quantitative research nursing study

Nursing Research (NURS 3321/4325/5366)

• Introduction
• Understand What Quantitative Research Is
• Understand What Qualitative Research Is
• Sage Methods Map
• Step 1: Accessing CINAHL
• Step 2: Create a Keyword Search
• Step 3: Create a Subject Heading Search
• Step 4: Repeat Steps 1-3 for Second Concept
• Step 5: Repeat Steps 1-3 for Quantitative Terms
• Step 6: Combining All Searches
• Step 7: Adding Limiters
• Step 8: Save Your Search!
• What Kind of Article is This?
• PICO Keyword Search Strategy
• PICO Keyword Search
• PICO Subject Heading Search
• Combining Keyword and Subject Heading Searches
• Adding Filters/Limiters
• Finding Health Statistics
• Find Clinical Guidelines This link opens in a new window
• APA Format & Citations This link opens in a new window

What is Quantitative Research?

Quantitative methodology is the dominant research framework in the social sciences. it refers to a set of strategies, techniques and assumptions used to study psychological, social and economic processes through the exploration of numeric patterns . quantitative research gathers a range of numeric data. some of the numeric data is intrinsically quantitative (e.g. personal income), while in other cases the numeric structure is  imposed (e.g. ‘on a scale from 1 to 10, how depressed did you feel last week’). the collection of quantitative information allows researchers to conduct simple to extremely sophisticated statistical analyses that aggregate the data (e.g. averages, percentages), show relationships among the data (e.g. ‘students with lower grade point averages tend to score lower on a depression scale’) or compare across aggregated data (e.g. the usa has a higher gross domestic product than spain). quantitative research includes methodologies such as questionnaires, structured observations or experiments and stands in contrast to qualitative research. qualitative research involves the collection and analysis of narratives and/or open-ended observations through methodologies such as interviews, focus groups or ethnographies..

Coghlan, D., Brydon-Miller, M. (2014).  The SAGE encyclopedia of action research  (Vols. 1-2). London, : SAGE Publications Ltd doi: 10.4135/9781446294406

What is the purpose of quantitative research?

The purpose of quantitative research is to generate knowledge and create understanding about the social world. Quantitative research is used by social scientists, including communication researchers, to observe phenomena or occurrences affecting individuals. Social scientists are concerned with the study of people. Quantitative research is a way to learn about a particular group of people, known as a sample population. Using scientific inquiry, quantitative research relies on data that are observed or measured to examine questions about the sample population.

Allen, M. (2017).  The SAGE encyclopedia of communication research methods  (Vols. 1-4). Thousand Oaks, CA: SAGE Publications, Inc doi: 10.4135/9781483381411

How do I know if the study is a quantitative design?  What type of quantitative study is it?

Quantitative Research Designs: Descriptive non-experimental, Quasi-experimental or Experimental?

Studies do not always explicitly state what kind of research design is being used.  You will need to know how to decipher which design type is used.  The following video will help you determine the quantitative design type.

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NUR 39000: Nursing Research: Quantitative Study Searching

• Quantitative Study Searching
• Qualitative Study from a Specific Journal
• Inferential Statistics Tips
• Find Informative Articles
• Primary & Secondary Sources
• Nursing Databases
• Journal Types
• Accessing Full-Text
• Asking the PICO or PICo Question
• Acquiring Evidence
• Appraising the Evidence
• Research Designs
• Levels of Evidence
• Grey Literature Resources
• Writing & APA Citation Help
• How to Get Help
• COVID-19 Resources
• Video Tutorials

Identifying Research Articles

Identify research articles by reviewing the abstract and other bibliographic information. Many citations for research articles include the following headings:

• Participants
• Data Collection
• Data Analysis

Read the full text  of the article to learn more.

Identifying Peer Reviewed Sources

There are several ways that you can determine the peer reviewed status of a journal. Review the selections in the database advanced search page for a peer reviewed check box or menu limiter. You can also look at  title lists  which include  peer reviewed information. Click on the following database to see the title lists for  CINAHL Plus with Full Text ,  MEDLINE  or  Health Source: Nursing .

A basic Google search of "Is Journal Name peer reviewed" will often produce results that link you to a reliable source and answer.  The journal’s website will usually mention if it is peer reviewed in the description. 

Tips for Finding Nursing Journals

Tip: You may choose to use a journal-type limiter to narrow your search to nursing journals.

Here are nursing journals limits from CINAHL, MEDLINE (Ebsco), and PubMed:

In CINAHL you can target nursing journals by selecting Nursing from the Journal Subset menu options. This is not usually necessary, since CINAHL stands for Cumulative Index to Nursing and Allied Health Literature.  Nearly all publications in the CINAHL database are nursing journals.

In MEDLINE (Ebsco) you can target nursing journals by selecting Nursing from the Journal & Citation Subset menu options.

In PubMed, you can target nursing journals after you have performed your search.  On the results page, there will be a column on the left with filters including Article types, Text availability, Publication dates. Select Show additional filters , check the box next to Journal categories then the Show button. Click on Nursing journals to see results from nursing journals. 

Starting Your Assignment

This page offers tips on locating research articles from library databases for your NUR 390 assignment to find a primary quantitative research study.  Before you start your database search it is important to familiarize yourself with the requirements outlined on the assignment checklist.    

Please note that the help provided on this page is not exhaustive. The tips are intended to help generate potential relevant search results. Librarians will NOT be able to help you distinguish quantitative vs. qualitative research or determine whether or not a chosen article includes appropriate descriptive and inferential statistics.  Ultimately, you must read the full text of an article and use your textbook and other course materials to determine if it meets the assignment's criteria.

Video for Selecting a Quantitative Research Article

This link connects you to a demonstration video on how to locate articles for the assignment to find a primary quantitative research study.

PLEASE NOTE: The example demonstrates searching for research articles using search limiters in the CINAHL database.  However, the date range at the time of the recording will not necessarily match the range for your specific assignment.  

Please be sure to note the correct date range and other criteria from your instructor's checklist .

Tips for Finding Quantitative Research

The following are tips that can help you find quantitative research articles. These tips work best when your initial search produces a large amount of results. I do not recommend these methods if your initial search generates few results or if your required date range is less than one year.

Tip:  Although CINAHL does not have a checkbox to limit your search to either quantitative or qualitative research, it is sometimes helpful to add vocabulary that describes quantitative research tools, methodology or assessments. In the advanced search screen page, you can add a search box that will include words that describe quantitative research.

Tip: CINAHL allows you to filter by publication type.  If your initial search has returned lots of results, you might try using the Publication Type limiter to select only  Clinical Trial and/or  Randomized Controlled Trial.   These are types of  quantitative studies .  

Tips for Finding Nurse as Author

In CINHAL, you can find articles where a nurse is the first author by checking the First Author is Nurse checkbox in the advanced search page.

Although this limiter is useful for searches with a long date range (several years), it is not recommended for searches with a shorter date range, since the detailed index information in each record is not always up to date.  You may miss articles that were authored by a nurse but do not show up in your search results.

You may need to search the databases using other criteria, and then scan the resulting studies to see if the first author's credentials are listed on the page.

Library Liaison for Nursing Students & Faculty

About the Library

The library offers a wide range of online resources, including databases with various journals from which to choose articles and research studies.

To access your Library resources, please visit the homepage

Please consult your Library Liaison directly for research assistance.

If your Librarian is unavailable, please contact the Library's Reference desk at (219) 989-2676 or click on the CHAT WITH A LIBRARIAN  link below to submit a question or see answers to frequently asked questions.

Library Hours : 

Library staff members are available to assist you during library hours . 

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• Quantitative vs. Qualitative Research

You can find evidence for clinical decision making in quantitative and qualitative research studies .  Quantitative research  refers to any research based on something that can be accurately and precisely measured and will include studies that have numerical data . Quantitative data are expressed numerically and analyzed statistically. The data are collected from experiments and tests, metrics, databases, and surveys. In healthcare research they  often  include studies of intervention effectiveness, satisfaction with care, the incidence, prevalence, and etiology of diseases, and the properties of measurement tools (Kolaski, 2023).

Findings in qualitative studies are not based on measurable statistics. Qualitative data are descriptive rather than numerical. Qualitative research derives data from observation, interviews, verbal interactions, or textual analyses and focuses on the meanings and interpretations of the participants. Qualitative research studies in healthcare investigate the impact of illnesses and interventions. The research explores experiences, attitudes, beliefs, and perspectives of patients, caregivers, and clinicians (Kolaski, 2023). The analysis of qualitative research is interpretative, subjective, and impressionistic.  

Kolaski, K., Logan, L. R., & Ioannidis, J. P. A. (2023). Guidance to best tools and practices for systematic reviews. Systematic Reviews , 12 (1), 96. https://doi.org/10.1186/s13643-023-02255-9

Video:  UniversityNow: Quantitative vs. Qualitative Research

Appraising Quantitative and Qualitative Research

The articles below provide a step-by-step appraisal on how to critique quantitative and qualitative research articles:

Ryan, F., Coughlan, M. & Cronin, P. (2007). Step-by-step guide to critiquing research. Part 1: quantitative research.  British Journal of Nursing, 16 (11), 658-663 .

Ryan, F., Coughlan, M. & Cronin, P. (2007). Step-by-step guide to critiquing research. Part 2: qualitative research.  British Journal of Nursing, 16 (2), 738-744 .

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What is Quantitative Research?

Typical attributes of Quantitative Research:

• The basic element of analysis: numbers, statistical analyses (p values, chi square, t-test)
• Methods: counting, measuring, quantifying (e.g. Likert scale)
• Tests a theory

How to Find Peer-reviewed Quantitative Research Articles

In CINAHL and MEDLINE , to find Peer-reviewed Quantitative Research articles, add several of the following subject terms to your search:

CINAHL terms:

• Quantitative Studies
• Analysis of Variance 
• Chi Square Test

MEDLINE terms:

• Evaluation Studies
• Analysis of Variance
• Chi Square Distribution 

Identifying Quantitative Research Articles

Here's an example of an article that has several quantitative research terms as Minor Subjects in the CINAHL database.

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Mixed Methods in Nursing Research : An Overview and Practical Examples

Ardith z. doorenbos.

School of Nursing, University of Washington, USA, Box 357266, Seattle, WA 98177

Mixed methods research methodologies are increasingly applied in nursing research to strengthen the depth and breadth of understanding of nursing phenomena. This article describes the background and benefits of using mixed methods research methodologies, and provides two examples of nursing research that used mixed methods. Mixed methods research produces several benefits. The examples provided demonstrate specific benefits in the creation of a culturally congruent picture of chronic pain management for American Indians, and the determination of a way to assess cost for providing chronic pain care.

Introduction

Mixed methods is one of the three major research paradigms: quantitative research, qualitative research, and mixed methods research. Mixed methods research combines elements of qualitative and quantitative research approaches for the broad purpose of increasing the breadth and depth of understanding. The definition of mixed methods, from the first issue of the Journal of Mixed Methods Research, is “research in which the investigator collects and analyzes data, integrates the findings, and draws inferences using both qualitative and quantitative approaches or methods in a single study or program of inquiry” ( Tashakkori & Creswell, 2007 , p.4).

Mixed methods research began among anthropologists and sociologists in the early 1960s. In the late 1970s, the term “triangulation” began to enter methodology conversations. Triangulation was identified as a combination of methodologies in the study of the same phenomenon to decrease the bias inherent in using one particular method ( Morse, 1991 ). Two types of sequencing for mixed methods design have been proposed: simultaneous and sequential. Type of sequencing is one of the key decisions in mixed methods study design. Simultaneous sequencing is postulated to be simultaneous use of qualitative and quantitative methods, where there is limited interaction between the two sources of data during data collection, but the data obtained is used in the data interpretation stage to support each method's findings and to reach a final understanding. Sequential sequencing is postulated to be the use of one method before the other, as when the results of one method are necessary for planning the next method.

Since the 1960s, the use of mixed methods has continued to grow in popularity ( O'Cathain, 2009 ). Currently, although there are numerous designs to consider for mixed methods research, the four major types of mixed methods designs are triangulation design, embedded design, explanatory design, and exploratory design ( Creswell & Plano Clark, 2007 ). The most common and well-known approach to mixed methods research continues to be triangulation design.

There are many benefits to using mixed methods. Quantitative data can support qualitative research components by identifying representative patients or outlying cases, while qualitative data can shed light on quantitative components by helping with development of the conceptual model or instrument. During data collection, quantitative data can provide baseline information to help researchers select patients to interview, while qualitative data can help researchers understand the barriers and facilitators to patient recruitment and retention. During data analysis, qualitative data can assist with interpreting, clarifying, describing, and validating quantitative results.

