments encouraging collaboration, self-care, and stress management techniques can help alleviate academic stress. Additionally, providing mentorship and counselling services tailored to nursing students’ unique challenges can contribute to their overall well-being and academic success [ 16 , 17 , 18 ].

Despite the scarcity of research focusing on the link between academic stress and learning methods in nursing students, it’s crucial to identify the unique stressors they encounter. The intensity of these stressors can be connected to the learning strategies employed by these students. Academic stress and learning approach are intertwined aspects of the student experience. While academic stress can influence learning approaches, the choice of learning approach can also impact the level of academic stress experienced. By understanding this relationship and implementing strategies to promote healthy learning approaches and manage academic stress, educators and institutions can foster an environment conducive to deep learning and student well-being.

Hence, this study aims to investigate the correlation between academic stress and learning approaches experienced by nursing students.

Study objectives

Assess the levels of academic stress among nursing students.

Assess the learning approaches among nursing students.

Identify the relationship between academic stress and learning approach among nursing students.

Identify the effect of academic stress and related factors on learning approach and among nursing students.

Materials and methods

Research design.

A cross-sectional descriptive correlation research design adhering to the STROBE guidelines was used for this study.

A research project was conducted at Alexandria Nursing College, situated in Egypt. The college adheres to the national standards for nursing education and functions under the jurisdiction of the Egyptian Ministry of Higher Education. Alexandria Nursing College comprises nine specialized nursing departments that offer various nursing specializations. These departments include Nursing Administration, Community Health Nursing, Gerontological Nursing, Medical-Surgical Nursing, Critical Care Nursing, Pediatric Nursing, Obstetric and Gynecological Nursing, Nursing Education, and Psychiatric Nursing and Mental Health. The credit hour system is the fundamental basis of both undergraduate and graduate programs. This framework guarantees a thorough evaluation of academic outcomes by providing an organized structure for tracking academic progress and conducting analyses.

Participants and sample size calculation

The researchers used the Epi Info 7 program to calculate the sample size. The calculations were based on specific parameters such as a population size of 9886 students for the academic year 2022–2023, an expected frequency of 50%, a maximum margin of error of 5%, and a confidence coefficient of 99.9%. Based on these parameters, the program indicated that a minimum sample size of 976 students was required. As a result, the researchers recruited a convenient sample of 1010 nursing students from different academic levels during the 2022–2023 academic year [ 19 ]. This sample size was larger than the minimum required, which could help to increase the accuracy and reliability of the study results. Participation in the study required enrollment in a nursing program and voluntary agreement to take part. The exclusion criteria included individuals with mental illnesses based on their response and those who failed to complete the questionnaires.

socio-demographic data that include students’ age, sex, educational level, hours of sleep at night, hours spent studying, and GPA from the previous semester.

Tool two: the perceived stress scale (PSS)

It was initially created by Sheu et al. (1997) to gauge the level and nature of stress perceived by nursing students attending Taiwanese universities [ 20 ]. It comprises 29 items rated on a 5-point Likert scale, where (0 = never, 1 = rarely, 2 = sometimes, 3 = reasonably often, and 4 = very often), with a total score ranging from 0 to 116. The cut-off points of levels of perceived stress scale according to score percentage were low < 33.33%, moderate 33.33–66.66%, and high more than 66.66%. Higher scores indicate higher stress levels. The items are categorized into six subscales reflecting different sources of stress. The first subscale assesses “stress stemming from lack of professional knowledge and skills” and includes 3 items. The second subscale evaluates “stress from caring for patients” with 8 items. The third subscale measures “stress from assignments and workload” with 5 items. The fourth subscale focuses on “stress from interactions with teachers and nursing staff” with 6 items. The fifth subscale gauges “stress from the clinical environment” with 3 items. The sixth subscale addresses “stress from peers and daily life” with 4 items. El-Ashry et al. (2022) reported an excellent internal consistency reliability of 0.83 [ 21 ]. Two bilingual translators translated the English version of the scale into Arabic and then back-translated it into English by two other independent translators to verify its accuracy. The suitability of the translated version was confirmed through a confirmatory factor analysis (CFA), which yielded goodness-of-fit indices such as a comparative fit index (CFI) of 0.712, a Tucker-Lewis index (TLI) of 0.812, and a root mean square error of approximation (RMSEA) of 0.100.

Tool three: revised study process questionnaire (R-SPQ-2 F)

It was developed by Biggs et al. (2001). It examines deep and surface learning approaches using only 20 questions; each subscale contains 10 questions [ 22 ]. On a 5-point Likert scale ranging from 0 (never or only rarely true of me) to 4 (always or almost always accurate of me). The total score ranged from 0 to 80, with a higher score reflecting more deep or surface learning approaches. The cut-off points of levels of revised study process questionnaire according to score percentage were low < 33%, moderate 33–66%, and high more than 66%. Biggs et al. (2001) found that Cronbach alpha value was 0.73 for deep learning approach and 0.64 for the surface learning approach, which was considered acceptable. Two translators fluent in English and Arabic initially translated a scale from English to Arabic. To ensure the accuracy of the translation, they translated it back into English. The translated version’s appropriateness was evaluated using a confirmatory factor analysis (CFA). The CFA produced several goodness-of-fit indices, including a Comparative Fit Index (CFI) of 0.790, a Tucker-Lewis Index (TLI) of 0.912, and a Root Mean Square Error of Approximation (RMSEA) of 0.100. Comparative Fit Index (CFI) of 0.790, a Tucker-Lewis Index (TLI) of 0.912, and a Root Mean Square Error of Approximation (RMSEA) of 0.100.

Ethical considerations

The Alexandria University College of Nursing’s Research Ethics Committee provided ethical permission before the study’s implementation. Furthermore, pertinent authorities acquired ethical approval at participating nursing institutions. The vice deans of the participating institutions provided written informed consent attesting to institutional support and authority. By giving written informed consent, participants confirmed they were taking part voluntarily. Strict protocols were followed to protect participants’ privacy during the whole investigation. The obtained personal data was kept private and available only to the study team. Ensuring participants’ privacy and anonymity was of utmost importance.

Tools validity

The researchers created tool one after reviewing pertinent literature. Two bilingual translators independently translated the English version into Arabic to evaluate the applicability of the academic stress and learning approach tools for Arabic-speaking populations. To assure accuracy, two additional impartial translators back-translated the translation into English. They were also assessed by a five-person jury of professionals from the education and psychiatric nursing departments. The scales were found to have sufficiently evaluated the intended structures by the jury.

Pilot study

A preliminary investigation involved 100 nursing student applicants, distinct from the final sample, to gauge the efficacy, clarity, and potential obstacles in utilizing the research instruments. The pilot findings indicated that the instruments were accurate, comprehensible, and suitable for the target demographic. Additionally, Cronbach’s Alpha was utilized to further assess the instruments’ reliability, demonstrating internal solid consistency for both the learning approaches and academic stress tools, with values of 0.91 and 0.85, respectively.

Data collection

The researchers convened with each qualified student in a relaxed, unoccupied classroom in their respective college settings. Following a briefing on the study’s objectives, the students filled out the datasheet. The interviews typically lasted 15 to 20 min.

Data analysis

The data collected were analyzed using IBM SPSS software version 26.0. Following data entry, a thorough examination and verification were undertaken to ensure accuracy. The normality of quantitative data distributions was assessed using Kolmogorov-Smirnov tests. Cronbach’s Alpha was employed to evaluate the reliability and internal consistency of the study instruments. Descriptive statistics, including means (M), standard deviations (SD), and frequencies/percentages, were computed to summarize academic stress and learning approaches for categorical data. Student’s t-tests compared scores between two groups for normally distributed variables, while One-way ANOVA compared scores across more than two categories of a categorical variable. Pearson’s correlation coefficient determined the strength and direction of associations between customarily distributed quantitative variables. Hierarchical regression analysis identified the primary independent factors influencing learning approaches. Statistical significance was determined at the 5% (p < 0.05).

Table  1 presents socio-demographic data for a group of 1010 nursing students. The age distribution shows that 38.8% of the students were between 18 and 21 years old, 32.9% were between 21 and 24 years old, and 28.3% were between 24 and 28 years old, with an average age of approximately 22.79. Regarding gender, most of the students were female (77%), while 23% were male. The students were distributed across different educational years, a majority of 34.4% in the second year, followed by 29.4% in the fourth year. The students’ hours spent studying were found to be approximately two-thirds (67%) of the students who studied between 3 and 6 h. Similarly, sleep patterns differ among the students; more than three-quarters (77.3%) of students sleep between 5- to more than 7 h, and only 2.4% sleep less than 2 h per night. Finally, the student’s Grade Point Average (GPA) from the previous semester was also provided. 21% of the students had a GPA between 2 and 2.5, 40.9% had a GPA between 2.5 and 3, and 38.1% had a GPA between 3 and 3.5.