Four broad types of research situations have been reported as benefiting particularly from mixed methods research. The first situation is when concepts are new and not well understood. Thus, there is a need for qualitative exploration before quantitative methods can be used. The second situation is when findings from one approach can be better understood with a second source of data. The third situation is when neither a qualitative nor a quantitative approach, by itself, is adequate to understanding the concept being studied. Lastly, the fourth situation is when the quantitative results are difficult to interpret, and qualitative data can assist with understanding the results ( Creswell & Plano Clark, 2007 ).

The purpose of this article is to illustrate mixed methods methodology by using examples of research into the chronic pain management experience among American Indians. These examples demonstrate the methodology used to provide (a) a detailed multilevel understanding of the chronic pain care experience for American Indians using triangulation design (multilevel model), and (b) a comparison of cost for two different chronic pain care delivery models, also using triangulation design (data transformation model).

An Example : Understanding the Pain Management Experience Among American Indians

Chronic pain poses unique challenges to the American health care system, including ever-escalating costs, unintentional poisonings and deaths from overdoses of painkillers, and incalculable suffering for patients as well as their families. Approximately 100 million adults in the United States are affected by chronic pain, with treatment costs and losses in productivity totaling $635 billion annually ( Institute of Medicine, 2011 ). Symptoms of pain are the leading reason patients visit health care providers ( Hing, Cherry, & Woodwell, 2006 ).

At the level of the community-based primary care provider, especially in tribal areas of the United States, there is often not enough capacity to manage complex chronic pain cases, and this is often due to lack of access to specialty pain care ( Momper, Delva, Tauiliili, Mueller-Williams, & Goral, 2013 ). The American Indian population in particular is underserved by health care and the most vulnerable to the impact of chronic pain, with high rates of drug poisoning due to opioid analgesics ( Warner, Chen, Makuc, Anderson, & Minino, 2011 ). There are 2.9 million people who report exclusive and an additional 1.6 million who report partial American Indian ancestry in the United States. They are a diverse group, residing in 35 states and organized into 564 federally recognized tribes ( U.S. Census Bureau, 2010 ). However, there is a scarcity of published literature exploring the experience, epidemiology, and management of pain among American Indians ( Haozous, Knobf, & Brant, 2010 ; Haozous & Knobf, 2013 ; Jimenez, Garroutte, Kundu, Morales, & Buchwald, 2011 ).

Using Mixed Methods to Overcome Barriers to Research

Barriers to effective research into chronic pain management among American Indians include the relatively small number of American Indian patients in any circumscribed area or tribe, the limitations of individual databases, and widespread racial misclassification. A mixed methods research approach is needed to understand the complex experience, epidemiology, and management of chronic pain among American Indians and to address the strengths and weaknesses of quantitative methodologies (large sample size, trends, generalizable) with those of qualitative methodologies (small sample size, details, in-depth).

This first example is from an ongoing study that uses triangulation design to provide a better understanding of the phenomenon of chronic pain management among American Indians. The study uses a multilevel model in which quantitative data collected at the national and state levels will be analyzed in parallel with the collection and analysis of the qualitative data at the patient level (see Figure 1 ). This allows the weakness of one approach to be offset by the strengths of the other. The results of the separate level analyses will be compared, contrasted, and blended leading to an overall interpretation of results.

Role of quantitative data

Previous examination of U.S. national databases has reported a higher prevalence of lower back pain in American Indians than in the general population (35% compared to 26% ; Deyo, Mirza, & Martin, 2002 ). Thus, at level 1, quantitative administrative data sets representing health care received by American Indians, both across the United States and in broad regions, will be used to evaluate macro-level trends in utilization of health care and in basic outcomes, such as opioid-related deaths.

At level 2, more detailed quantitative Washington state tribal clinic data will be used to identify American Indian populations, evaluate breakdowns in the delivery of care, and identify processes that lead to unsuccessful outcomes. For example, in a study conducted with community health practitioners in Alaska, participants reported low levels of knowledge and comfort around discussing cancer pain ( Cueva, Lanier, Dignan, Kuhnley, & Jenkins, 2005 ).

Role of qualitative data

At level 3, qualitative research through focus groups and key informant interviews will provide even more refined information about perceptions of recommended and received care. These interviews will provide insight into selected immediate and proximal factors. These factors include patients' choice and use of services; attitudes, motivations, and perceptions that influence their decisions; interpersonal factors, such as social support; and perceived discrimination. This qualitative data will shed light on potential barriers to care that are not easily recognized in administrative or clinical records, and thereby will provide greater detail about patient views of chronic pain care.

Role of (qualitative) indigenous methodologies

Since the focus of this study is on the chronic pain experience among American Indian patients, it is important that the qualitative work in level 3 be guided by indigenous methodologies, in both data collection and analysis. The phrase “indigenous methodologies” refers to an evolving framework for creating research that places the epistemologies of indigenous participants and communities at the center of the work, while building an equitable and respectful setting for bidirectional learning ( Evans, Hole, Berg, Hutchinson, & Sookraj, 2009 ; Louis, 2007 .; Smith, 2004 ). Although the tenets of indigenous methodologies vary according to the source, there is agreement among sources that research with indigenous populations should be wellness-oriented, holistic, community-oriented, and focused on indigenous knowledge, and should incorporate bidirectional learning ( Louis, 2007 ; Smith, 2004 ).

The ongoing project aligns with these guidelines by building knowledge about the chronic pain experience from the perspective of American Indian patients. The data is being interpreted with the goal of designing a usable and relevant model that will resonate at the American Indian community level. The researchers have conducted focus groups with the needs and priorities of the participants placed at the forefront, to best achieve the goals of learning and building knowledge that reflects the participants' experiences. Specifically, the focus groups were scheduled within three tribes, ensuring high familiarity and social support among group members. These focus groups met either at a tribal community center or in a nearby tribally owned casino in the evening. Each focus group started with a dinner, followed by discussion.

The focus group facilitator was well-known to the community, and although not American Indian, had been an active participant in community events and had provided expert knowledge and consultation to the tribes. Additionally, each focus group was co-facilitated by a tribal elder. The high familiarity among the participants and the research team was an important component of the bidirectional learning: it helped reduce much of the mistrust that has historically prevented medical researchers from obtaining high-quality data in similarly vulnerable populations ( Guadagnolo, Cina, & Helbig, 2009 ).

Benefits of Triangulation Design: Multilevel Model

In summary, only a mixed methods study that included quantitative and qualitative methods could provide the data required for a comprehensive multilevel assessment of the chronic pain experience among American Indians. Although this study is ongoing, the plan is for a nationwide analysis of variations in chronic pain outcomes among American Indians to examine the structure of service delivery and organization. Analysis of the state tribal clinic data will address intermediate factors and will examine community-level variation in pain management and local access to pain specialists. Preliminary analysis of the focus group data has already demonstrated that there is insufficient pain management among American Indians, due in part to lack of knowledge about pain management among providers and lack of access to pain specialists.

An Example; Comparing the Costs of Two Models for Providing Chronic Pain Care to American Indians

Telehealth is one innovative approach to providing access to high-quality interdisciplinary pain care for American Indians. A telehealth model with a unique approach based on provider-to-provider videoconference consultations allows community-based providers to present complex chronic pain cases to a panel of pain specialists through a videoconferencing infrastructure that also incorporates longitudinal outcomes tracking to monitor patient progress. Telehealth is an innovative model of health care delivery, and its use among American Indians has been expanding over the past several years ( Doorenbos et al., 2010 ; Doorenbos et al., 2011a ; 2011b ). Although the use of telehealth for providing chronic pain consultation is still in early stages, the long-term effectiveness of this approach and its impact on increasing capacity for pain management among community providers is being investigated ( Haozous et al., 2012 ; Tauben, Towle, Gordon, Theodore, & Doorenbos, 2013 ). The mixed methods approach for this transaction cost analysis used a unique triangulation design with a data transformation model to build a body of evidence for telehealth pain management.

With ever increasing mandates to reduce the cost and increase the quality of pain management, health care institutions are faced with the challenge of demonstrating that new technologies provide value while maintaining or even improving the quality of care ( Harries & Yellowlees, 2013 ). Transaction cost analysis can provide this evidence by using mixed methods research methodologies to provide comparative evaluation of the costs and consequences of using alternative technologies and the accompanying organizational arrangements for delivering care ( Williamson, 2000 ).

The theory of transaction cost developed from the observation that our structures for governing transactions—the ways in which we organize, manage, support, and carry out exchange — have economic consequences ( Williamson, 1991 ). Though prices matter, this theory recognizes that prices can and do deviate from the cost of production and do not include the cost of transacting ( Coase, 1960 ). Setting aside neoclassical economic conceptions of price, output, demand, and supply, the transaction becomes the unit of analysis ( Williamson, 1985 ).

In transactions, there are typically two parties engaging in the exchange of goods or services, and both exert effort to carry out the transaction, incurring costs in the hope or with the expectation of realizing benefits. Some ways of structuring or supporting a given transaction, such as consultation or treatment for a patient from a health care provider, may be more efficient than others. The analysis examines the actual costs incurred and the related consequences experienced by the parties over time, with the hypothesis that efficiency results from the discriminating alignment of transactions with alternative, more efficient structures of governance ( Williamson, 2002 ).

Specialty health care services participating in the study described here included the University of Washington (UW) Center for Pain Relief and the UW TelePain program. The UW Center for Pain Relief is an outpatient multispecialty consultation and treatment clinic that uses the assembled expertise and skills of physicians and other medical team providers to assist in diagnosis and care for chronic pain, for example for people with painful disorders that have persisted beyond expected duration, or for people who have persistent uncontrolled pain despite appropriate treatment for the underlying medical condition. The clinic also offers pain consultation and treatment for a variety of new-onset or acute problems that may benefit from selective anesthetic procedures, such as nerve blocks or spinal nerve root compression.

The UW TelePain program serves tribal providers in the Washington, Wyoming, Alaska, Montana, and Idaho (WWAMI) region. These tribal providers include primary care physicians, physician assistants, and nurse practitioners. The tribal providers have access to weekly videoconferences both with other community providers and with university-based pain and symptom management experts. During videoconferences, providers manage cases, engage in evidence-based practice activities, and receive peer support. Throughout the process, these community providers are responsible for direct patient care, and they act on recommendations of the consulting pain specialists.

The two care delivery models discussed above — traditional in-clinic consultation at the Center for Pain Relief and telehealth case consultation through TelePain — provided this mixed methods study using triangulation design and a data transformation model with two comparative arrangements for delivering the same transaction: delivery of pain care to patients (see Figure 2 ).

Qualitative and Quantitative Data Collection Procedures

Participant observation and structured interviews were used to identify and describe two comparable completed transactions for patients with chronic pain. Members of the clinical care teams selected one transaction from each service for which the care could be said to represent the routines and norms of their health care organization. The chosen transactions were carried out with patients of the same gender, similar age, and similar health characteristics. For the study, clinical care teams from each service provided two qualitative on-site interviews documenting clinical work flow and processes (i.e., the steps in the transaction). For the in-clinic transaction, members of the clinical care team interviewed included a nurse care coordinator, pain specialist, medical assistant, patient outcomes assessment coordinator, nurse triage manager, patient support services supervisor, and financial authorization specialist. For the Tele-Pain transaction, team members interviewed included the TelePain nurse care coordinator, two pain specialists, an information technology specialist, and the clinic provider.

The following details the process of the mixed methods analysis. First, individual steps, or discrete tasks, within each transaction (in-clinic versus TelePain) were identified using qualitative interviews and itemized in detail. Details from the qualitative data included a description of each task, the person (s) engaged, the duration of engagement of each person in minutes, the information accrued to the patient's medical record, the technologies employed, and the locations where tasks were conducted and information was transmitted or stored.

The quantitative data collected included date and time, and therefore duration in business days, that accumulated with each step in the transaction. Finally, the costs of each step collected from the qualitative data were identified and transformed into quantitatively estimated data for each transaction. Analysis focused on the primary costs in health care: the value of people's time. These values were limited to labor costs for the in-clinic and telehealth personnel; proxies for the value of time were used with estimates of time for the patient. Costs were estimated as a function of time spent per task and per patient, and the actual wage, including benefits, of personnel engaged in the transaction.

Qualitative and Quantitative Data Analysis

Personal identifiable information was redacted from each patient's medical record, and the records were reviewed for comparability as well as for norms and routines of care for the in-clinic and telehealth organizations. The characteristics of the two patients were similar. Both were first-time patients to their respective organizations, and were referred by their primary care providers for specialized care. The reasons for seeking care and report of conditions potentially related to chronic pain were similar. Both transactions resulted in a consultation recommending referral for additional specialized care or treatment.

Two work flows, one in-clinic and one telehealth, were developed by documenting actual tasks undertaken during the transactions. In follow-up interviews, these work flows were presented to participants for review and comment. These interviews resulted in a complete itemized list of dates, personnel, and time spent per person on discrete steps or tasks. Tables and graphs expressing the steps, with cost accrual over time and in sum, were developed and compared for each transaction, to each other, and with respect to participants' rationales for the tasks in each transaction.

The equation expressing the cost per transaction is as follows, where the total cost of the transaction ( C T ) is the sum of the costs of each discrete task ( k i ) in the transaction, measured per participant ( x, y, z …) on the task, as the product of time ( t ) and wage rate ( w ), or in the case of the patient ( x, y, z …), a proxy for the value of time ( w ) and estimated time ( t ).

In total, 46 discrete steps were taken for the typical in-clinic transaction at the UW Center for Pain Relief (one patient case, reviewed by two pain specialists) versus 27 steps for the typical TelePain transaction (three patient cases, reviewed by six pain specialists). The greater number and types of administrative steps taken to schedule, execute, and follow up the in-clinic consultation resulted in greater duration of time between receipt of initial referral request and completion of the initial consultation with the pain specialists. A total of 153 business days (213 calendar days) elapsed between referral and the completion of the entire in-clinic transaction, versus 4 business days (4 calendar, days) for the TelePain transaction. Importantly, for the transaction at the UW Center for Pain Relief, 72 business days transpired before consultation concluded with a referral for the patient's record; the same conclusion was reached in 4 days in the TelePain transaction. These methods used to determine transaction costs provide an excellent example of mixed methods research, where both qualitative and quantitative data and analysis are needed to provide the transaction cost results.

Mixed methods are increasingly being used in nursing research. We have detailed two studies in which mixed methods research with triangulation design brought a richness to the examination of the phenomenon that a single methodology would not In the two examples described, a major advantage of the triangulation design is its efficiency, because both types of data are collected simultaneously. Each type of data can be collected and analyzed separately and independently, using the techniques traditionally associated with each data type. Both simultaneous and sequential data collection lend themselves to team research, in which the team includes researchers with both quantitative and qualitative expertise.

Challenges include the effort and expertise required due to the simultaneous data collection, and the fact that equal weight is usually given to each data type. Thus this research requires a team, or extensive training in both quantitative and qualitative methodologies, and careful adherence to the methodological rigor required for both methodologies. Nursing researchers may face the possibility of inconsistency in research findings arising from the objectivity of quantitative methods and the subjectivity of qualitative methods. In these cases, additional data collection may be required.

The first example, regarding the pain management experience among American Indians, used triangulation design in a multilevel model format. The multilevel model was useful in designing this study as different methods were needed at different levels to fully understand the complex health care system. In this example, quantitative data is being collected and analyzed at the national and state levels, and qualitative data is being collected at the patient level. Both qualitative and quantitative data are being collected simultaneously. The findings from each level will then be blended into one overall interpretation.

The second example, a transaction cost analysis, also used triangulation design, but the model used was that of data transformation. As in the multilevel model used in the first example, the data transformation model involved the separate but concurrent collection of qualitative and quantitative data. A novel step in this model involves transforming the qualitative data into quantitative data, and then comparing and interrelating the data sets. This required the development of procedures for transforming the qualitative data, related to, time spent on a step and salary of the provider, into quantitative cost data.

The two studies presented as examples demonstrate mixed methods research resulting in the creation of (a) a rich description of the American Indian chronic pain experience, and (b) a way to assess cost for providing chronic pain care via tribal clinics. In both examples, the quantitative data and their subsequent analysis provide a general understanding of the research problem. The qualitative data and their analysis refine and explain the results by exploring participants' views in more depth. Research using a single methodology would not have been able to achieve the same results.

Acknowledgments

Research reported in this paper was supported by the National Institute of Nursing Research of the National Institutes of Health under award number #R01NR012450 and the National Cancer Institute of the National Institutes of Health under award number #R42 CA141875. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

• Coase R. The problem of social cost. Journal of Law and Economics. 1960; 3 :1–44. [ Google Scholar ]
• Creswell JW, Plano Clark VL. Designing and conducting mixed methods research. Thousand Oaks, CA: Sage; 2007. [ Google Scholar ]
• Cueva M, Lanier A, Dignan M, Kuhnley R, Jenkins C. Cancer education for community health aides/practitioners (CHA/Ps) in Alaska assessing comfort with cancer. Journal of Cancer Education. 2005; 20 :85–88. [ PubMed ] [ Google Scholar ]
• Deyo RA, Mirza SK, Martin BI. Back pain prevalence and visit rates : Estimates from U.S. national surveys. Spine. 2002; 31 :2724–2727. [ PubMed ] [ Google Scholar ]
• Doorenbos AZ, Demiris G, Towle C, Kundu A, Revels L, Colven R, Norris TE, Buchwald D. Developing the Native People for Cancer Control Telehealth Network. Telemedicine and E-Health. 2011; 17 :30–34. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Doorenbos AZ, Eaton LH, Haozous E, Towle C, Revels L, Buchwald D. Satisfaction with telehealth for cancer support groups in rural American Indian/Alaska Native communities. Clinical Journal of Oncology Nursing. 2010; 14 :765–770. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Doorenbos AZ, Kundu A, Eaton LH, Demiris G, Haozous EA, Towle C, Buchwald D. Enhancing access to cancer education for rural health care providers via Telehealth. Journal of Cancer Education. 2011; 26 :682–686. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Evans M, Hole R, Berg L, Hutchinson P, Sookraj D. Common insights, differing methodologies : Toward a fusion of indigenous methodologies, participatory action research, and White studies in an urban Aboriginal research agenda. Qualitative Inquiry. 2009; 15 (5):893–910. [ Google Scholar ]
• Guadagnolo BA, Cina K, Helbig P. Medical mistrust and less satisfaction with health care among Native Americans presenting for cancer treatment. Journal of Health Care for the Poor and Underserved. 2009; 20 (1):210–226. doi: 10.1353/hpu.0.0108. [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Haozous E, Doorenbos AZ, Demiris G, Eaton LH, Towle C, Kundu A, Buchwald D. Role of Telehealth/videoconferencing in managing cancer pain in rural American Indian communities. Psycho-Oncology. 2012; 21 :219–223. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Haozous EA, Knobf MT. ‘All My Tears Were Gone’: Suffering and cancer pain in Southwest American Indians. Journal of Pain and Symptom Management. 2013; 45 :1050–1060. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Haozous EA, Knobf MT, Brant J. Understanding the cancer pain experience in American Indians of the Northern Plains. Psycho Oncology. 2010; 20 (4):404–410. doi: 10.1002/pon.l741. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Harries D, Yellowlees PM. Cyberterrorism: Is the U.S. healthcare system safe? Telemedicine Journal and e-Health. 2013; 19 (1):61–66. [ PubMed ] [ Google Scholar ]
• Hing E, Cherry DK, Woodwell DA. National Ambulatory Medical Care Survey : 2004 Summary. Hyattsville, MD: National Center of Health Statistics; 2006. [ PubMed ] [ Google Scholar ]
• Institute of Medicine, Committee on Advancing Pain Research Care, and Education. Relieving pain in America : A blueprint for transforming prevention, care, education, and research. Washington, DC: Institute of Medicine; 2011. [ PubMed ] [ Google Scholar ]
• Jimenez N, Garroutte E, Kundu A, Morales L, Buchwald D. A review of the experience, epidemiology, and management of pain among American Indian, Alaska Native, and Aboriginal Canadian peoples. Journal of Pain. 2011; 12 :511–522. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Louis R. Can you hear us now? Voices from the margin: Using indigenous methodologies in geographic research. Geographic Research. 2007; 45 (2):130–139. [ Google Scholar ]
• Momper SL, Delva J, Tauiliili D, Mueller-Williams AC, Goral P. OxyContin use on a rural Midwest American Indian reservation : Demographic correlates and reasons for using. American Journal of Public Health. 2013; 103 :1997–1999. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Morse JM. Approaches to qualitative-quantitative methodological triangulation. Nursing Research. 1991; 40 :120–123. [ PubMed ] [ Google Scholar ]
• O'Cathain A. Mixed methods research in the health sciences : A quiet revolution. Journal of Mixed Methods Research. 2009; 3 :3–6. [ Google Scholar ]
• Smith L. Decolonizing methodologies: Research and indigenous peoples. London: Zed Books; 2004. [ Google Scholar ]
• Tashakkori A, Creswell J. The new era of mixed methods. Journal of Mixed Methods Research. 2007; 1 :3–7. [ Google Scholar ]
• Tauben D, Towle C, Gordon DB, Theodore BR, Doorenbos AZ. TelePain : A platform for concurrent education, clinical care, and research. Pain Medicine. 2013; 14 (4):560. [ Google Scholar ]
• U.S. Census Bureau. Statistical Abstract of the United States. Washington, DC, U.S: Bureau of the Census; 2010. [ Google Scholar ]
• Warner M, Chen LH, Makuc DM, Anderson RN, Minino AM. Drug poisoning deaths in the United States, 1980-2008. NCHS Data Brief. 2011; 81 :1–8. [ PubMed ] [ Google Scholar ]
• Williamson OE. The Economic Institutions of Capitalism. New York: The Free Press; 1985. [ Google Scholar ]
• Williamson OE. Comparative economic organization : The analysis of discrete structural alternatives. Administrative Science Quarterly. 1991; 36 (2):269–296. [ Google Scholar ]
• Williamson OE. The new institutional economics : Taking stock, looking ahead. Journal of Economic Literature. 2000; 38 (3):595–613. [ Google Scholar ]
• Williamson OE. The theory of the firm as governance structure : From choice to contract. Journal of Economic Perspectives. 2002; 16 (3):171–195. [ Google Scholar ]

• Open access
• Published: 03 April 2024

The environmental awareness of nurses as environmentally sustainable health care leaders: a mixed method analysis

• Olga María Luque-Alcaraz   ORCID: orcid.org/0000-0003-1598-1422 1 , 2 , 3 , 5 ,
• Pilar Aparicio-Martínez   ORCID: orcid.org/0000-0002-2940-8697 3 , 4 ,
• Antonio Gomera   ORCID: orcid.org/0000-0003-0603-3017 2 &
• Manuel Vaquero-Abellán   ORCID: orcid.org/0000-0002-0602-317X 2 , 3 , 4  

BMC Nursing volume  23 , Article number:  229 ( 2024 ) Cite this article

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People worldwide are concerned with the possibility of climate change, microplastics, air pollution, and extreme weather affecting human health. Countries are implementing measures to reduce environmental impacts. Nurses play a vital role, primarily through Green Teams, in the process of promoting sustainable practices and minimizing the environmental footprint of health care facilities. Despite existing knowledge on this topic, assessing nurses’ environmental awareness and behavior, including the barriers they face, is crucial with regard to improving sustainable health care practices.

To analyze the environmental awareness and behavior of nurses, especially nurse leaders, as members of the Green Team and to identify areas for improvement with regard to the creation of a sustainable environment.

A sequential mixed-method study was conducted to investigate Spanish nurses. The study utilized an online survey and interviews, including participant observation. An online survey was administered to collect quantitative data regarding environmental awareness and behavior. Qualitative interviews were conducted with environmental nurses in specific regions, with a focus on Andalusia, Spain.

Most of the surveyed nurses ( N  = 314) exhibited moderate environmental awareness (70.4%), but their environmental behavior and activities in the workplace were limited (52.23% of participants rarely performed relevant actions, and 35.03% indicated that doing so was difficult). Nurses who exhibited higher levels of environmental awareness were more likely to engage in sustainable behaviors such as waste reduction, energy conservation, and environmentally conscious purchasing decisions ( p  < 0.05). Additionally, the adjusted model indicated that nurses’ environmental behavior and activities in the workplace depend on the frequency of their environmental behaviors outside work as well as their sustainable knowledge ( p  < 0.01). The results of the qualitative study ( N  = 10) highlighted certain limitations in their daily practices related to environmental sustainability, including a lack of time, a lack of bins and the pandemic. Additionally, sustainable environmental behavior on the part of nursing leadership and the Green Team must be improved.

Conclusions

This study revealed that most nurses have adequate knowledge, attitudes, and behaviors related to environmental sustainability both inside and outside the workplace. Limitations were associated with their knowledge and behaviors outside of work. This study also highlighted the barriers and difficulties that nurses face in their attempts to engage in adequate environmental behaviors in the workplace. Based on these findings, interventions led by nurses and the Green Team should be developed to promote sustainable behaviors among nurses and address the barriers and limitations identified in this research.

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Introduction

The impact of climate change on human society is a global concern, especially with regard to microplastics, resource shortages, air pollution, droughts, and extreme weather. Such consequences affect human health both directly and indirectly, resulting in an increase in pathologies and a deterioration in medical attention [ 1 , 2 ]. In this context, diverse measures aimed at reducing the environmental impact of daily activities and minimizing the ecological footprint thereof [ 3 ] have been implemented by multiple countries [ 4 , 5 , 6 , 7 ]; these activities have been framed as environmental regulations in line with the Sustainable Development Goals (SDGs) [ 8 ].