Figure  1 provides the learning approach level among nursing students. In terms of learning approach, most students (55.0%) exhibited a moderate level of deep learning approach, followed by 25.9% with a high level and 19.1% with a low level. The surface learning approach was more prevalent, with 47.8% of students showing a moderate level, 41.7% showing a low level, and only 10.5% exhibiting a high level.

Nursing students? levels of learning approach (N=1010)

Figure  2 provides the types of academic stress levels among nursing students. Among nursing students, various stressors significantly impact their academic experiences. Foremost among these stressors are the pressure and demands associated with academic assignments and workload, with 30.8% of students attributing their high stress levels to these factors. Challenges within the clinical environment are closely behind, contributing significantly to high stress levels among 25.7% of nursing students. Interactions with peers and daily life stressors also weigh heavily on students, ranking third among sources of high stress, with 21.5% of students citing this as a significant factor. Similarly, interaction with teachers and nursing staff closely follow, contributing to high-stress levels for 20.3% of nursing students. While still significant, stress from taking care of patients ranks slightly lower, with 16.7% of students reporting it as a significant factor contributing to their academic stress. At the lowest end of the ranking, but still notable, is stress from a perceived lack of professional knowledge and skills, with 15.9% of students experiencing high stress in this area.

Nursing students? levels of academic stress subtypes (N=1010)

Figure  3 provides the total levels of academic stress among nursing students. The majority of students experienced moderate academic stress (56.3%), followed by those experiencing low academic stress (29.9%), and a minority experienced high academic stress (13.8%).

Nursing students? levels of total academic stress (N=1010)

Table  2 displays the correlation between academic stress subscales and deep and surface learning approaches among 1010 nursing students. All stress subscales exhibited a negative correlation regarding the deep learning approach, indicating that the inclination toward deep learning decreases with increasing stress levels. The most significant negative correlation was observed with stress stemming from the lack of professional knowledge and skills (r=-0.392, p < 0.001), followed by stress from the clinical environment (r=-0.109, p = 0.001), stress from assignments and workload (r=-0.103, p = 0.001), stress from peers and daily life (r=-0.095, p = 0.002), and stress from patient care responsibilities (r=-0.093, p = 0.003). The weakest negative correlation was found with stress from interactions with teachers and nursing staff (r=-0.083, p = 0.009). Conversely, concerning the surface learning approach, all stress subscales displayed a positive correlation, indicating that heightened stress levels corresponded with an increased tendency toward superficial learning. The most substantial positive correlation was observed with stress related to the lack of professional knowledge and skills (r = 0.365, p < 0.001), followed by stress from patient care responsibilities (r = 0.334, p < 0.001), overall stress (r = 0.355, p < 0.001), stress from interactions with teachers and nursing staff (r = 0.262, p < 0.001), stress from assignments and workload (r = 0.262, p < 0.001), and stress from the clinical environment (r = 0.254, p < 0.001). The weakest positive correlation was noted with stress stemming from peers and daily life (r = 0.186, p < 0.001).

Table  3 outlines the association between the socio-demographic characteristics of nursing students and their deep and surface learning approaches. Concerning age, statistically significant differences were observed in deep and surface learning approaches (F = 3.661, p = 0.003 and F = 7.983, p < 0.001, respectively). Gender also demonstrated significant differences in deep and surface learning approaches (t = 3.290, p = 0.001 and t = 8.638, p < 0.001, respectively). Female students exhibited higher scores in the deep learning approach (31.59 ± 8.28) compared to male students (29.59 ± 7.73), while male students had higher scores in the surface learning approach (29.97 ± 7.36) compared to female students (24.90 ± 7.97). Educational level exhibited statistically significant differences in deep and surface learning approaches (F = 5.599, p = 0.001 and F = 17.284, p < 0.001, respectively). Both deep and surface learning approach scores increased with higher educational levels. The duration of study hours demonstrated significant differences only in the surface learning approach (F = 3.550, p = 0.014), with scores increasing as study hours increased. However, no significant difference was observed in the deep learning approach (F = 0.861, p = 0.461). Hours of sleep per night and GPA from the previous semester did not exhibit statistically significant differences in deep or surface learning approaches.

Table  4 presents a multivariate linear regression analysis examining the factors influencing the learning approach among 1110 nursing students. The deep learning approach was positively influenced by age, gender (being female), educational year level, and stress from teachers and nursing staff, as indicated by their positive coefficients and significant p-values (p < 0.05). However, it was negatively influenced by stress from a lack of professional knowledge and skills. The other factors do not significantly influence the deep learning approach. On the other hand, the surface learning approach was positively influenced by gender (being female), educational year level, stress from lack of professional knowledge and skills, stress from assignments and workload, and stress from taking care of patients, as indicated by their positive coefficients and significant p-values (p < 0.05). However, it was negatively influenced by gender (being male). The other factors do not significantly influence the surface learning approach. The adjusted R-squared values indicated that the variables in the model explain 17.8% of the variance in the deep learning approach and 25.5% in the surface learning approach. Both models were statistically significant (p < 0.001).

Nursing students’ academic stress and learning approaches are essential to planning for effective and efficient learning. Nursing education also aims to develop knowledgeable and competent students with problem-solving and critical-thinking skills.

The study’s findings highlight the significant presence of stress among nursing students, with a majority experiencing moderate to severe levels of academic stress. This aligns with previous research indicating that academic stress is prevalent among nursing students. For instance, Zheng et al. (2022) observed moderated stress levels in nursing students during clinical placements [ 23 ], while El-Ashry et al. (2022) found that nearly all first-year nursing students in Egypt experienced severe academic stress [ 21 ]. Conversely, Ali and El-Sherbini (2018) reported that over three-quarters of nursing students faced high academic stress. The complexity of the nursing program likely contributes to these stress levels [ 24 ].

The current study revealed that nursing students identified the highest sources of academic stress as workload from assignments and the stress of caring for patients. This aligns with Banu et al.‘s (2015) findings, where academic demands, assignments, examinations, high workload, and combining clinical work with patient interaction were cited as everyday stressors [ 25 ]. Additionally, Anaman-Torgbor et al. (2021) identified lectures, assignments, and examinations as predictors of academic stress through logistic regression analysis. These stressors may stem from nursing programs emphasizing the development of highly qualified graduates who acquire knowledge, values, and skills through classroom and clinical experiences [ 26 ].

The results regarding learning approaches indicate that most nursing students predominantly employed the deep learning approach. Despite acknowledging a surface learning approach among the participants in the present study, the prevalence of deep learning was higher. This inclination toward the deep learning approach is anticipated in nursing students due to their engagement with advanced courses, requiring retention, integration, and transfer of information at elevated levels. The deep learning approach correlates with a gratifying learning experience and contributes to higher academic achievements [ 3 ]. Moreover, the nursing program’s emphasis on active learning strategies fosters critical thinking, problem-solving, and decision-making skills. These findings align with Mahmoud et al.‘s (2019) study, reporting a significant presence (83.31%) of the deep learning approach among undergraduate nursing students at King Khalid University’s Faculty of Nursing [ 27 ]. Additionally, Mohamed &Morsi (2019) found that most nursing students at Benha University’s Faculty of Nursing embraced the deep learning approach (65.4%) compared to the surface learning approach [ 28 ].

The study observed a negative correlation between the deep learning approach and the overall mean stress score, contrasting with a positive correlation between surface learning approaches and overall stress levels. Elevated academic stress levels may diminish motivation and engagement in the learning process, potentially leading students to feel overwhelmed, disinterested, or burned out, prompting a shift toward a surface learning approach. This finding resonates with previous research indicating that nursing students who actively seek positive academic support strategies during academic stress have better prospects for success than those who do not [ 29 ]. Nebhinani et al. (2020) identified interface concerns and academic workload as significant stress-related factors. Notably, only an interest in nursing demonstrated a significant association with stress levels, with participants interested in nursing primarily employing adaptive coping strategies compared to non-interested students.

The current research reveals a statistically significant inverse relationship between different dimensions of academic stress and adopting the deep learning approach. The most substantial negative correlation was observed with stress arising from a lack of professional knowledge and skills, succeeded by stress associated with the clinical environment, assignments, and workload. Nursing students encounter diverse stressors, including delivering patient care, handling assignments and workloads, navigating challenging interactions with staff and faculty, perceived inadequacies in clinical proficiency, and facing examinations [ 30 ].

In the current study, the multivariate linear regression analysis reveals that various factors positively influence the deep learning approach, including age, female gender, educational year level, and stress from teachers and nursing staff. In contrast, stress from a lack of professional knowledge and skills exert a negative influence. Conversely, the surface learning approach is positively influenced by female gender, educational year level, stress from lack of professional knowledge and skills, stress from assignments and workload, and stress from taking care of patients, but negatively affected by male gender. The models explain 17.8% and 25.5% of the variance in the deep and surface learning approaches, respectively, and both are statistically significant. These findings underscore the intricate interplay of demographic and stress-related factors in shaping nursing students’ learning approaches. High workloads and patient care responsibilities may compel students to prioritize completing tasks over deep comprehension. This pressure could lead to a surface learning approach as students focus on meeting immediate demands rather than engaging deeply with course material. This observation aligns with the findings of Alsayed et al. (2021), who identified age, gender, and study year as significant factors influencing students’ learning approaches.

Deep learners often demonstrate better self-regulation skills, such as effective time management, goal setting, and seeking support when needed. These skills can help manage academic stress and maintain a balanced learning approach. These are supported by studies that studied the effect of coping strategies on stress levels [ 6 , 31 , 32 ]. On the contrary, Pacheco-Castillo et al. study (2021) found a strong significant relationship between academic stressors and students’ level of performance. That study also proved that the more academic stress a student faces, the lower their academic achievement.

Strengths and limitations of the study

This study has lots of advantages. It provides insightful information about the educational experiences of Egyptian nursing students, a demographic that has yet to receive much research. The study’s limited generalizability to other people or nations stems from its concentration on this particular group. This might be addressed in future studies by using a more varied sample. Another drawback is the dependence on self-reported metrics, which may contain biases and mistakes. Although the cross-sectional design offers a moment-in-time view of the problem, it cannot determine causation or evaluate changes over time. To address this, longitudinal research may be carried out.

Notwithstanding these drawbacks, the study substantially contributes to the expanding knowledge of academic stress and nursing students’ learning styles. Additional research is needed to determine teaching strategies that improve deep-learning approaches among nursing students. A qualitative study is required to analyze learning approaches and factors that may influence nursing students’ selection of learning approaches.

According to the present study’s findings, nursing students encounter considerable academic stress, primarily stemming from heavy assignments and workload, as well as interactions with teachers and nursing staff. Additionally, it was observed that students who experience lower levels of academic stress typically adopt a deep learning approach, whereas those facing higher stress levels tend to resort to a surface learning approach. Demographic factors such as age, gender, and educational level influence nursing students’ choice of learning approach. Specifically, female students are more inclined towards deep learning, whereas male students prefer surface learning. Moreover, deep and surface learning approach scores show an upward trend with increasing educational levels and study hours. Academic stress emerges as a significant determinant shaping the adoption of learning approaches among nursing students.

Implications in nursing practice

Nursing programs should consider integrating stress management techniques into their curriculum. Providing students with resources and skills to cope with academic stress can improve their well-being and academic performance. Educators can incorporate teaching strategies that promote deep learning approaches, such as problem-based learning, critical thinking exercises, and active learning methods. These approaches help students engage more deeply with course material and reduce reliance on surface learning techniques. Recognizing the gender differences in learning approaches, nursing programs can offer gender-specific support services and resources. For example, providing targeted workshops or counseling services that address male and female nursing students’ unique stressors and learning needs. Implementing mentorship programs and peer support groups can create a supportive environment where students can share experiences, seek advice, and receive encouragement from their peers and faculty members. Encouraging students to reflect on their learning processes and identify effective study strategies can help them develop metacognitive skills and become more self-directed learners. Faculty members can facilitate this process by incorporating reflective exercises into the curriculum. Nursing faculty and staff should receive training on recognizing signs of academic stress among students and providing appropriate support and resources. Additionally, professional development opportunities can help educators stay updated on evidence-based teaching strategies and practical interventions for addressing student stress.

Data availability

The datasets generated and/or analysed during the current study are not publicly available due to restrictions imposed by the institutional review board to protect participant confidentiality, but are available from the corresponding author on reasonable request.

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Acknowledgements

Our sincere thanks go to all the nursing students in the study. We also want to thank Dr/ Rasha Badry for their statistical analysis help and contribution to this study.

The research was not funded by public, commercial, or non-profit organizations.

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

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Critical Care & Emergency Nursing, Faculty of Nursing, Alexandria University, Alexandria, Egypt

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Obstetrics and Gynecology Nursing, Faculty of Nursing, Alexandria University, Alexandria, Egypt

Asmaa Saber Ghaly

Faculty of Nursing, Beni-Suef University, Beni-Suef, Egypt

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Psychiatric and Mental Health Nursing, Faculty of Nursing, Alexandria University, Alexandria, Egypt

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Ayman M. El-Ashry & Rawhia S. Dogham: conceptualization, preparation, and data collection; methodology; investigation; formal analysis; data analysis; writing-original draft; writing-manuscript; and editing. Heba F. Mansy Ali & Asmaa S. Ghaly: conceptualization, preparation, methodology, investigation, writing-original draft, writing-review, and editing. Nermine M. Elcokany & Mohamed M. Seweid: Methodology, investigation, formal analysis, data collection, writing-manuscript & editing. All authors reviewed the manuscript and accept for publication.

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Dogham, R.S., Ali, H.F.M., Ghaly, A.S. et al. Deciphering the influence: academic stress and its role in shaping learning approaches among nursing students: a cross-sectional study. BMC Nurs 23 , 249 (2024). https://doi.org/10.1186/s12912-024-01885-1

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DOI : https://doi.org/10.1186/s12912-024-01885-1

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The date filter allows for daily selection of dates from March 1, 2020, to July 1, 2022. A slider is included under the date selection box for viewing policy progression throughout the pandemic. The health care settings filter consists of 4 checkboxes, allowing for the selection of target health care settings (general health care settings, nursing homes, home health care agencies, and both). Comprehensive definitions are found in the eTable in Supplement 1. The COVID-19 burden parameter consists of 5 checkboxes, allowing for the selection of 5 distinct categories of COVID-19 burden (cases and deaths) at the community and nursing home levels. The policy type filter allows for the selection of 5 broad policy categories. The policy subtype filter contains 38 distinct subcategories related to the broader categories. On the map, the number of policies is indicated by a color gradient, ranging from the least (light gray) to the most (dark blue). COVID-19 burden is depicted as circles of varying size, with larger diameters signifying increasing severity. Circles are red if there were deaths recorded during that period, green if there were no deaths, and gray if no data were available. The central US map can be enlarged for ease of viewing, while the 5 US territories remain fixed in size.

Maps depict May 24, 2020 (during first wave and after mandatory case and death reporting in nursing homes begins), January 12, 2021 (Alpha and Delta variants), and January 16, 2022 (Omicron variant). On the maps, the number of COVID-19 policies is indicated by a color gradient, ranging from the least (light gray color) to the most (darker blue color). All targeted health care settings (general, nursing homes, home health agencies, and both) were selected for this visual. COVID-19 burden is depicted as circles of varying size, with larger circles signifying increasing severity. The 7-day average of COVID-19 community deaths per 100 000 population was selected for this visual. Circles are red if there were deaths recorded during that period and green if there were no deaths.

eMethods. Policy Dataset and Dashboard Development

eTable. Definitions of Post–Acute Care COVID-19 Policy Categories and Subcategories

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Stone PW , Zhao S , Chastain AM, et al. State- and Territory-Level Nursing Home and Home Health Care COVID-19 Policies and Disease Burden. JAMA Netw Open. 2024;7(4):e247683. doi:10.1001/jamanetworkopen.2024.7683

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State- and Territory-Level Nursing Home and Home Health Care COVID-19 Policies and Disease Burden

• 1 Center for Health Policy, Columbia University School of Nursing, New York, New York
• 2 Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine, Rochester, New York
• 3 Department of Public Health Sciences, University of Rochester School of Medicine, Rochester, New York
• 4 RAND Health, RAND Corporation, Boston, Massachusetts

The COVID-19 pandemic disproportionately affected older persons, 1 many of whom were served by home health care agencies (HHAs) and nursing homes (NHs). The extent to which state- and territory-level COVID-19 policies reinforced or expanded federal policies is unknown. Building on the work of others, 2 we created a dataset and dashboard of state- and territory-specific NH and HHA policies linked with community and NH COVID-19 burden for researchers and public health officials to evaluate policy efficacy.

In this cross-sectional study, we used the Council of State Government’s 2020-2021 State Executive Orders website 3 and comprehensive searches of state and territory government websites to identify state- and territory-specific policies enacted from March 1, 2020, to July 1, 2022. We collected start and end dates and categorized policies as general or specific to NHs, HHAs, or both. Policies were grouped into 5 categories with 38 subcategories as (1) preventing virus transmission (n = 18), (2) expanding NH and/or HHA capacity (n = 5), (3) relaxing administrative requirements (n = 5), (4) reporting COVID-19 data (n = 3), and (5) admission and discharge policies (n = 7) (eMethods in Supplement 1 ).

We linked these policy data with community-level 4 and NH-specific COVID-19 burden (case and mortality counts) 5 and entered data into Tableau Desktop, version 2023.2. 6 We used a color gradient and circle size to visualize policy counts and COVID-19 burden, respectively. The interactive dashboard displays temporality with zoom capability of setting, policy, and COVID-19 burden.

This study was approved by the Columbia University Institutional Review Board, who waived the need for informed consent because the study was not deemed human participant research. We followed the STROBE reporting guideline.