The SDGs are being integrated into governments and a variety of other contexts, including the health care system. Spain is dedicated to such a goal, i.e., that of promoting a greener and more democratic health care transition. To achieve this goal, strategic plans have been developed to mitigate the effects of climate change [ 9 , 10 ]. One specific such program is the Strategic Health and Environment Plan (PESMA) [ 11 ], whose aim is to enhance the synergy between health and the environment innovatively by assessing the impact of the population in terms of 14 environmental indicators [ 12 ].

One such indicator focuses on the resources and support needed for sustainable practices, especially for nurses, due to the impact of the environment on their work [ 13 , 14 ]. The PESMA highlights the fact that health care providers should be included in strategies to reduce carbon footprints, build resilience to address the challenges associated with climate change and embrace a leadership role in the task of promoting sustainable health care practices [ 13 , 14 , 15 , 16 ]. Another critical aspect of PESMA focuses on education, training, and incentives that can promote sustainable behavior among health care workers, especially nurses [ 17 , 18 ]. As frontline health care workers, nurses have a unique opportunity to advocate for sustainable practices and reduce the environmental impact of the health care system. Nurses’ knowledge and behavior are limited despite the fact that nurses have positive attitudes toward environmental sustainability [ 19 ].

This situation stands in contrast to the role of nurses in the creation of more sustainable hospitals via the “Green Team” [ 20 ]. The Green Team, which originated in the United States of America a decade ago, is a committee that is responsible for finding and implementing sustainability projects to decrease the environmental impacts of daily operations. Members of various departments collaborate with sustainability staff to detect opportunities, spread awareness, and promote staff involvement in line with the Committee’s mission [ 21 ]. The team, which typically consists of and is led by nurses, aims to increase awareness of the health care industry’s effect on the environment and to develop tactics to mitigate the adverse environmental effects of hospitals.

In Spain, Green Teams, which span multiple disciplines and usually led by nursing professionals, are committed to sustainable change in health care [ 22 ]. Environmental nursing leaders on Green Teams control environmental sustainability in health care settings and provide education, resources, and support to other professionals with regard to the implementation of sustainable practices [ 23 ]. Accordingly, all nurses can contribute to the tasks of mitigating the impact of climate change on public health outcomes and promoting sustainable health for all [ 24 ]. These actions improve nurses’ knowledge, attitudes, and behavior in terms of sustainability and promote sustainable practices in health care settings, thus leading to a better understanding of the barriers faced by nurses in this context [ 24 , 25 , 26 ].

However, measuring and identifying nurses’ environmental awareness is essential for the promotion of sustainable hospitals [ 27 , 28 ]. Multidimensional indicators have been proposed for this purpose [ 16 ], the responsibility for which lies with nurse leaders on Green Teams. Nurses are responsible for promoting sustainability in health care organizations, as discussed by Kallio et al. (2018) [ 29 ], as well as for promoting nursing competencies related to environmental sustainability [ 30 ]. Several studies, including Harris et al. (2009) and Phiri et al. (2022), have examined nurses’ roles in environmental health and the effects of their leadership on the promotion of sustainability, especially during the COVID-19 pandemic, thereby emphasizing the importance of leadership [ 31 , 32 ].

As Ojemeni et al. (2019) discussed, leadership effectiveness in Green Teams, nursing teams and health care organizations must prioritize quality control and health care improvement to ensure sustainable development [ 33 ].

The topic of environmental management in health care organizations has been studied extensively, and an environmental or ecological model of care for promoting sustainability has been proposed [ 34 ]. As environmental creators and leaders on Green Teams, nurses are vital for minimizing hazardous waste in health care settings and improving awareness [ 35 ].

Although nurses have some degree of existing knowledge and awareness of sustainability, it is crucial to assess their proficiency in environmental matters and to gauge their environmental awareness. Such an evaluation can help identify areas for improvement within clinical management units [ 20 , 33 , 36 ]. Education and training programs can effectively promote sustainable behavior among nurses, but interventions should also address the barriers they face in their attempts to implement sustainable practices [ 37 ]. Therefore, it is imperative to examine the factors that foster sustainable behavior among nurses and to identify effective interventions that can promote sustainable health care practices and minimize the environmental footprint of health care facilities. Accordingly, this study aimed to analyze the environmental awareness and behavior of nurses, especially nurse leaders, as members of the Green Team and to identify areas for improvement with regard to creating a sustainable environment.

Study design

A sequential mixed-method study was conducted based on an online survey and interviews with a representative sample of Spanish nurses, including participant observation.

The study was divided into two phases. In the first phase, a cross-sectional, descriptive exploratory analysis was performed; this analysis relied on the results revealed using the Nurse’s Environmental Awareness Tool in Spanish (NEAT-es) [ 38 ], which was divided into three subscales: nursing awareness scale (NAS), environmental behaviors outside the workplace (PEB) and sustainable behaviors in the workplace (NPEB). In the second phase, qualitative interviews with environmental nurses (see Supplementary file 1 ) were conducted in regions featuring specific environmental units that were available in person (Andalusia).

Participants

The participants were recruited from public and private institutions associated with the National Health System, particularly from the nursing staff. The scope of the study focused on Spain, and the sample included all the nursing staff who completed the questionnaire and met the inclusion criteria.

The sampling process focused on the population of nurses in Spain in 2020, which was estimated to consist of 388,153 nurses. Therefore, a random sample of 314 participating individuals was sufficient to estimate the population with 95% confidence and an accuracy of +/- 2% units, which was expected to account for approximately 90% of the overall population. The inclusion and exclusion criteria used for the sample focused on nursing staff, nursing care auxiliary technicians, and students with relevant degrees, as this members of this group have the most significant presence in the health system and engage in direct and daily contact with environmental management in health centers (hospitals, primary care centers, sociosanitary centers and others). The remaining health and nonhealth personnel were excluded.

Additionally, the person from each unit who served as the environmental coordinator and other nurses from the ward who were members of the Green Team were asked to participate in the interviews and observations. The environmental coordinators, most of who were nursing supervisors, were determined based on the number of members of the Green Team and the sampling calculation used for the observational study. The interviews took place after various sessions, talks, or courses pertaining to environmental sustainability at the clinical management units.

Data collection

An intentional sampling process was implemented, and the data collection period spanned from November 2019 to March 2021. The observational data were collected in Spain via messages and posts on social media with the goal of quantifying nurses’ environmental awareness.

The initial sample of qualitative study included five environmental nursing leaders (NLs), 14 registered nurses (RNs), and ten nursing undergraduates. The final sample was reduced when the interviews reached data saturation ( N  = 10, five NLs, and five RNs). Before the interviews, a focal group composed of one nurse, one physician, two engineers and a psychologist was tested using the questions included in this research as part of a pilot study ( Supplementary file 1 ). These interviews were conducted at the beginning of the participant’s shift, usually in the morning, and they featured a median time of 30 min, a minimum of 20 min and a maximum of one hour per participant.

One researcher (O.A.L.) also observed nurses during their daily work after the interview from a position within the ward as an added team member or staff member. Nevertheless, the observer did not highlight mistakes or sustainability issues during the observation process. No other researcher was involved in this step of the ethnographic analysis to avoid bias with regard to observing a variety of tasks ranging from preparing medication to implementing treatments.

The data collected through the interviews were recorded on a Samsung Galaxy 31 A, and observations were collected in a field notebook based on the Google Keep and Evernote mobile applications from November 2019 to mid-March 2021. This study was conducted at a regional level 1 hospital in southern Spain, particularly in various clinical management units (neurosurgery, internal medicine, cardiology, traumatology, and COVID-19 units, among others), and it focused on nursing supervisors, who are the leaders who bear responsibility for environmental awareness (NLs), and registered nurses (RNs) who were members of the Green Team.

Data analysis

The quantitative data were analyzed by reference to descriptive statistics, including the mean, standard deviation (SD), and 95% confidence interval (CI); the relative frequencies of the variables were also analyzed. Normalization tests, Kolmogorov‒Smirnov tests with Lilliefors correction, and Q‒Q tests were used to compare the goodness-of-fit to an average data distribution with regard to continuous or discrete quantitative variables. The comparison of two or three independent means was performed using Student’s t test and analyses of variance for each variable. The Χ 2 test with Yates’ correction was used to compare percentages and Pearson’s correlation (r) coefficients across the quantitative variables. Finally, associations among the NPEB and the other variables were studied through multiple linear regression. Participant observation was used to support the qualitative study of the reflective ethnographic type [ 39 , 40 ], and this process ended when the data reached saturation. Two researchers developed transcripts for the interviews based on the recorded interviews and added descriptions based on the notes from the field notebook. The identification of themes and patrons was based on a process of triangulation among the researchers and by cross-checking the results. The interviews with nurses were analyzed to summarize the content analysis and identify keywords and concurrency among the terms. The themes thus identified included Green Teams, sustainable environmental behaviors, environment awareness, leadership barriers and limitations and areas for improvement.

EPIDAT (version 4.2) and SPSS (version 25) software were used to support the quantitative analysis. The computer program ATLAS.ti (version 22) and the Office Package with Microsoft Word Excel (version 2019) were used for the interviews and the visualization of the keywords based on the themes identified based on the records, observations and field notebooks.

Nurses’ awareness, knowledge, attitudes and skills.

The ages of the Spanish staff, mainly nurses, included in this study ( N  = 314) ranged from 19 to 68, with a mean age of 37.02 ± 12.7, CI = 95%, 35.6–38.4 years); in addition, 76.4% of these participants were women with more than 20 years of working experience (35.1%), and the majority were registered nurses (70.4%). Moreover, 113 (36%) participants worked at a local or regional hospital (30%) and were employees of a public institution (85.3%). Half of the nurses (157) worked only a morning shift (Table  1 ) in Andalusia, Madrid, or Catalonia (62.4%). The diverse autonomous regions on which this research focused were homogenously distributed and structured in line with the population. The analysis of these areas was also based on the specific inclusion of environmental units led by nurses (Andalusia, Madrid, and Catalonia), in contrast with regions featuring undetermined units or leaders related to this topic (such as Valencia) (37.5%).

Regarding nursing awareness, nurses scored higher on the PEB (31.83 ± 8.02 CI 95% 30.94–32.72 with regard to frequency vs. 32.36 ± 7.15 CI 95% 31.57–33.15 with respect to difficulty) than on the NAS (26.13 ± 9.91 CI 95% 25.03–27.23 with regard to knowledge vs. 47.39 ± 5.97 CI 95% 46.73–48.05 with respect to impact) and the NPEB (23.82 ± 6.45 CI 95% 23.10-24.53 with regard to frequency vs. 25.71 ± 6.31 CI 95% 25.01–26.41 with respect to difficulty). These results indicated that environmental knowledge among the Spanish population was limited (55.7%), although the nurses included in this research were aware of their potential impact on the environment (70.4%). The PEB subscale focused mostly on following environmental guidelines in their homes (57.3%) because these sustainable domestic tasks are easier for them (63.1%) than tasks in the professional field. The second subscale, NPEB, indicated that sustainable activities such as recycling were easy for the participants (57.6%), but sometimes they engaged in such activities less frequently than they would like (52.2%) (Fig.  1 and Fig.  2 ).

Representation of the frequency of nursing environmental behavior

Difficulty of engaging in adequate environmental behaviors

The sociodemographic variables indicated differences among the NEAT subscales (Table  2 ). Gender, working experience (with a median value of 10 years), and the position held in the institution and region were relevant with regard to environmental knowledge ( p  < 0.01), environmental behavior outside the workplace ( p  < 0.01), and environmental behavior in the workplace ( p  < 0.01).

The NPEB was associated with the worst scores, thereby reflecting the nurses’ environmental behavior and activities in the workplace (52.23% rarely performed relevant activities, and 35.03% indicated that doing so was difficult) (Fig.  1 and Fig.  2 ). The NPEB values pertaining to environmental behavior were positively linked to age ( r  = 0.412; p  < 0.001), NAS knowledge ( r  = 0.526; p  < 0.001), PEB frequency ( r  = 0. 57; p  < 0.001), PEB difficulty ( r  = 0.329; p  < 0.001), and finally, difficulty performing adequate environmental behaviors ( r  = 0.499; p  < 0.001). Additionally, the value of the NPEB with regard to the difficulty of performing adequate environmental behaviors was positively associated with age ( r  = 0.149; p  = 0.008), NAS knowledge ( r  = 0.249; p  < 0.001), PEB frequency ( r  = 0. 244; p  < 0.001) and PEB difficulty ( r  = 0.442; p  < 0.001).