We identified 1400 policies across 50 states and 5 territories. Most included all health care settings (n = 846), followed by NH-specific (n = 486), NH- and HHA-specific (n = 43), and HHA-specific (n = 25) policies. The most common policy category was preventing virus transmission (n = 736), followed by expanding NH and HHA capacity (n = 325), relaxing administrative requirements (n = 184), reporting COVID-19 data (n = 79), and admission and discharge (n = 54). The dashboard ( Figure 1 ) illustrates variation in the number of policies per state and severity of COVID-19 burden indicated by color gradient and circle diameter, respectively. Figure 2 highlights the dynamic change in NH and HHA policies and COVID-19 burden. For example, on May 24, 2020, Montana, Hawaii, and Alaska had no COVID-19 deaths or policies, in contrast with North Carolina’s moderate burden and several policies. By January 12, 2021, New York had a severe COVID-19 burden and the greatest number of policies, while Pennsylvania, Montana, and Florida had a similar COVID-19 burden but fewer policies.

The dataset and dashboard described in this study are potentially important tools for researchers and public health officials and could provide a template for visual platforms that may inform future efforts to manage public health crises. Variations in COVID-19 burden and state and territory policy responses displayed in the dashboard highlight the complexity of pandemic management. Exploratory analyses demonstrated that higher numbers of policies at the state and territory levels were not consistently associated with reductions in community- or NH-level COVID-19 burden, suggesting policy effectiveness may depend on implementation and compliance. We also found limited attention to HHAs compared with NHs, despite both settings serving vulnerable older populations. This suggests a gap in public health planning, raising questions about resource allocation and prioritization among health care settings during pandemics.

Study limitations include the primarily descriptive data, underlying data from various sources, and limited evaluation of efficacy of public health policies on population COVID-19 outcomes. Future public health planning and pandemic responses should include adaptive and targeted policy interventions and should consider specific needs of all health care settings. Dashboards have the potential to help formulate data-driven decision-making during public health crises.

Accepted for Publication: February 17, 2024.

Published: April 22, 2024. doi:10.1001/jamanetworkopen.2024.7683

Open Access: This is an open access article distributed under the terms of the CC-BY License . © 2024 Stone PW et al. JAMA Network Open .

Corresponding Author: Patricia W. Stone, PhD, RN, Center for Health Policy, Columbia University School of Nursing, 560 W 168th St, New York, NY 10032 ( [email protected] ).

Author Contributions: Dr Stone had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Stone, Shang, Glance, Dick.

Acquisition, analysis, or interpretation of data: Stone, Zhao, Chastain, Perera, Shang, Dick.

Drafting of the manuscript: Stone, Zhao, Chastain, Perera, Shang, Glance.

Critical review of the manuscript for important intellectual content: Stone, Shang, Glance, Dick.

Statistical analysis: Zhao, Shang, Glance, Dick.

Obtained funding: Stone, Shang, Dick.

Administrative, technical, or material support: Stone, Chastain, Perera.

Supervision: Stone, Chastain, Perera, Shang, Dick.

Conflict of Interest Disclosures: Dr Stone reported receiving grant funding from the National Institutes of Health outside the submitted work. Ms Zhao reported participating in an internship through EmblemHealth outside the submitted work. Dr Chastain reported receiving grant funding from the National Institutes of Health outside the submitted work. Dr Perera reported receiving grant funding from the National Institutes of Health outside the submitted work. Dr Shang reported receiving grant funding from the National Institutes of Health outside the submitted work. Dr Glance reported receiving grant funding from the National Institutes of Health outside the submitted work. Dr Dick reported receiving grant funding from the National Institutes of Health outside the submitted work. No other disclosures were reported.

Funding/Support: This work was funded by grant R01NR016865 from the National Institute of Nursing Research and by grant R01AG074492 from the National Institute on Aging, the National Institute of Minority Health and Health Disparities, and the National Institute of Allergy and Infectious Diseases.

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Data Sharing Statement: See Supplement 2 .

Additional Contributions: Albert Chavesta, MS, MPH, assisted in compiling and categorizing the state- and territory-level policies, as well as drafting the policy dataset development methodology. Tenzin Trinley, MPH, Jung A. Kang, MSN, RN, and Charity Ogunlusi, MD, MPH, assisted with compiling state-level policies. All those acknowledged were affiliated with the Columbia University School of Nursing during the conduct of the study and were compensated via the study funding.

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Qualitative Methods in Health Care Research

Vishnu renjith.

School of Nursing and Midwifery, Royal College of Surgeons Ireland - Bahrain (RCSI Bahrain), Al Sayh Muharraq Governorate, Bahrain

Renjulal Yesodharan

1 Department of Mental Health Nursing, Manipal College of Nursing Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India

Judith A. Noronha

2 Department of OBG Nursing, Manipal College of Nursing Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India

Elissa Ladd

3 School of Nursing, MGH Institute of Health Professions, Boston, USA

Anice George

4 Department of Child Health Nursing, Manipal College of Nursing Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India

Healthcare research is a systematic inquiry intended to generate robust evidence about important issues in the fields of medicine and healthcare. Qualitative research has ample possibilities within the arena of healthcare research. This article aims to inform healthcare professionals regarding qualitative research, its significance, and applicability in the field of healthcare. A wide variety of phenomena that cannot be explained using the quantitative approach can be explored and conveyed using a qualitative method. The major types of qualitative research designs are narrative research, phenomenological research, grounded theory research, ethnographic research, historical research, and case study research. The greatest strength of the qualitative research approach lies in the richness and depth of the healthcare exploration and description it makes. In health research, these methods are considered as the most humanistic and person-centered way of discovering and uncovering thoughts and actions of human beings.

Introduction

Healthcare research is a systematic inquiry intended to generate trustworthy evidence about issues in the field of medicine and healthcare. The three principal approaches to health research are the quantitative, the qualitative, and the mixed methods approach. The quantitative research method uses data, which are measures of values and counts and are often described using statistical methods which in turn aids the researcher to draw inferences. Qualitative research incorporates the recording, interpreting, and analyzing of non-numeric data with an attempt to uncover the deeper meanings of human experiences and behaviors. Mixed methods research, the third methodological approach, involves collection and analysis of both qualitative and quantitative information with an objective to solve different but related questions, or at times the same questions.[ 1 , 2 ]

In healthcare, qualitative research is widely used to understand patterns of health behaviors, describe lived experiences, develop behavioral theories, explore healthcare needs, and design interventions.[ 1 , 2 , 3 ] Because of its ample applications in healthcare, there has been a tremendous increase in the number of health research studies undertaken using qualitative methodology.[ 4 , 5 ] This article discusses qualitative research methods, their significance, and applicability in the arena of healthcare.

Qualitative Research

Diverse academic and non-academic disciplines utilize qualitative research as a method of inquiry to understand human behavior and experiences.[ 6 , 7 ] According to Munhall, “Qualitative research involves broadly stated questions about human experiences and realities, studied through sustained contact with the individual in their natural environments and producing rich, descriptive data that will help us to understand those individual's experiences.”[ 8 ]

Significance of Qualitative Research

The qualitative method of inquiry examines the 'how' and 'why' of decision making, rather than the 'when,' 'what,' and 'where.'[ 7 ] Unlike quantitative methods, the objective of qualitative inquiry is to explore, narrate, and explain the phenomena and make sense of the complex reality. Health interventions, explanatory health models, and medical-social theories could be developed as an outcome of qualitative research.[ 9 ] Understanding the richness and complexity of human behavior is the crux of qualitative research.

Differences between Quantitative and Qualitative Research

The quantitative and qualitative forms of inquiry vary based on their underlying objectives. They are in no way opposed to each other; instead, these two methods are like two sides of a coin. The critical differences between quantitative and qualitative research are summarized in Table 1 .[ 1 , 10 , 11 ]

Differences between quantitative and qualitative research

Qualitative Research Questions and Purpose Statements

Qualitative questions are exploratory and are open-ended. A well-formulated study question forms the basis for developing a protocol, guides the selection of design, and data collection methods. Qualitative research questions generally involve two parts, a central question and related subquestions. The central question is directed towards the primary phenomenon under study, whereas the subquestions explore the subareas of focus. It is advised not to have more than five to seven subquestions. A commonly used framework for designing a qualitative research question is the 'PCO framework' wherein, P stands for the population under study, C stands for the context of exploration, and O stands for the outcome/s of interest.[ 12 ] The PCO framework guides researchers in crafting a focused study question.

Example: In the question, “What are the experiences of mothers on parenting children with Thalassemia?”, the population is “mothers of children with Thalassemia,” the context is “parenting children with Thalassemia,” and the outcome of interest is “experiences.”

The purpose statement specifies the broad focus of the study, identifies the approach, and provides direction for the overall goal of the study. The major components of a purpose statement include the central phenomenon under investigation, the study design and the population of interest. Qualitative research does not require a-priori hypothesis.[ 13 , 14 , 15 ]

Example: Borimnejad et al . undertook a qualitative research on the lived experiences of women suffering from vitiligo. The purpose of this study was, “to explore lived experiences of women suffering from vitiligo using a hermeneutic phenomenological approach.” [ 16 ]

Review of the Literature

In quantitative research, the researchers do an extensive review of scientific literature prior to the commencement of the study. However, in qualitative research, only a minimal literature search is conducted at the beginning of the study. This is to ensure that the researcher is not influenced by the existing understanding of the phenomenon under the study. The minimal literature review will help the researchers to avoid the conceptual pollution of the phenomenon being studied. Nonetheless, an extensive review of the literature is conducted after data collection and analysis.[ 15 ]

Reflexivity

Reflexivity refers to critical self-appraisal about one's own biases, values, preferences, and preconceptions about the phenomenon under investigation. Maintaining a reflexive diary/journal is a widely recognized way to foster reflexivity. According to Creswell, “Reflexivity increases the credibility of the study by enhancing more neutral interpretations.”[ 7 ]

Types of Qualitative Research Designs

The qualitative research approach encompasses a wide array of research designs. The words such as types, traditions, designs, strategies of inquiry, varieties, and methods are used interchangeably. The major types of qualitative research designs are narrative research, phenomenological research, grounded theory research, ethnographic research, historical research, and case study research.[ 1 , 7 , 10 ]

Narrative research

Narrative research focuses on exploring the life of an individual and is ideally suited to tell the stories of individual experiences.[ 17 ] The purpose of narrative research is to utilize 'story telling' as a method in communicating an individual's experience to a larger audience.[ 18 ] The roots of narrative inquiry extend to humanities including anthropology, literature, psychology, education, history, and sociology. Narrative research encompasses the study of individual experiences and learning the significance of those experiences. The data collection procedures include mainly interviews, field notes, letters, photographs, diaries, and documents collected from one or more individuals. Data analysis involves the analysis of the stories or experiences through “re-storying of stories” and developing themes usually in chronological order of events. Rolls and Payne argued that narrative research is a valuable approach in health care research, to gain deeper insight into patient's experiences.[ 19 ]

Example: Karlsson et al . undertook a narrative inquiry to “explore how people with Alzheimer's disease present their life story.” Data were collected from nine participants. They were asked to describe about their life experiences from childhood to adulthood, then to current life and their views about the future life. [ 20 ]

Phenomenological research

Phenomenology is a philosophical tradition developed by German philosopher Edmond Husserl. His student Martin Heidegger did further developments in this methodology. It defines the 'essence' of individual's experiences regarding a certain phenomenon.[ 1 ] The methodology has its origin from philosophy, psychology, and education. The purpose of qualitative research is to understand the people's everyday life experiences and reduce it into the central meaning or the 'essence of the experience'.[ 21 , 22 ] The unit of analysis of phenomenology is the individuals who have had similar experiences of the phenomenon. Interviews with individuals are mainly considered for the data collection, though, documents and observations are also useful. Data analysis includes identification of significant meaning elements, textural description (what was experienced), structural description (how was it experienced), and description of 'essence' of experience.[ 1 , 7 , 21 ] The phenomenological approach is further divided into descriptive and interpretive phenomenology. Descriptive phenomenology focuses on the understanding of the essence of experiences and is best suited in situations that need to describe the lived phenomenon. Hermeneutic phenomenology or Interpretive phenomenology moves beyond the description to uncover the meanings that are not explicitly evident. The researcher tries to interpret the phenomenon, based on their judgment rather than just describing it.[ 7 , 21 , 22 , 23 , 24 ]

Example: A phenomenological study conducted by Cornelio et al . aimed at describing the lived experiences of mothers in parenting children with leukemia. Data from ten mothers were collected using in-depth semi-structured interviews and were analyzed using Husserl's method of phenomenology. Themes such as “pivotal moment in life”, “the experience of being with a seriously ill child”, “having to keep distance with the relatives”, “overcoming the financial and social commitments”, “responding to challenges”, “experience of faith as being key to survival”, “health concerns of the present and future”, and “optimism” were derived. The researchers reported the essence of the study as “chronic illness such as leukemia in children results in a negative impact on the child and on the mother.” [ 25 ]

Grounded Theory Research

Grounded theory has its base in sociology and propagated by two sociologists, Barney Glaser, and Anselm Strauss.[ 26 ] The primary purpose of grounded theory is to discover or generate theory in the context of the social process being studied. The major difference between grounded theory and other approaches lies in its emphasis on theory generation and development. The name grounded theory comes from its ability to induce a theory grounded in the reality of study participants.[ 7 , 27 ] Data collection in grounded theory research involves recording interviews from many individuals until data saturation. Constant comparative analysis, theoretical sampling, theoretical coding, and theoretical saturation are unique features of grounded theory research.[ 26 , 27 , 28 ] Data analysis includes analyzing data through 'open coding,' 'axial coding,' and 'selective coding.'[ 1 , 7 ] Open coding is the first level of abstraction, and it refers to the creation of a broad initial range of categories, axial coding is the procedure of understanding connections between the open codes, whereas selective coding relates to the process of connecting the axial codes to formulate a theory.[ 1 , 7 ] Results of the grounded theory analysis are supplemented with a visual representation of major constructs usually in the form of flow charts or framework diagrams. Quotations from the participants are used in a supportive capacity to substantiate the findings. Strauss and Corbin highlights that “the value of the grounded theory lies not only in its ability to generate a theory but also to ground that theory in the data.”[ 27 ]

Example: Williams et al . conducted a grounded theory research to explore the nature of relationship between the sense of self and the eating disorders. Data were collected form 11 women with a lifetime history of Anorexia Nervosa and were analyzed using the grounded theory methodology. Analysis led to the development of a theoretical framework on the nature of the relationship between the self and Anorexia Nervosa. [ 29 ]

Ethnographic research

Ethnography has its base in anthropology, where the anthropologists used it for understanding the culture-specific knowledge and behaviors. In health sciences research, ethnography focuses on narrating and interpreting the health behaviors of a culture-sharing group. 'Culture-sharing group' in an ethnography represents any 'group of people who share common meanings, customs or experiences.' In health research, it could be a group of physicians working in rural care, a group of medical students, or it could be a group of patients who receive home-based rehabilitation. To understand the cultural patterns, researchers primarily observe the individuals or group of individuals for a prolonged period of time.[ 1 , 7 , 30 ] The scope of ethnography can be broad or narrow depending on the aim. The study of more general cultural groups is termed as macro-ethnography, whereas micro-ethnography focuses on more narrowly defined cultures. Ethnography is usually conducted in a single setting. Ethnographers collect data using a variety of methods such as observation, interviews, audio-video records, and document reviews. A written report includes a detailed description of the culture sharing group with emic and etic perspectives. When the researcher reports the views of the participants it is called emic perspectives and when the researcher reports his or her views about the culture, the term is called etic.[ 7 ]

Example: The aim of the ethnographic study by LeBaron et al . was to explore the barriers to opioid availability and cancer pain management in India. The researchers collected data from fifty-nine participants using in-depth semi-structured interviews, participant observation, and document review. The researchers identified significant barriers by open coding and thematic analysis of the formal interview. [ 31 ]

Historical research

Historical research is the “systematic collection, critical evaluation, and interpretation of historical evidence”.[ 1 ] The purpose of historical research is to gain insights from the past and involves interpreting past events in the light of the present. The data for historical research are usually collected from primary and secondary sources. The primary source mainly includes diaries, first hand information, and writings. The secondary sources are textbooks, newspapers, second or third-hand accounts of historical events and medical/legal documents. The data gathered from these various sources are synthesized and reported as biographical narratives or developmental perspectives in chronological order. The ideas are interpreted in terms of the historical context and significance. The written report describes 'what happened', 'how it happened', 'why it happened', and its significance and implications to current clinical practice.[ 1 , 10 ]

Example: Lubold (2019) analyzed the breastfeeding trends in three countries (Sweden, Ireland, and the United States) using a historical qualitative method. Through analysis of historical data, the researcher found that strong family policies, adherence to international recommendations and adoption of baby-friendly hospital initiative could greatly enhance the breastfeeding rates. [ 32 ]

Case study research

Case study research focuses on the description and in-depth analysis of the case(s) or issues illustrated by the case(s). The design has its origin from psychology, law, and medicine. Case studies are best suited for the understanding of case(s), thus reducing the unit of analysis into studying an event, a program, an activity or an illness. Observations, one to one interviews, artifacts, and documents are used for collecting the data, and the analysis is done through the description of the case. From this, themes and cross-case themes are derived. A written case study report includes a detailed description of one or more cases.[ 7 , 10 ]

Example: Perceptions of poststroke sexuality in a woman of childbearing age was explored using a qualitative case study approach by Beal and Millenbrunch. Semi structured interview was conducted with a 36- year mother of two children with a history of Acute ischemic stroke. The data were analyzed using an inductive approach. The authors concluded that “stroke during childbearing years may affect a woman's perception of herself as a sexual being and her ability to carry out gender roles”. [ 33 ]

Sampling in Qualitative Research

Qualitative researchers widely use non-probability sampling techniques such as purposive sampling, convenience sampling, quota sampling, snowball sampling, homogeneous sampling, maximum variation sampling, extreme (deviant) case sampling, typical case sampling, and intensity sampling. The selection of a sampling technique depends on the nature and needs of the study.[ 34 , 35 , 36 , 37 , 38 , 39 , 40 ] The four widely used sampling techniques are convenience sampling, purposive sampling, snowball sampling, and intensity sampling.