Based on the relevance of certain sociodemographic variables, the nurses’ environmental awareness (NAS) and their behavior outside the workplace (PEB), linear multiple regression was performed to investigate nursing behavior in the workplace (NPEB). The initial model (square sum = 488.655; p  < 0.0001) indicated that age, the impact of nursing awareness (NAS), and the frequency of sustainable behaviors outside the workplace (PEB) were not relevant to nursing behavior in the workplace (NPEB) in terms of the frequency of performing adequate behavior or the difficulties experienced ( p  > 0.05). Based on these results, the adjusted model was calculated (Table  3 ), indicating that NPEB depends on PEB frequency and NAS knowledge ( p  < 0.01).

Nursing environmental behavior in the context of Green Teams: Barriers and areas for improvement.

The participants in the qualitative study ( N  = 10) included nine women and one man; their median age was 49 years; they exhibited an interval quartile range of 35–60; they had levels of working experience ranging between 20 and 30 years, and they worked only in the mornings (7/10). Furthermore, the group including nurses and nursing supervisors (5/10) exhibited higher levels of education (see Supplementary file 2 ). The themes identified via repetition and associations during the interviews and observations indicated links among nurses’ responsibilities on the Green Team since they conformed to the nature of such teams (i). This team and nursing leaders identified sustainable environmental behavior (ii) that could improve environmental awareness (iii), knowledge, aptitude, and skills. The nurses who are responsible for sustainable changes should be the leaders (iv), and the relevant barriers and limitations (v) and areas for improvement (vi) in diverse areas should be identified simultaneously.

Green teams were linked to nursing responsibilities in the context of environmental sustainability.

In the interviews, the Green Teams, led by environmental leader nurses and comprising various staff members, were identified as crucial committees dedicated to enhancing environmental awareness and knowledge among hospital staff. Participants indicated that these teams facilitated regular meetings to discuss sustainable practices and played a pivotal role in testing behaviors and knowledge related to environmental sustainability. The Green Teams were highlighted as platforms for fostering collaboration and discussion surrounding sustainable practices. Participants noted that these teams facilitated the main purpose of the team and its members to improve the hospital staff’s knowledge and attitudes via meetings (RN 2,3 and NL 1,3). Subsequently, the NL also indicated a key role of the team in the testing of behaviors and knowledge. The behavior of registered nurses should be tested using questions according to the NLs. Also, the NLs are included in disponibility of of proper disposal methods for medical waste:

“So, where is the rubbish bin for medicines, that white one that you showed in the session that is used for the remains of medicines that we do not give to patients?” [(NL5)]

By such comments, it can be inferred that the Green Team not only disseminates information, manages the training and measures knowledge but also ensures that staff members understand and adhere to best practices in waste management. These tasks of the NLs and other RNs in the Green Team contribute to the overall efficiency and effectiveness of environmental sustainability efforts within the hospital.

Sustainable environmental behaviors were emerged by Green Teams.

The results of the analysis indicated some degree of resistance among the nurses working at the clinical management units with regard to their lack of competencies, especially those pertaining to knowledge, skills and attitudes. The comments from the interviews highlighted potential factors contributing to this resistance, including age-related differences, varying levels of awareness, and challenges in applying the principles of reduce, reuse, and recycle (the three Rs). For instance, one repetitive comment expressed a sentiment of uncertainty, stating “It is what is, but we don’t know it or what to do with it” (RN 3,4,5, and NL 2,3).

“We know what the light packing is, and they (maintenance people) installed it to reduce the lights and reduce the expense and cost, but we don’t know what to do with the rubbish bins” [(NL 4)]

This comment highlights a disconnect between awareness of specific sustainable initiatives and the practical knowledge to implement them effectively. All comments reflect the importance of addressing knowledge gaps and providing practical guidance to support nurses in adopting sustainable environmental behaviours. By acknowledging and addressing these challenges, healthcare facilities can enhance their environmental stewardship efforts and promote a culture of sustainability among staff members.

Environmental awareness were drawn from the nursing responsibilities that led to the creation of the Green Team.

The comments indicated that environmental awareness among nurses was influenced by training sessions and courses on environmental sustainability. After receiving training featuring lectures and courses on environmental sustainability, the leaders also reflected on the ways in which nurses put the recommendations made during the environmental sustainability courses into practice. Moreover, the leaders indicated that education should be beyond formal training sessions. The environmental leaders were interested in supplementing these courses with environmental education practices for the general population, as noted, for example, in reports of discharge from patient care or cycling on the ward. These activities indicated the ideal of including a holistic approach to sustainability within the healthcare setting.

Relevant statements included, “We have to separate residues according to the material… light plastic goes to… it is important for the unit and all of us” (NL 2,5). One key point that the referees and registered nurses highlighted pertained to the climate, particularly the lack of water (NL 1–5 and RN 1,2).

“The drought is getting worse; I don’t know how we are going to keep up… we hope it rains soon” [(RN1)]

Overall, the interviews shed light on the efforts to foster environmental awareness among nurses through formal training and practical integration into everyday practices. These observations emphasize the importance of ongoing education and action in addressing environmental concerns within healthcare settings.

Leadership, which was linked by comments to the Green Teams.

The interviews revealed that leadership, particularly within the context of Green Teams, is crucial in promoting environmental awareness and fostering a culture of sustainability among nursing staff. All the participants ( n  = 10) indicated that the presence of adequate knowledge, meetings and awareness among nursing staff were the most important factors. These factors were identified as key drivers in promoting sustainable practices within the healthcare environment. NLs indicated the importance of creating a supportive working environment where nurses feel comfortable asking questions and seeking clarification without fear of negative feedback. Relevant statements included, “It is key to receive feedback from the nurses and provide a good working environment so that they can ask questions and reflect without negative comments” (NL 1,2,4, and RN 1,2). This working environment allowed the registered nurses to ask for help regarding the three Rs:

“Could you remind me (referring to the environmental coordinator) how the sustainable guidelines were included in the discharge report for the continuity of care; I remember some things from the course you gave us, but I want to convey it completely to my patient” [(RN2)]

Barriers and limitations, were drawn from nurses’ responsibilities.

Several nurses indicated that the difficulties they encountered with regard to performing environmental behaviors pertained to the lack of time, adequate bins, and space as well as the limited number of nurses per patient in the wards. Despite these challenges, participants noted a positive outcome in the form of increased awareness of sustainability issues among nurses, indicating a growing recognition of the importance of environmental stewardship within the healthcare setting. One factor that increased the barriers to environmental adequacy was the pandemic, which increased waste and rubbish. Despite these challenges, participants noted a positive outcome in the form of increased awareness of sustainability issues among nurses, indicating a growing recognition of the importance of environmental stewardship within the healthcare setting. Relevant statements included “There are not enough green rubbish bins for COVID waste” (EL 1,4,5 and RN1,2) and “How are we going to recycle if we don’t even have time to care for patients?” (RN 1,2 and NL 3).

All these comments indicated the barriers the nurses faced, but they also suggested possibilities for improvement. The pandemic, despite overloading nurses, also improved their awareness.

Areas subject to improvement emerged from nursing responsibilities, limitations and leadership.

Nurses indicated that despite their general levels of environmental awareness and the courses they had received, participants performed better regarding their recycling behaviors at home than at the hospital. Participants acknowledged performing better in recycling practices within their personal spaces, suggesting a potential gap in translating theoretical knowledge into practical action within the healthcare environment. Relevant statements included “It’s just that I recycle almost everything in my house, especially glass…, but here, there is no time…” (RN 1,4,5).

Moreover, time constraints emerged as a significant barrier impeding nurses’ ability to engage fully in environmental sustainability efforts. Participants cited the demanding nature of their work, particularly in the context of patient care responsibilities, as limiting their capacity to prioritize sustainability initiatives. This highlights the need for strategies to streamline environmental practices and integrate them seamlessly into nurses’ daily routines without adding undue burden.

Some statements also highlighted nurses’ willingness to improve paperwork and records. Nurses recognized the importance of incorporating environmental considerations into patient discharge reports and other documentation processes but sought further guidance on how to effectively implement these practices. Relevant statements included “Can you tell me how the patient’s continuity care report upon discharge was included in the recommendations for environmental sustainability… I want to do the report well with what you gave us in the clinical session the other day…” [(NL4)]

These comments indicated the opportunities for improvement in fostering a culture of environmental sustainability within the hospital setting. By addressing the identified challenges and providing targeted support and guidance, especially the lack of time, nurses can contribute to environmental stewardship efforts more effectively.

The current research highlights the relevance of nurses as promoters of environmentally sustainable behaviors in their roles as members of Green Teams and important leaders. The findings suggest that nurses exhibit acceptable knowledge, attitudes, and behaviors with regard to environmental sustainability both inside and outside the workplace. These results are complemented by a qualitative analysis indicating that such behaviors originate from nursing responsibility, Green Teams, leadership identification of barriers and areas of improvement. Both analyses highlight the fact that environmental nursing behavior in the workplace depends on sustainable behaviors outside the workplace. The qualitative analysis also identifies diverse barriers to the task of promoting sustainable behavior within the workplace, such as the COVID-19 pandemic and the need for more time to be allocated to this process. One key point identified by both analyses is that nurses have acceptable levels of knowledge; however, their attitudes, although as yet imperfect, are improving.

Several studies of nurses’ awareness of environmental sustainability have revealed that nurses exhibit moderate levels of awareness and a considerable degree of concern regarding the health impacts of climate change [ 37 , 42 , 43 ], as reflected in the NEAT-es results.

Interestingly, the participants exhibited a tendency to perform environmentally sustainable behaviors more consistently in their personal lives than in professional settings. These results are consistent with previous research on registered nurse and nursing students [ 36 , 41 , 42 ]. According to Swedish research, nurses generally recognize environmental issues but may lack awareness of the environmental impact of health care [ 43 ]. Polivka Barbara J. et al. (2012) highlighted the gap between nurses’ knowledge of sustainability and workplace behaviors, thereby emphasizing the need for education and training programs to promote sustainable practices [ 44 ]. These issues were also observed in a study conducted in Taiwan, which revealed that while nursing students exhibit positive attitudes toward sustainability, their knowledge and behaviors are inadequate [ 45 ].

By conducting qualitative analysis, this research also identified multiple barriers to the adoption of sustainable practices among nurses, including time constraints, disruptions caused by the COVID-19 pandemic, a lack of bins, and a lack of health care personnel. These findings are in line with those reported in other research, but certain barriers (in terms of resources, time, and support) to the implementation of sustainable practices in the workplace remain [ 29 ]. This study suggests that interventions should be designed to address these barriers and promote sustainable behavior among nurses, a suggestion which is consistent with the current research. These findings highlight the importance of comprehending nurses’ perspectives on environmental sustainability in health care contexts as well as the necessity for targeted interventions and support mechanisms [ 46 ]. The tasks assigned to nursing leaders and the Green Team involved addressing these barriers and promoting sustainable practices among nurses in the context of their professional roles. Environmental nursing leaders seem to be crucial with regard to establishing a more environmentally conscious health care environment, which is in line with recommendations to create a greener health care system [ 21 , 31 ]. Despite the results of the interviews, some global qualitative studies of nurses’ views on environmental issues have exhibited variations across countries [ 47 , 48 ]. In Sweden, nurses already exhibit pro-sustainability attitudes before the introduction of the 2030 SDGs [ 16 ]. However, the integration of environmental sustainability education into nursing programs can prepare future nurses more effectively to address the challenges associated with climate change and promote sustainable health outcomes [ 49 ].

Limitations

Although this investigation provides valuable insights, it is important to acknowledge its limitations. First, the study was conducted during the COVID-19 pandemic in Spain, which may have influenced the results due to the unique circumstances and stressors faced by health care workers during this period. Additionally, the assessment of nurses’ environmental awareness was performed on a larger scale, i.e., across multiple regions, and therefore may not accurately reflect individual attitudes and behaviors since the qualitative investigations focused on a specific region. However, this approach was adopted to minimize the risk of the ecological fallacy. Future studies could explore individual perspectives and experiences by reference to more diverse and representative samples.

Despite these limitations, this research is highly relevant because it sheds light on the role of nurses in the task of promoting environmental sustainability in health care settings. The research also emphasized the role of nursing leadership in the tasks of promoting environmental sustainability and providing nurses with the necessary resources and support to implement sustainable practices.

In conclusion, while nurses generally exhibit acceptable levels of knowledge, attitudes, and behaviors regarding environmental sustainability, a notable gap persists in terms of the frequency of sustainable actions within the professional settings in which they operate. This finding highlights the importance of closely aligning nurses’ personal and professional sustainability practices.

The qualitative analysis conducted as part of this study identified several barriers to the adoption of sustainable practices among nurses, including time constraints, disruptions resulting from the COVID-19 pandemic, issues with waste disposal, and challenges related to health care personnel. Despite the fact that these findings are in line with those reported in previous research, persistent barriers such as limited resources, time, and support hinder the implementation of sustainable practices in the workplace. Therefore, interventions aimed at addressing these barriers and promoting sustainable behavior among nurses are essential, as highlighted by both current research and the corresponding qualitative insights. Therefore, nursing leaders and Green Teams are pivotal with regard to overcoming these barriers and fostering sustainable practices within health care environments. Environmental nursing leaders in particular are instrumental to the cultivation of a more environmentally conscious health care system, thereby aligning with recommendations for greener health care practices.