Convenience sampling

It is otherwise called accidental sampling, where the researchers collect data from the subjects who are selected based on accessibility, geographical proximity, ease, speed, and or low cost.[ 34 ] Convenience sampling offers a significant benefit of convenience but often accompanies the issues of sample representation.

Purposive sampling

Purposive or purposeful sampling is a widely used sampling technique.[ 35 ] It involves identifying a population based on already established sampling criteria and then selecting subjects who fulfill that criteria to increase the credibility. However, choosing information-rich cases is the key to determine the power and logic of purposive sampling in a qualitative study.[ 1 ]

Snowball sampling

The method is also known as 'chain referral sampling' or 'network sampling.' The sampling starts by having a few initial participants, and the researcher relies on these early participants to identify additional study participants. It is best adopted when the researcher wishes to study the stigmatized group, or in cases, where findings of participants are likely to be difficult by ordinary means. Respondent ridden sampling is an improvised version of snowball sampling used to find out the participant from a hard-to-find or hard-to-study population.[ 37 , 38 ]

Intensity sampling

The process of identifying information-rich cases that manifest the phenomenon of interest is referred to as intensity sampling. It requires prior information, and considerable judgment about the phenomenon of interest and the researcher should do some preliminary investigations to determine the nature of the variation. Intensity sampling will be done once the researcher identifies the variation across the cases (extreme, average and intense) and picks the intense cases from them.[ 40 ]

Deciding the Sample Size

A-priori sample size calculation is not undertaken in the case of qualitative research. Researchers collect the data from as many participants as possible until they reach the point of data saturation. Data saturation or the point of redundancy is the stage where the researcher no longer sees or hears any new information. Data saturation gives the idea that the researcher has captured all possible information about the phenomenon of interest. Since no further information is being uncovered as redundancy is achieved, at this point the data collection can be stopped. The objective here is to get an overall picture of the chronicle of the phenomenon under the study rather than generalization.[ 1 , 7 , 41 ]

Data Collection in Qualitative Research

The various strategies used for data collection in qualitative research includes in-depth interviews (individual or group), focus group discussions (FGDs), participant observation, narrative life history, document analysis, audio materials, videos or video footage, text analysis, and simple observation. Among all these, the three popular methods are the FGDs, one to one in-depth interviews and the participant observation.

FGDs are useful in eliciting data from a group of individuals. They are normally built around a specific topic and are considered as the best approach to gather data on an entire range of responses to a topic.[ 42 Group size in an FGD ranges from 6 to 12. Depending upon the nature of participants, FGDs could be homogeneous or heterogeneous.[ 1 , 14 ] One to one in-depth interviews are best suited to obtain individuals' life histories, lived experiences, perceptions, and views, particularly while exporting topics of sensitive nature. In-depth interviews can be structured, unstructured, or semi-structured. However, semi-structured interviews are widely used in qualitative research. Participant observations are suitable for gathering data regarding naturally occurring behaviors.[ 1 ]

Data Analysis in Qualitative Research

Various strategies are employed by researchers to analyze data in qualitative research. Data analytic strategies differ according to the type of inquiry. A general content analysis approach is described herewith. Data analysis begins by transcription of the interview data. The researcher carefully reads data and gets a sense of the whole. Once the researcher is familiarized with the data, the researcher strives to identify small meaning units called the 'codes.' The codes are then grouped based on their shared concepts to form the primary categories. Based on the relationship between the primary categories, they are then clustered into secondary categories. The next step involves the identification of themes and interpretation to make meaning out of data. In the results section of the manuscript, the researcher describes the key findings/themes that emerged. The themes can be supported by participants' quotes. The analytical framework used should be explained in sufficient detail, and the analytic framework must be well referenced. The study findings are usually represented in a schematic form for better conceptualization.[ 1 , 7 ] Even though the overall analytical process remains the same across different qualitative designs, each design such as phenomenology, ethnography, and grounded theory has design specific analytical procedures, the details of which are out of the scope of this article.

Computer-Assisted Qualitative Data Analysis Software (CAQDAS)

Until recently, qualitative analysis was done either manually or with the help of a spreadsheet application. Currently, there are various software programs available which aid researchers to manage qualitative data. CAQDAS is basically data management tools and cannot analyze the qualitative data as it lacks the ability to think, reflect, and conceptualize. Nonetheless, CAQDAS helps researchers to manage, shape, and make sense of unstructured information. Open Code, MAXQDA, NVivo, Atlas.ti, and Hyper Research are some of the widely used qualitative data analysis software.[ 14 , 43 ]

Reporting Guidelines

Consolidated Criteria for Reporting Qualitative Research (COREQ) is the widely used reporting guideline for qualitative research. This 32-item checklist assists researchers in reporting all the major aspects related to the study. The three major domains of COREQ are the 'research team and reflexivity', 'study design', and 'analysis and findings'.[ 44 , 45 ]

Critical Appraisal of Qualitative Research

Various scales are available to critical appraisal of qualitative research. The widely used one is the Critical Appraisal Skills Program (CASP) Qualitative Checklist developed by CASP network, UK. This 10-item checklist evaluates the quality of the study under areas such as aims, methodology, research design, ethical considerations, data collection, data analysis, and findings.[ 46 ]

Ethical Issues in Qualitative Research

A qualitative study must be undertaken by grounding it in the principles of bioethics such as beneficence, non-maleficence, autonomy, and justice. Protecting the participants is of utmost importance, and the greatest care has to be taken while collecting data from a vulnerable research population. The researcher must respect individuals, families, and communities and must make sure that the participants are not identifiable by their quotations that the researchers include when publishing the data. Consent for audio/video recordings must be obtained. Approval to be in FGDs must be obtained from the participants. Researchers must ensure the confidentiality and anonymity of the transcripts/audio-video records/photographs/other data collected as a part of the study. The researchers must confirm their role as advocates and proceed in the best interest of all participants.[ 42 , 47 , 48 ]

Rigor in Qualitative Research

The demonstration of rigor or quality in the conduct of the study is essential for every research method. However, the criteria used to evaluate the rigor of quantitative studies are not be appropriate for qualitative methods. Lincoln and Guba (1985) first outlined the criteria for evaluating the qualitative research often referred to as “standards of trustworthiness of qualitative research”.[ 49 ] The four components of the criteria are credibility, transferability, dependability, and confirmability.

Credibility refers to confidence in the 'truth value' of the data and its interpretation. It is used to establish that the findings are true, credible and believable. Credibility is similar to the internal validity in quantitative research.[ 1 , 50 , 51 ] The second criterion to establish the trustworthiness of the qualitative research is transferability, Transferability refers to the degree to which the qualitative results are applicability to other settings, population or contexts. This is analogous to the external validity in quantitative research.[ 1 , 50 , 51 ] Lincoln and Guba recommend authors provide enough details so that the users will be able to evaluate the applicability of data in other contexts.[ 49 ] The criterion of dependability refers to the assumption of repeatability or replicability of the study findings and is similar to that of reliability in quantitative research. The dependability question is 'Whether the study findings be repeated of the study is replicated with the same (similar) cohort of participants, data coders, and context?'[ 1 , 50 , 51 ] Confirmability, the fourth criteria is analogous to the objectivity of the study and refers the degree to which the study findings could be confirmed or corroborated by others. To ensure confirmability the data should directly reflect the participants' experiences and not the bias, motivations, or imaginations of the inquirer.[ 1 , 50 , 51 ] Qualitative researchers should ensure that the study is conducted with enough rigor and should report the measures undertaken to enhance the trustworthiness of the study.

Conclusions

Qualitative research studies are being widely acknowledged and recognized in health care practice. This overview illustrates various qualitative methods and shows how these methods can be used to generate evidence that informs clinical practice. Qualitative research helps to understand the patterns of health behaviors, describe illness experiences, design health interventions, and develop healthcare theories. The ultimate strength of the qualitative research approach lies in the richness of the data and the descriptions and depth of exploration it makes. Hence, qualitative methods are considered as the most humanistic and person-centered way of discovering and uncovering thoughts and actions of human beings.

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April 23, 2024

Research in Context: Treating depression

Finding better approaches.

While effective treatments for major depression are available, there is still room for improvement. This special Research in Context feature explores the development of more effective ways to treat depression, including personalized treatment approaches and both old and new drugs.