Data availability

The datasets used and/or analyzed as part of the current study are available from the corresponding author upon reasonable request.

Romanello M, Di Napoli C, Drummond P, Green C, Kennard H, Lampard P, et al. The 2022 report of the Lancet countdown on health and climate change: health at the mercy of fossil fuels. Lancet. 2022;400(10363):1619–54. https://doi.org/10.1016/S0140-6736(22)01540-9

Article   PubMed   Google Scholar  

Watts N, Amann M, Ayeb-Karlsson S, Belesova K, Bouley T, Boykoff M, et al. The Lancet countdown on health and climate change: from 25 years of inaction to a global transformation for public health. Lancet. 2018;391(10120):581–630. https://doi.org/10.1016/S0140-6736(17)32464-9

Fadhullah W, Imran NIN, Ismail SNS, Jaafar MH, Abdullah H. Household solid waste management practices and perceptions among residents in the East Coast of Malaysia. BMC Public Health. 2022;22(1):1. https://doi.org/10.1186/s12889-021-12274-7

Article   PubMed   PubMed Central   Google Scholar  

Castañeda-Hidalgo H, Visovsky C, Hernández DE, González-Quirarte NH, Compeán-Ortiz L, Campiño SM. Nursing’s contributions to Sustainable Development Goals in Latin America through education, leadership, and partnerships. Int J Nurs Studi. 2021;121:104004. https://doi.org/10.1016/j.ijnurstu.2021.104004

Article   Google Scholar  

Dossey BM, Rosa WE, Beck DM. Nursing and the Sustainable Development Goals: from Nightingale to now. Am J Nurs. 2019;119(5):44–9. https://doi.org/10.1097/01.NAJ.0000557912.35398.8f

Rosa WE, Dossey BM, Koithan M, Kreitzer MJ, Manjrekar P, Meleis AI, et al. Nursing theory in the Quest for the Sustainable Development Goals. Nurs Sci Q. 2020;33(2):178–82. https://doi.org/10.1177/0894318420903495

United Nations Department of Economic and Social Affairs. Sustainable Development Knowledge Platform. In: Open Working Group proposal for Sustainable Development Goals. 2023. https://sustainabledevelopment.un.org/content/documents/1579SDGs Proposal.pdf.Accessed 17 Apr 2023.

Sanahuja JA. El Pacto Verde, NextGenerationEU y la nueva Europa geopolítica. In: Fundación Carolina.2022. https://www.fundacioncarolina.es/dt_fc_63/ . Accessed 17 Apr 2023.

Boto-Álvarez A, García-Fernández R. Implementation of the 2030 Agenda Sustainable Development Goals in Spain. Sustainability. 2020;12(6):2546. https://doi.org/10.3390/su12062546

Gomera Martínez A,Villamandos, de la Torre F, Vaquero Abellán. M,. Measurement and categorization of environmental awareness in university students: the contribution of the University to strengthen it. Ambientalización curricular y sostenibilidad. Nuevos retos de profesionalización docente. 2012;16(2):215– 28.

Ministerio de Sanidad. Plan Estratégico de Salud y Medioambiente 2022–2026. In: Ministerio para la Transición Ecológica y el Reto Demográfico.2021. https://www.sanidad.gob.es/ciudadanos/pesma/docs/241121_PESMA.pdf . Accessed 25 Apr 2023.

Ministerio de Sanidad. Plan Estratégico de Salud y Medioambiente. In: 1 a Programa de Actuación. Ministerio para la Transición Ecológica y el Reto Demográfico;2022. https://www.sanidad.gob.es/ciudadanos/pesma/docs/1er_PA_PESMA.pdf . Accessed 25 Apr 2023.

Hart J. Health Care without Harm: taking Environmental Action to improve lives and the planet. Integr Complement Ther. 2022;28(5):251–4. https://doi.org/10.1089/ict.2022.29036.pro

Health Care Without Harm. Hospitales que curan el planeta. In: Informe sobre el trabajo de los miembros de la Red Global de Hospitales Verdes y Saludables en América Latina. Red Global de Hospitales Verdes y Saludables en America Latina. 2022. https://saludsindanio.org/sites/default/files/documents-files/7287/Hospitales que curan el planeta 2022-FINAL_web_0 %281%29_0.pdf . Accessed 25 Apr 2023.

McDermott-Levy R. The nurse’s role on green teams: an environmental health opportunity. Pa Nurse. 2011;66(1):17–21.

PubMed   Google Scholar  

Schenk E, Johnson S. Nurse-sensitive environmental indicators: a qualitative study. J Nurs Manag. 2022;30(8):4378–86. https://doi.org/10.1111/jonm.13861 . Epub 2022 Oct 20.

Eckelman MJ, Sherman JD, MacNeill AJ. Life cycle environmental emissions and health damages from the Canadian healthcare system: an economic-environmental-epidemiological analysis. PLoS Med. 2018;15(7):e1002623. https://doi.org/10.1371/journal.pmed.1002623

Article   CAS   PubMed   PubMed Central   Google Scholar  

Mateen A, Nisar QA, Nasir N. Fostering pro-environmental behaviors in the healthcare organizations: an empirical analysis of psychological and strategic factors. Asia Pac Manage Rev. 2023;28(1):13–23. https://doi.org/10.1016/j.apmrv.2022.01.004

Michie S, West R. Sustained behavior change is key to preventing and tackling future pandemics. Nat Med. 2021;27(5):749–52. https://doi.org/10.1038/s41591-021-01345-2

Article   CAS   PubMed   Google Scholar  

Mejia EA, Sattler B. Starting a Health Care System Green Team. AORN J. 2009;90(1):33–40. https://doi.org/10.1016/j.aorn.2009.03.001

Practice Green Health. Comparison chart of hospital green teams and their structure. 2019. https://practicegreenhealth.org/sites/default/files/2019-02/Comparison chart of hospitals green team structure_2017.pdf . Accessed 1st Frebuary 2024.

Dickman E, Backler C, Berg CD, Komandt M, Schiller J. Climate change and oncology nursing: a call to action. Clin J Oncol Nurs. 2022;26(1):109–13. https://doi.org/10.1188/22.CJON.109-113

de la Gámez J, Padilla Fortes A. Análisis De La producción científica visible en internet de Los técnicos de salud ambiental del Servicio Andaluz De Salud. Rev GeI Inf Doc. 2010;20:409–25.

Google Scholar  

Filho W. Non-conventional learning on sustainable development: achieving the SDGs. Environ Sci Eur. 2021. https://doi.org/10.1186/s12302-021-00525-8 . 33;97.

Filho W, Tripathi S, Andrade Guerra JB, Gine R, Orlovic Lovren V, Willats J. Using the sustainable development goals towards a better understanding of sustainability challenges. Int J Sustainable Dev World Ecol. 2018;26:1–12. https://doi.org/10.1080/13504509.2018.1505674

Portela Dos Santos O, Melly P, Joost S, Verloo H. Climate Change, Environmental Health, and challenges for nursing Discipline. Int J Environ Res Public Health. 2023;20(9):5682. https://doi.org/10.3390/ijerph20095682

Sattler B, Randall KS, Choiniere D. Reducing Hazardous Chemical exposures in the neonatal intensive care unit: a New Role for nurses. Crit Care Nurs Q. 2012;35(1):102–11. https://doi.org/10.1097/CNQ.0b013e31823b2084

Trent L, Law J, Grimaldi D. Create intensive care green teams, there is no time to waste. Intensive Care Med. 2023;49(4):440–3. https://doi.org/10.1007/s00134-023-07015-w

Kallio H, Pietilä AM, Johnson M, Kangasniemi M. Environmental responsibility in hospital care: findings from a qualitative study. J Hosp Adm. 2018;7(5):56. https://doi.org/10.5430/jha.v7n5p56

Rosa WE, Catton H, Davidson PM, Hannaway CJ, Iro E, Klopper HC, et al. Nurses and midwives as Global Partners to achieve the Sustainable Development Goals in the Anthropocene. J Nurs Scholarsh. 2021;53(5):552–60. https://doi.org/10.1111/jnu.12672

Harris N, Pisa L, Talioaga S, Vezeau T. Hospitals going green: a holistic view of the issue and the critical role of the nurse leader. Holist Nurs Pract. 2009;23(2):101–11. https://doi.org/10.1097/HNP.0b013e3181a110fe

Phiri MM, MacPherson EE, Panulo M, Chidziwisano K, Kalua K, Chawanangwa M, Chirambo, et al. Preparedness for and impact of COVID-19 on primary health care delivery in urban and rural Malawi: a mixed methods study. BMJ Open. 2022;12(6):e051125. https://doi.org/10.1136/bmjopen-2021-051125

Ojemeni MT, Karanja V, Cadet G, Charles A, Dushimimana E, McMahon C, et al. Fostering nursing leadership: an important key to achieving sustainable development goals and universal health care. Int J Nurs Stud. 2019;100:103421. https://doi.org/10.1016/j.ijnurstu.2019.103421

German E. The environmental or ecological model of care. Nriagu JO. Encyclopedia of Environmental Health. Netherlands:Elsevier Science; 2019. pp. 447–50.

Vasset F, Fagerstrøm L, Frilund M. Sustainable Nursing Leadership in Nordic Health Care Organizations. Scand J Caring Sci. 2021;14(2):2–1527.

Kallio H, Pietilä AM, Kangasniemi M. Environmental responsibility in nursing in hospitals: a modified Delphi study of nurses’ views. J Clin Nurs. 2020;29(21–22):4045–56. https://doi.org/10.1111/jocn.15429

Richardson J, Grose J, Bradbury M, Kelsey J. Developing awareness of sustainability in nursing and midwifery using a scenario-based approach: evidence from a pre and post educational intervention study. Nurse Educ Today. 2017;54:51–5. https://doi.org/10.1016/j.nedt.2017.04.022

Luque-Alcaraz OM, Gomera A, Ruíz Á, Aparicio-Martinez P, Vaquero-Abellan M. Validation of the Spanish Version of the questionnaire on environmental awareness in nursing (NEAT). Healthcare. 2022;10(8):1420. https://doi.org/10.3390/healthcare10081420

Amezcua M. El Trabajo De Campo Etnográfico En Salud. Index Enferm (Gran). 2000;30:30–5.

Jamali HR. Does research using qualitative methods (grounded theory, ethnography, and phenomenology) have more impact? Libr Inform Sci Res. 2018;40(3):201–7. https://doi.org/10.1016/j.lisr.2018.09.002

Cowie J, Nicoll A, Dimova ED, Campbell P, Duncan EA. The barriers and facilitators influencing the sustainability of hospital-based interventions: a systematic review. BMC Health Serv Res. 2020;20(1):588. https://doi.org/10.1186/s12913-020-05434-9

Kircher M, Doheny BM, Raab K, Onello E, Gingerich S, Potter T. Understanding the knowledge, attitudes, and practices of Healthcare professionals toward Climate Change and Health in Minnesota. Challenges. 2022;13(2):57. https://doi.org/10.3390/challe13020057

Boström M, Andersson E, Berg M, Gustafsson K, Gustavsson E, Hysing E, et al. Conditions for transformative learning for Sustainable Development: A Theoretical Review and Approach. Sustainability. 2018;10(12):4479. https://doi.org/10.3390/su10124479

Polivka BJ, Chaudry RV, Crawford JM. Public Health nurses’ knowledge and attitudes regarding Climate Change. Environ Health Perspecti. 2012;120(3):321–5. https://doi.org/10.1289/ehp.1104025

Hsieh PL, Chen SH, Chang LC. School nurses’ perceptions, knowledge, and related factors Associated with evidence-based practice in Taiwan. Int J Environ Res Public Health. 2018;15(9):1845. https://doi.org/10.3390/ijerph15091845

Rojas-Perez HL, Díaz-Vásquez MA, Díaz-Manchay RJ, Zeña-Ñañez S, Failoc-Rojas VE, Smith D. Nurses’ environmental practices in Northern Peruvian hospitals. Workplace Health Saf. 2024;72(2):68–74. https://doi.org/10.1177/21650799231163130

Anåker A, Nilsson M, Holmner Å, Elf M. Nurses’ perceptions of climate and environmental issues: a qualitative study. J Adv Nurs. 2015;71(8):1883–91. https://doi.org/10.1111/jan.12655

Kallio H, Pietilä AM, Johnson M, Kangasniemi M. Systematic methodological review: developing a framework for a qualitative semi-structured interview guide. J Adv Nurs. 2016;72(12):2954–65. https://doi.org/10.1111/jan.13031

International Council of Nurses. International Nurses Day 2023 report. Value, protect, respect and invest in our nurses for a sustainable future for nursing and health care.2023. https://www.icn.ch/news/icn-marks-international-nurses-day-launch-its-our-nurses-our-future-campaign . Accessed 25 Apr 2023.