Everyone has a bad day sometimes. People experience various types of stress in the course of everyday life. These stressors can cause sadness, anxiety, hopelessness, frustration, or guilt. You may not enjoy the activities you usually do. These feelings tend to be only temporary. Once circumstances change, and the source of stress goes away, your mood usually improves. But sometimes, these feelings don’t go away. When these feelings stick around for at least two weeks and interfere with your daily activities, it’s called major depression, or clinical depression.

In 2021, 8.3% of U.S. adults experienced major depression. That’s about 21 million people. Among adolescents, the prevalence was much greater—more than 20%. Major depression can bring decreased energy, difficulty thinking straight, sleep problems, loss of appetite, and even physical pain. People with major depression may become unable to meet their responsibilities at work or home. Depression can also lead people to use alcohol or drugs or engage in high-risk activities. In the most extreme cases, depression can drive people to self-harm or even suicide.

The good news is that effective treatments are available. But current treatments have limitations. That’s why NIH-funded researchers have been working to develop more effective ways to treat depression. These include finding ways to predict whether certain treatments will help a given patient. They're also trying to develop more effective drugs or, in some cases, find new uses for existing drugs.

Finding the right treatments

The most common treatments for depression include psychotherapy, medications, or a combination. Mild depression may be treated with psychotherapy. Moderate to severe depression often requires the addition of medication.

Several types of psychotherapy have been shown to help relieve depression symptoms. For example, cognitive behavioral therapy helps people to recognize harmful ways of thinking and teaches them how to change these. Some researchers are working to develop new therapies to enhance people’s positive emotions. But good psychotherapy can be hard to access due to the cost, scheduling difficulties, or lack of available providers. The recent growth of telehealth services for mental health has improved access in some cases.

There are many antidepressant drugs on the market. Different drugs will work best on different patients. But it can be challenging to predict which drugs will work for a given patient. And it can take anywhere from 6 to 12 weeks to know whether a drug is working. Finding an effective drug can involve a long period of trial and error, with no guarantee of results.

If depression doesn’t improve with psychotherapy or medications, brain stimulation therapies could be used. Electroconvulsive therapy, or ECT, uses electrodes to send electric current into the brain. A newer technique, transcranial magnetic stimulation (TMS), stimulates the brain using magnetic fields. These treatments must be administered by specially trained health professionals.

“A lot of patients, they kind of muddle along, treatment after treatment, with little idea whether something’s going to work,” says psychiatric researcher Dr. Amit Etkin.

One reason it’s difficult to know which antidepressant medications will work is that there are likely different biological mechanisms that can cause depression. Two people with similar symptoms may both be diagnosed with depression, but the causes of their symptoms could be different. As NIH depression researcher Dr. Carlos Zarate explains, “we believe that there’s not one depression, but hundreds of depressions.”

Depression may be due to many factors. Genetics can put certain people at risk for depression. Stressful situations, physical health conditions, and medications may contribute. And depression can also be part of a more complicated mental disorder, such as bipolar disorder. All of these can affect which treatment would be best to use.

Etkin has been developing methods to distinguish patients with different types of depression based on measurable biological features, or biomarkers. The idea is that different types of patients would respond differently to various treatments. Etkin calls this approach “precision psychiatry.”

One such type of biomarker is electrical activity in the brain. A technique called electroencephalography, or EEG, measures electrical activity using electrodes placed on the scalp. When Etkin was at Stanford University, he led a research team that developed a machine-learning algorithm to predict treatment response based on EEG signals. The team applied the algorithm to data from a clinical trial of the antidepressant sertraline (Zoloft) involving more than 300 people.

EEG data for the participants were collected at the outset. Participants were then randomly assigned to take either sertraline or an inactive placebo for eight weeks. The team found a specific set of signals that predicted the participants’ responses to sertraline. The same neural “signature” also predicted which patients with depression responded to medication in a separate group.

Etkin’s team also examined this neural signature in a set of patients who were treated with TMS and psychotherapy. People who were predicted to respond less to sertraline had a greater response to the TMS/psychotherapy combination.

Etkin continues to develop methods for personalized depression treatment through his company, Alto Neuroscience. He notes that EEG has the advantage of being low-cost and accessible; data can even be collected in a patient’s home. That’s important for being able to get personalized treatments to the large number of people they could help. He’s also working on developing antidepressant drugs targeted to specific EEG profiles. Candidate drugs are in clinical trials now.

“It’s not like a pie-in-the-sky future thing, 20-30 years from now,” Etkin explains. “This is something that could be in people's hands within the next five years.”

New tricks for old drugs

While some researchers focus on matching patients with their optimal treatments, others aim to find treatments that can work for many different patients. It turns out that some drugs we’ve known about for decades might be very effective antidepressants, but we didn’t recognize their antidepressant properties until recently.

One such drug is ketamine. Ketamine has been used as an anesthetic for more than 50 years. Around the turn of this century, researchers started to discover its potential as an antidepressant. Zarate and others have found that, unlike traditional antidepressants that can take weeks to take effect, ketamine can improve depression in as little as one day. And a single dose can have an effect for a week or more. In 2019, the FDA approved a form of ketamine for treating depression that is resistant to other treatments.

But ketamine has drawbacks of its own. It’s a dissociative drug, meaning that it can make people feel disconnected from their body and environment. It also has the potential for addiction and misuse. For these reasons, it’s a controlled substance and can only be administered in a doctor’s office or clinic.

Another class of drugs being studied as possible antidepressants are psychedelics. These include lysergic acid diethylamide (LSD) and psilocybin, the active ingredient in magic mushrooms. These drugs can temporarily alter a person’s mood, thoughts, and perceptions of reality. Some have historically been used for religious rituals, but they are also used recreationally.

In clinical studies, psychedelics are typically administered in combination with psychotherapy. This includes several preparatory sessions with a therapist in the weeks before getting the drug, and several sessions in the weeks following to help people process their experiences. The drugs are administered in a controlled setting.

Dr. Stephen Ross, co-director of the New York University Langone Health Center for Psychedelic Medicine, describes a typical session: “It takes place in a living room-like setting. The person is prepared, and they state their intention. They take the drug, they lie supine, they put on eye shades and preselected music, and two therapists monitor them.” Sessions last for as long as the acute effects of the drug last, which is typically several hours. This is a healthcare-intensive intervention given the time and personnel needed.

In 2016, Ross led a clinical trial examining whether psilocybin-assisted therapy could reduce depression and anxiety in people with cancer. According to Ross, as many as 40% of people with cancer have clinically significant anxiety and depression. The study showed that a single psilocybin session led to substantial reductions in anxiety and depression compared with a placebo. These reductions were evident as soon as one day after psilocybin administration. Six months later, 60-80% of participants still had reduced depression and anxiety.

Psychedelic drugs frequently trigger mystical experiences in the people who take them. “People can feel a sense…that their consciousness is part of a greater consciousness or that all energy is one,” Ross explains. “People can have an experience that for them feels more ‘real’ than regular reality. They can feel transported to a different dimension of reality.”

About three out of four participants in Ross’s study said it was among the most meaningful experiences of their lives. And the degree of mystical experience correlated with the drug’s therapeutic effect. A long-term follow-up study found that the effects of the treatment continued more than four years later.

If these results seem too good to be true, Ross is quick to point out that it was a small study, with only 29 participants, although similar studies from other groups have yielded similar results. Psychedelics haven’t yet been shown to be effective in a large, controlled clinical trial. Ross is now conducting a trial with 200 people to see if the results of his earlier study pan out in this larger group. For now, though, psychedelics remain experimental drugs—approved for testing, but not for routine medical use.

Unlike ketamine, psychedelics aren’t considered addictive. But they, too, carry risks, which certain conditions may increase. Psychedelics can cause cardiovascular complications. They can cause psychosis in people who are predisposed to it. In uncontrolled settings, they have the risk of causing anxiety, confusion, and paranoia—a so-called “bad trip”—that can lead the person taking the drug to harm themself or others. This is why psychedelic-assisted therapy takes place in such tightly controlled settings. That increases the cost and complexity of the therapy, which may prevent many people from having access to it.

Better, safer drugs

Despite the promise of ketamine or psychedelics, their drawbacks have led some researchers to look for drugs that work like them but with fewer side effects.

Depression is thought to be caused by the loss of connections between nerve cells, or neurons, in certain regions of the brain. Ketamine and psychedelics both promote the brain’s ability to repair these connections, a quality called plasticity. If we could understand how these drugs encourage plasticity, we might be able to design drugs that can do so without the side effects.

Dr. David Olson at the University of California, Davis studies how psychedelics work at the cellular and molecular levels. The drugs appear to promote plasticity by binding to a receptor in cells called the 5-hydroxytryptamine 2A receptor (5-HT2AR). But many other compounds also bind 5-HT2AR without promoting plasticity. In a recent NIH-funded study, Olson showed that 5-HT2AR can be found both inside and on the surface of the cell. Only compounds that bound to the receptor inside the cells promoted plasticity. This suggests that a drug has to be able to get into the cell to promote plasticity.

Moreover, not all drugs that bind 5-HT2AR have psychedelic effects. Olson’s team has developed a molecular sensor, called psychLight, that can identify which compounds that bind 5-HT2AR have psychedelic effects. Using psychLight, they identified compounds that are not psychedelic but still have rapid and long-lasting antidepressant effects in animal models. He’s founded a company, Delix Therapeutics, to further develop drugs that promote plasticity.

Meanwhile, Zarate and his colleagues have been investigating a compound related to ketamine called hydroxynorketamine (HNK). Ketamine is converted to HNK in the body, and this process appears to be required for ketamine’s antidepressant effects. Administering HNK directly produced antidepressant-like effects in mice. At the same time, it did not cause the dissociative side effects and addiction caused by ketamine. Zarate’s team has already completed phase I trials of HNK in people showing that it’s safe. Phase II trials to find out whether it’s effective are scheduled to begin soon.  

“What [ketamine and psychedelics] are doing for the field is they’re helping us realize that it is possible to move toward a repair model versus a symptom mitigation model,” Olson says. Unlike existing antidepressants, which just relieve the symptoms of depression, these drugs appear to fix the underlying causes. That’s likely why they work faster and produce longer-lasting effects. This research is bringing us closer to having safer antidepressants that only need to be taken once in a while, instead of every day.

—by Brian Doctrow, Ph.D.

Related Links

• How Psychedelic Drugs May Help with Depression
• Biosensor Advances Drug Discovery
• Neural Signature Predicts Antidepressant Response
• How Ketamine Relieves Symptoms of Depression
• Protein Structure Reveals How LSD Affects the Brain
• Predicting The Usefulness of Antidepressants
• Depression Screening and Treatment in Adults
• Serotonin Transporter Structure Revealed
• Placebo Effect in Depression Treatment
• When Sadness Lingers: Understanding and Treating Depression
• Psychedelic and Dissociative Drugs

References:  An electroencephalographic signature predicts antidepressant response in major depression.  Wu W, Zhang Y, Jiang J, Lucas MV, Fonzo GA, Rolle CE, Cooper C, Chin-Fatt C, Krepel N, Cornelssen CA, Wright R, Toll RT, Trivedi HM, Monuszko K, Caudle TL, Sarhadi K, Jha MK, Trombello JM, Deckersbach T, Adams P, McGrath PJ, Weissman MM, Fava M, Pizzagalli DA, Arns M, Trivedi MH, Etkin A.  Nat Biotechnol.  2020 Feb 10. doi: 10.1038/s41587-019-0397-3. Epub 2020 Feb 10. PMID: 32042166. Rapid and sustained symptom reduction following psilocybin treatment for anxiety and depression in patients with life-threatening cancer: a randomized controlled trial. Ross S, Bossis A, Guss J, Agin-Liebes G, Malone T, Cohen B, Mennenga SE, Belser A, Kalliontzi K, Babb J, Su Z, Corby P, Schmidt BL. J Psychopharmacol . 2016 Dec;30(12):1165-1180. doi: 10.1177/0269881116675512. PMID: 27909164. Long-term follow-up of psilocybin-assisted psychotherapy for psychiatric and existential distress in patients with life-threatening cancer. Agin-Liebes GI, Malone T, Yalch MM, Mennenga SE, Ponté KL, Guss J, Bossis AP, Grigsby J, Fischer S, Ross S. J Psychopharmacol . 2020 Feb;34(2):155-166. doi: 10.1177/0269881119897615. Epub 2020 Jan 9. PMID: 31916890. Psychedelics promote neuroplasticity through the activation of intracellular 5-HT2A receptors.  Vargas MV, Dunlap LE, Dong C, Carter SJ, Tombari RJ, Jami SA, Cameron LP, Patel SD, Hennessey JJ, Saeger HN, McCorvy JD, Gray JA, Tian L, Olson DE.  Science . 2023 Feb 17;379(6633):700-706. doi: 10.1126/science.adf0435. Epub 2023 Feb 16. PMID: 36795823. Psychedelic-inspired drug discovery using an engineered biosensor.  Dong C, Ly C, Dunlap LE, Vargas MV, Sun J, Hwang IW, Azinfar A, Oh WC, Wetsel WC, Olson DE, Tian L.  Cell . 2021 Apr 8: S0092-8674(21)00374-3. doi: 10.1016/j.cell.2021.03.043. Epub 2021 Apr 28. PMID: 33915107. NMDAR inhibition-independent antidepressant actions of ketamine metabolites. Zanos P, Moaddel R, Morris PJ, Georgiou P, Fischell J, Elmer GI, Alkondon M, Yuan P, Pribut HJ, Singh NS, Dossou KS, Fang Y, Huang XP, Mayo CL, Wainer IW, Albuquerque EX, Thompson SM, Thomas CJ, Zarate CA Jr, Gould TD. Nature . 2016 May 26;533(7604):481-6. doi: 10.1038/nature17998. Epub 2016 May 4. PMID: 27144355.

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Understaffed nursing homes in disadvantaged neighborhoods more likely to overuse antipsychotics

Boosting staffing may help limit use of 'chemical restraints,' study finds.

Nursing homes in disadvantaged communities are more likely to overmedicate residents with antipsychotics, especially homes that are understaffed, according to a new study published in JAMA Network Open .

"The neighborhood in which a nursing home is located seems to influence how widely antipsychotics are used, even when they may not be indicated," said Jasmine Travers, assistant professor at NYU Rory Meyers College of Nursing and the study's senior author.

Antipsychotic medications are used to treat serious psychiatric disorders such as schizophrenia. These medications have long been given to nursing home residents with and without dementia who are agitated or have behavioral issues. -- Sometimes staff rely on their sedating side effects for "chemical restraint" rather than redirecting residents in distress.

"We know that nursing homes with lower staffing levels use more antipsychotics. These medications may be compensating for understaffing by sedating residents instead of having adequate staff to support their needs," said Travers.

Antipsychotic use in older adults can be dangerous, increasing their risk for falls, strokes, and even death. As a result, in recent years, there has been a significant push by the Centers for Medicare and Medicaid Services (CMS) to reduce the use of antipsychotics to manage behaviors such as aggression or wandering in nursing homes.

However, this may be more challenging in disadvantaged neighborhoods, where residents may be exposed to greater stressors, including higher crime rates, noise pollution, and less green space, all of which can harm their mental and physical health. For older adults, these stressors might translate to poor sleep or agitation, increasing the risk that an antipsychotic medication is used, even without an appropriate diagnosis.

To better understand the connection between nursing home staffing, neighborhood factors, and antipsychotic use, Travers and her colleagues looked at data from 10,666 nursing homes across the U.S., 1,867 of which were in severely disadvantaged neighborhoods. Neighborhood socioeconomics were measured using data on income, education, employment, and housing for small geographic units called census blocks.

The researchers also looked at what percentage of residents received an antipsychotic drug in the last week but didn't have a qualifying diagnosis of schizophrenia, Tourette syndrome, or Huntington's disease. (The study did not take into account residents who are falsely diagnosed with schizophrenia to get around the CMS reporting requirement, a troubling practice documented in a 2022 report by the U.S. Department of Health and Human Services.)

The researchers found that nursing homes that were understaffed -- measured as having less than three hours of nurse staffing per resident each day -- had greater antipsychotic medication use in severely disadvantaged neighborhoods (19.2%) compared to less disadvantaged neighborhoods (17.1%).

"This means that in a 100-bed nursing home that is understaffed, two additional residents would inappropriately receive an antipsychotic medication if the nursing home was in a disadvantaged neighborhood versus a more well-off area," said Travers.

Notably, when nursing homes met or exceeded the federal government's proposed staffing levels of at least three hours of nursing per resident per day, there was not a significant difference in antipsychotic use based on neighborhood, providing support for having minimum staffing levels. The researchers call for a more focused effort on improving staffing in nursing homes in lower income areas, which could include additional funding -- similar to funds provided to federally qualified health centers -- or other tailored interventions to address gaps in staffing.

"Addressing staffing deficiencies, particularly in nursing homes in disadvantaged neighborhoods, will be critical for reducing the overuse of antipsychotics," said Travers. "Understanding this vulnerability can help inform policy solutions to support, not penalize, nursing homes in disinvested communities."

In addition to Travers, study authors include Erinn Hade and Steven Friedman of NYU Grossman School of Medicine, Aasha Raval and Kimberly Hadson of NYU Meyers, and Jason Falvey of the University of Maryland School of Medicine. The research was supported by the National Institute on Aging (K76AG074922, K76AG074926, P30AG028747) and the Patrick and Catherine Weldon Donaghue Medical Research Foundation.

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Journal Reference :

• Jasmine L. Travers, Erinn M. Hade, Steven Friedman, Aasha Raval, Kimberly Hadson, Jason R. Falvey. Staffing and Antipsychotic Medication Use in Nursing Homes and Neighborhood Deprivation . JAMA Network Open , 2024; 7 (4): e248322 DOI: 10.1001/jamanetworkopen.2024.8322

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