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Acknowledgements

The authors would like to thank the Excellent Official Nursing School and all the professionals who participated in this research for their support.

This research received no external funding; however, the project did receive an award from the Excellent Official Nursing School in Cordoba, Spain, in 2020.

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A.G. and M. V-A. conceived and designed the study, and O.M. L. and P.A-M. acquired the data, analyzed and interpreted the data, and drafted the article. The publication and supervision of the article were the responsibility of A.G. and M. V-A. All authors contributed equally to the writing and preparation of the final manuscript.

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Ethical approval was obtained from the Ethics Committee of Reina Sofia Hospital of Cordoba, which is part of the Andalusian Health Care System in Spain (Act No. 267, ref.3605). This research was in line with the Organic Law 3/2018 of December 5 on the Protection of Personal Data and Guarantee of Digital Rights as well as the Nursing Ethics Code and the 1964 Declaration of Helsinki. The participants were informed of the study’s purpose before participation; their informed consent was obtained, and they were informed that they were able to withdraw from the study at any stage. All the data were obtained after informed consent was collected; in addition, the data were anonymized and saved securely in a database, thereby maintaining all stipulations of the Personal Data Law.

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Luque-Alcaraz, O.M., Aparicio-Martínez, P., Gomera, A. et al. The environmental awareness of nurses as environmentally sustainable health care leaders: a mixed method analysis. BMC Nurs 23 , 229 (2024). https://doi.org/10.1186/s12912-024-01895-z

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• Wendy McInally   ORCID: orcid.org/0000-0002-9900-4612 1 ,
• Vanessa Taylor   ORCID: orcid.org/0000-0003-4117-4675 2 ,
• Celia Diez de los Rios de la Serna   ORCID: orcid.org/0000-0003-2630-2106 3 ,
• Virpi Sulosaari   ORCID: orcid.org/0000-0002-0898-3297 4 ,
• Eugenia Trigoso   ORCID: orcid.org/0000-0003-2743-4522 5 ,
• Sara Margarida Rodrigues Gomes   ORCID: orcid.org/0000-0003-4599-7345 6 ,
• Ana Rita Cesario Dias 7 ,
• Silvija Piskorjanac   ORCID: orcid.org/0009-0002-6133-4285 8 ,
• Mary Anne Tanay   ORCID: orcid.org/0000-0002-3637-6742 9 ,
• Halldóra Hálfdánardóttir   ORCID: orcid.org/0009-0004-2764-9069 10 &
• Maura Dowling   ORCID: orcid.org/0000-0002-7832-6276 11  

The European Oncology Nursing Society (EONS) is a pan-European not for profit society involving approximately 28,000 cancer nurses from 32 countries in the region. The European College of Cancer Nursing (ECCN) exists under the umbrella of EONS and was established in 2020 with a strategic priority to develop, promote and deliver educational opportunities for nurses across Europe. ECCN introduced a pilot on-line education programme for 20 nurses in January 2023. This study evaluated participating nurses’ views and experience of learning on the pilot programme. The study adopted a mixed method approach guided by the four levels of the Kirkpatrick theoretical framework. A dominant focus on qualitative data was used with supplementary quantitative data. The Standards for Reporting Qualitative Research (SRQR) was followed. Eleven nurses completed the pre-pilot online questionnaire (response rate 65%) and seven ( n  = 7) completed the post-pilot questionnaire (41% response rate). Five ( n  = 5) nurses participated in two focus group interviews. Data analysis resulted in the development of four overarching themes: A wider world of cancer nursing; Shapeless mentorship; Impact on Practice; Learning online and what now? On commencement of online education programmes, nurses value a structured timetable and support from nursing management to maximise engagement with the learning materials.

Avoid common mistakes on your manuscript.

Introduction

Cancer is a key priority worldwide for people affected by cancer [ 1 ]. Caring for people affected by cancer requires a range of specific knowledge, skills and experience in the delivery of complex care regimes within hospital and community settings [ 2 ].

Nursing plays a pivotal and often varied role in meeting the needs of people affected by cancer [ 3 ], and there is an expectation that the cancer workforce can meet these needs. As we strive to develop our future nursing workforce, it is imperative that all Higher Education Institutions (HEIs) embed cancer care within their pre-registration nursing programmes, so they have the knowledge and some experience once qualified [ 4 ]. In Europe, while there is standardization of education for entry-level (pre-registration) nursing [ 5 ], cancer content in entry-level curricula varies. Efforts to develop a common European cancer curriculum for pre-registration nurses are underway [ 6 ]. Similarly, following registration as a General Nurse, European nurses’ opportunities for specialist nursing (post-registration) education vary across countries [ 7 ].

It is important to recognise that cancer care is a highly specialised field of nursing practice, which requires a higher level of education, training, and competence, beyond undergraduate nursing education [ 7 , 8 ]. This statement is reinforced by the European Code of Cancer Practice [ 9 ] p.35 in one of its ten key overarching rights, “You have a right to receive care from a specialised multidisciplinary team, ideally as part of a cancer care network”. Thus, it is essential to understand what is necessary within the cancer care pathway to enable Healthcare Professionals (HCPs) to work together holistically and to ensure this level of care is provided for all people affected by cancer [ 10 , 11 ].

To support the cancer burden worldwide education and training of all HCPs including nurses, is crucial, especially in the current and predicted context of shortages in the healthcare workforce [ 12 ]. Embedding cancer care into entry-level (pre-registration) nursing programmes is recommended. Nurses caring for people with cancer consistently express the need for more education and training [ 13 ]. However, the opportunities for cancer nursing education and training vary, with 80% of Western and 27% of Eastern European countries implementing specialized training for oncology nurses [ 14 ]. The recent survey by EONS, including cancer nursing data from 38 of the 53 WHO European countries, found that as many as 17 (45%) countries do not provide university-level, specialist cancer nursing education that is nationally recognised. In addition, only 13 of the 38 countries (34%) offer Master programmes in cancer nursing and only 10 (29%) have professors in cancer nursing. This means that a large proportion of cancer nurses have limited access to specialist education and career opportunities in cancer care. This can have serious consequences for the future of cancer nursing and may impact care quality indicators such as patient safety [ 15 ].

The current shortage of nurses in Europe has various causes, including limited career prospects and education, low salaries, restricted participation in decision-making, migration and lack of professional standards and quality indicators [ 3 ]. WHO Europe state that the first step in tackling these challenges is to improve nursing education, at both pre- and post-registration level. Cancer nurses provide a 24-h care, and it is imperative that nurses provide the highest quality of cancer care. This requires accessible and quality education and training. While the Bologna Declarations (1999) have helped to harmonise undergraduate nursing education in Europe, major differences in specialist nursing education persist between countries [ 16 ]. Moreover, while great progress has been achieved in developing a common European Credit Transfer System to guide educational programs in Europe, it is increasingly challenging for nurses to find the time or funding to engage in continuing education, and there remains a wide variation in availability and access to continuing education for cancer nurses across Europe [ 17 ].

The European Oncology Nursing Society (EONS) is a pan-European not for profit society involving approximately 28,000 cancer nurses from 32 countries in the region. EONS provides leadership in all areas of cancer nursing, research, practice, continued professional development (CPD) through education, communication and advocacy across Europe. The EONS mission is to ensure that all people affected by cancer benefit from the care of highly educated, well-informed and competent cancer nurses, whether as an early career or experienced cancer nurse.

The European College of Cancer Nursing (ECCN) exists under the umbrella of EONS. ECCN was established in 2020 with a strategic priority to develop, promote and deliver educational opportunities for nurses across Europe in line with the EONS Education Framework (2022), which comprises eight modules focused on fundamental knowledge and skills required for post-registration nurses working with people affected by cancer. In particular, ECCN is committed to support nurses from the lower middle income European countries where education and need for learning is sparse [ 14 ].

Regardless of practice setting, all nurses will encounter people living with or beyond cancer within their area of practice, whether in a specialist or non-specialist environment. The ECCN offers a collegiate environment promoting and providing cancer education, professional development and networking opportunities for all nurses supporting people affected by cancer across Europe to enhance care.

Within the vision of EONS, the ECCN has three strategic priorities which underpin the college’s vision of advancing cancer nursing, as follows:

Developing, promoting and delivering educational opportunities guided by the EONS Education Framework which supports nurses at all stages of their career and levels of practice.

Fulfilling nurses’ professional development needs and career aspirations in a manner that is appropriate to their country or region of employment.

Supporting the EONS Working Groups of which there are five (Communication, Advocacy, Research, Education and Early career Nurse) to influence and shape cancer nursing education and continuing professional development policy and practice across Europe, building career and education pathways for the current and future cancer nursing workforce with the aim of improving care of all people affected by cancer.

Arising from ECCN’s vision, a learning pathway with three incremental levels was developed [ 7 ] illustrated in Table  1 . This paper presents the evaluation of the first-level pilot offered to a sample of 20 nurses working in various cancer care settings across Europe. Because the college was a pilot initiative, it was agreed by the EONS board members that 20 nurses was an appropriate sample size.

The ECCN’s pilot first-level pathway commenced in January 2023 and was accessed via an online learning platform. As the participating nurses were geographically dispersed across Europe the option of face-to-face was not feasible. The use of the Virtual Learning Environment (VLE) offers flexibility and is suited to all learners who are required to access the learning environment in ways that suit their work patterns, lifestyles and learning preferences, as well as the needs of future employers [ 18 ]. Positive experiences of the VLE suggest that it prepares nurses to be digitally aware and competent in using digital systems, required for both online learning and within contemporary health care practice where digital technologies like telehealth are being used more extensively [ 19 , 20 ].

The college was supported by a Task group (TG), project administrator and a learning technologist throughout the development and delivery of the on-line materials. The learning materials which consisted of five learning blocks (Risk Reduction, Early Detection and Health, Higher Education England (HEE) modules 1 to 4, Nightingale Challenge and Safety webinars) aimed to enhance nurses’ practice by improving their understanding of cancer, cancer prevention, early diagnosis and treatment. The box illustrates the learning outcomes for each of the five learning blocks for the first level of the pathway. The pilot pathway was nine months in duration with pre-arranged synchronous online support sessions where all participating nurses could meet each other. Meetings were arranged for at least once per month with the timings altered from noon to early evening to accommodate nurses in practice. These sessions were not mandatory and attendance was minimal with two to four attending per session, mostly at noon. In addition, each participating nurse was assigned a mentor. All mentors were experienced cancer nurses and members of EONS. All mentors were orientated to their role on the pilot which was to support participating nurses’ learning on the pathway and in practice during the pathway. While mentorship was not compulsory, participants undertaking the pilot pathway were given the option, and all agreed to be assigned a mentor. Furthermore, online support by the TG was factored in at the beginning, middle and near the end. Participating nurses were encouraged to attend the online support by communicating dates in advance. In addition, within the Moodle environment there was an area for “chat” or any queries which was monitored weekly.

Learning Outcomes

Discuss health promotion, early detection and prevention of cancer.

Demonstrate an understanding of the pathophysiology of cancer as a disease process.

Describe communication challenges in the cancer trajectory and strategies to therapeutic communication.

Outline treatments for cancer.

Describe common adverse events from cancer treatments and principles of management.

Identify common oncological/haematological emergencies and outline their management.

Explain how distress is identified in a person with cancer and appropriate responses.

Describe how to recognize signs of compassion fatigue in oneself and others.

This study aimed to evaluate participating nurses’ views and experience of learning on the ECCN pilot pathway. Specific objectives were as follows:

To describe nurses’ views on and explore their experiences of learning.

To identify enablers and barriers to learning on the pilot pathway.

The study adopted a mixed method approach with a dominant focus on qualitative and supplementary quantitative data [ 21 ] and followed the Standards for Reporting Qualitative Research (SRQR) guideline [ 22 ]. The evaluation was guided by the first three levels of the Kirkpatrick (1967) theoretical framework; (reaction: how well did they like the programme; learning: what principles, facts and techniques were learned; behaviour what changes in behaviour resulted [ 23 ]. This framework is the most widely cited in educational evaluations [ 24 ] and has been used extensively in evaluating cancer education [ 25 , 26 ]. Kirkpatrick proposed the levels as different but complementary. The first two levels of the framework guided the development of the post-pilot questionnaire. The third level was explored in the focus group interviews where nurses were questioned about perceived changes to their practice. Kirkpatrick (1967) frames the fourth level as “tangible results”, which was not possible to ascertain in the pilot. In future developments of the ECCN, the fourth level could be adopted by including line managers of participating nurses in the evaluation and their views on the clinical impact of the pilot ascertained.

Setting and Study Population

Recruitment for the pilot was launched in September 2022 with an open call shared on the EONS website and social media. Using a scoring system, 20 nurses (from England, Ireland Romania, Croatia, Spain, Portugal and Greece) were chosen from a total of 33 applications.

Data Collection

Qualitative data were collected through two virtual focus group on Microsoft Teams and interviews were recorded with nurses upon completion of the five learning blocks within the first level. Each focus group was approximately 60 min in duration. The interviews were facilitated by two authors (WM and MD), both experienced qualitative researchers.

Quantitative data were collected using an online questionnaire on QuestionPro® pre- and post-pilot. The pre-pilot questionnaire requested participants’ demographic, educational and work-related information. Participants’ comfort with their digital literacy skills was also measured pre- and post-pilot using a five-point Likert scale on 13 items related to their attitudes towards technology and technical dimensions of their digital literacy previously adapted by [ 27 ] from the Digital Literacy Scale [ 28 ].

Additional qualitative data were also collected through open questions on QuestionPro® asking participants about their motivation and workplace supports to undertake the pilot. The post-pilot questionnaire also asked participants to rank their experience of learning and satisfaction with the pilot using Likert scales. In addition, both pre- and post-questionnaires asked the nurses to rank how well prepared they thought they were to care for people with cancer, on a Likert scale of 1 (not at all prepared) to 10 (very well prepared) [ 29 ].

Data Analysis

Two authors (WM and MD) undertook qualitative analysis guided by [ 30 ] reflexive approach. Reflective journaling and discussion between both authors were carried out to ensure critical reflection on the process of data collection and analysis. The transcripts were coded inductively, read and re-read to become familiar with the data. Initial codes were generated from the data and subsequently organised and reorganised, searching for themes and sub-themes. Themes were reviewed through a deductive re-analysis process by the wider project team; themes which lacked sufficient data were discarded. This shift from coding should maintain complexity and depth, which was created through exploratory coding while also reducing the amount of data.

Quantitative data were descriptively analysed from data obtained on the pre- and post-pilot online questionnaire. The final stage of analysis included discussion of both qualitative and quantitative findings to reach an agreed interpretation of participants’ experience of learning on the pilot pathway.

Ethical Considerations

Ethical approval to undertake the evaluation was granted by the Research Ethics Committee of the University of Galway, Ireland (Ref: 2022.11.005). All participants received information explaining the purpose of the study, pseudonymization of data, and requested to complete an online consent using QuestionPro® providing their email address if they wished to participate. Following completion of the online consent, participants were emailed the link to the pre- and post-pilot questionnaires and invited to participate in the focus groups.

Seventeen participants consented to take part in the programme evaluation (response rate of 85%). However, following two reminders, 11 completed the pre-pilot online questionnaire (response rate 65%) and seven ( n  = 7) completed the post-pilot questionnaire (41% response rate) (Table  2 and 3 ). There was one male participant, all were aged between 25 and 40 years, and had little or no education and training in cancer care post-registration. Participants’ experience in cancer care ranged from 1 to 15 years with all having some experience of online learning.

Five ( n  = 5) nurses participated in two focus group interviews. All were employed in either adult, or children and young peoples’ cancer services in England, Spain and Croatia.

Data analysis resulted in the development of four overarching themes from twenty two sub-themes.

Theme 1: A Wider World of Cancer Nursing

This theme describes participants’ feelings and views following their exposure on the pilot to cancer care in other practice centres across Europe. The experience provided them with an insight into “a room with a view” to a broader cancer nursing world, with opportunities and possibilities. It also enabled them to recognise that practice challenges and barriers they have experienced in their own countries also exist in other countries; and learned about potential solutions in the process. As one nurse explained: “ I felt a bit stuck about what I could do and this (the pilot programme) gave me different opportunities that I have taken and I’m trying to start a new project at the hospital now after doing this (pilot programme) so this is gratifying and it gave me a bit more of a purpose or took me out of that feeling of being, feeling stuck as a nurse, as an oncology nurse, so it was a good experience, made me take my career to another step. “ Listening to other nurses, things that can be done, that I was unaware off that existed or that these things could be done[…]” [P1:FG1].

This view was supported by another participant: “[…] the thing that I noticed and I may be wrong, I think there were a couple of UK speakers from [names area] and I recognise that although it’s all hospitals from different countries around Europe the problems and the situations everyone faces are very similar, even though the healthcare systems are set up differently” [P3:FG1].

In addition, most expressed that the opportunity to be part of this pilot was welcomed and they “[…] found it very interesting, and very informative” [P45:FG2].

Theme 2: Shapeless Mentorship

Participants were provided with the contact details of their named mentor and mentors were encouraged to contact their mentee. However, little or no mentoring ensued following the initial contact between mentors and mentee. Participants were unclear on what the mentorship process entailed.

Some disappointment in the mentorship experience “For me, I didn’t know what I was expecting. In the beginning, I introduced myself with an email and she told me to ask her whatever I needed but she wasn’t going to be on top of me all the time” [P1:FG1]. “It wasn’t clear what their role should be so I don’t know how much input they needed to our overall learning and I think that I’m sure they’d be there if you needed them, could email if I had any problems. I sent one email towards the end saying I’m not sure whether I have completed it [pilot program] correctly and they posted me in the right direction. So I think, as long as it’s set out what support they need, what to contact them if you needed….I didn’t need that sort of input but I presume they would be there if I did….I didn’t know whether we needed to do anything for the mentorship program” [P3:FG1]. Some disappointment in the mentorship experience was also shared.

“I honestly expected more. As it was introduced as a college as not a course I expected that my mentor would have been involved a lot more. I think I had one meeting with my mentor in the beginning and afterwards when I wanted to discuss about later meetings I didn’t get a last answer to it. I didn’t want to be pushy. So I honestly thought it would be like where somebody would guide me and we potentially would do something together as a team" [P2:FG1]. Nonetheless, the potential of a mentoring relationship beyond its intention was revealed in the experience of one participant who reached out to their mentor for guidance in introducing a service initiative at their hospital. The mentor linked with another colleague in EONS who together, supported the nurse in introducing the initiative. “So, I got introduced this this [the pilot programme] but we haven’t really been doing much for this course, but more from what I want to do from the outside, which is related to this as well. So it worked out for me because I didn’t know what I could use from them [mentor]….she was available to me when I had that doubt, what can I do here in [names country], I want to move on with this idea and she has been very helpful and we keep in touch with updates. For me, it worked out for what I wanted and what I needed” [P1:FG1].

Theme 3: Impact on Practice

This theme reflects participants’ views on the changes perceived in their practice. These varied from a better understanding of safety and cancer treatments to a deeper confidence and appreciation of holistic care. “[…] the thing that I really got was me as an individual, just to know what to look after in my patients, look at the more holistically and to be aware of their psychosocial needs and not just their physical needs and just to take the time for being there with them and to talk with them and to learn about the right tools and how to address their needs [pauses] it’s really nice when you get to know proper tools to use with your patients” (P2:FG1). “I think around the basic stuff of cancer treatments and I explain a lot about this to patients at my hospital” [P3:FG1]. “I took some ideas from the safety information, the idea of the red jacket, or green one or whatever so we don’t get distracted giving medication […] I brought this idea to my superiors which they thought was good and at least to try, especially knowing that it has worked previously in different hospitals and it’s actually useful. And the other one as well related to patient safety” [P1:FG1]. “The course gives you the confidence to speak out about practice” [P4:FG2].

The post-pilot questionnaire responses support this finding. The items “The pilot project was a worthwhile use of my time” and “I would recommend this pilot project to my co-workers” were ranked 4.67 and 4.57 out of a score of 5, respectively. Moreover, participants’ scoring for how well prepared they were to care for people affected by cancer increased from an average of 58.08 pre-pilot to 73.88 post-pilot (Table  4 ).

Theme 4: Learning Online and What Now?

Participants’ responses to the pre- and post-pilot digital literacy indicates their high level of digital literacy (mean scale score of 3.9 pre-pilot and 3.97 post-pilot). This was supported in the qualitative findings with no participant expressing any issues with using online learning resources. However, participants did share views with challenges experienced using the programme’s materials and delivery and shared their views on future directions for the college. “Some of the recorded sessions could be re-recorded […] some of them are very long and you cannot hear what they are saying and they are interrupted by the questions from the people that were there and the people giving them that are not English speakers as well, it’s way more difficult for us to understand. I had to pay more attention to listen. It was very tiring” [P1:FG1]. “The thing that I found was missing, I would appreciate if we had one or two sessions [live] like maybe per module, that would be a good thing for me. If I had some misunderstanding or something wasn’t clear for me because some of the health systems in Europe are completely different, and just for some kind of a clarification, I would appreciate that […] I would prefer if recorded sessions came with a transcript” [P2:FG1].

Issues with the webinar recordings were highlighted and the challenges in understanding speakers whose first language is not English.

Suggestions for the future role of the ECCN included the need for some form of assessment to promote engagement and feedback and synchronous sessions. “It should be a college, it’s not just a course, should be more part of a project, do some kind of assignments, more interactive” [P2:FG1]. “Maybe it would be easier for us, to create a kind of small classroom, just to get to know each other and maybe to exchange our opinions…could be a useful platform in networking” [P2:FG1]. “But I do believe that your focus session should be part of the course that you have to set a time and a date, be it a weekend or an evening or something, where you have to attend to make people become a part of the team of learning” [P4:FG2].

In addition, participants suggested that a structured timetable should be provided at the beginning: “Work is so busy and “there is no time to learn” [P5:FG2]. therefore more structure and timeline at beginning required” [P5:FG2].

The need for mandatory attendance at synchronous sessions was also considered essential to promoting participants’ learning experience. “Have a prerequisite at the beginning of the course that you have to attend at least two or three to pass the course. […] Make some of the sessions mandatory […] a couple of live sessions as well because it’s hard to follow something and if you’ve got a question […] and people could suggest what sessions they would find helpful […] I think assessment, it’s more formal; you’re doing a piece of work as opposed to watching video after video” [P3:FG1]. “Maybe make one or two mandatory sessions [to attend] and even attending one, you might see that it’s actually helpful and you might want to join the rest” [P1:FG1].

These findings are supported by the post-pilot questionnaire responses (Table  4 ). The items with the lowest rating (0–5) included “The learning materials made me feel engaged with the pilot project” (average score 3.57), “The learning materials were clear and organised” (average score 3.43), and “The learning materials made me feel engaged with the pilot project” (average score 3.57).

Online education has the potential to enhance cancer nurses’ access to education that supports professional development but poses challenges, including some learners’ difficulties with webinar speed and length (3). Also, educational opportunities to develop their knowledge about cancer and cancer nursing in countries where limited education exists. This will be addressed with the TG and new materials are being developed taking into consideration the speed, length and language. For example, shortening the hourly e-sessions to a maximum of 20 min and allowing some extra time for reflection and/or questions at the end to solidify the learning. In addition, ensuring that there are support sessions built into the timeline will also open up opportunities to connect with nurses delivering care to people affected by cancer in other countries to compare and contrast the challenges and sharing good practice. Our findings support this, highlighting issues with the quality of webinar recordings and understanding speakers whose first language is not English. For example, the Nightingale Challenges were not all developed and delivered by nurses from the UK where English is the first language. Moreover, our findings highlight the importance of interaction for engagement in online learning with participants suggesting synchronous learning as an approach to improve their online learning experience. This is supported by a qualitative study exploring rural nurses’ experiences of continuing professional development (CPD) in Australia, where key findings included the importance of addressing a range of learning styles, including feedback and opportunities for peer interaction [ 31 ]. In addition, using digital tools that support learner interaction is a key element of well-designed online programmes [ 32 ].

Despite the challenges with on-line learning, a recent systematic review ( n  = 15 studies) reported that irrespective of approach, learning activities and country, e-learning is an effective approach for nurses’ assimilation of theory and practice when compared to traditional learning approaches [ 33 ], and an ideal platform to increase the availability of education for specialist cancer nursing, as outlined in the aims of the RECaN (Recognition of European Cancer Nursing) project [ 15 ] where the overall goal is to increase recognition of the value and contribution of cancer nursing across Europe.

However, our findings have revealed limited representation from across Europe especially from the lower middle income European countries where education and need for learning is sparse which we know from the European Cancer Nursing Index (3). While it is unclear why few nurses from these countries applied for the pilot, a recent integrative review of mobile-social learning for CPD in low- and middle-income countries reports high acceptability for using digital platforms [ 34 ]. Furthermore, the focus group discussions did highlight limited support from line managers and employers. In addition, responses to an open question on the pre-pilot questionnaire revealed that nine participants did not receive support, such as some time off work to engage with the pilot’s learning materials, from their managers. Support should be made available to learners as evidence suggests leadership and support from key stakeholders are essential for HCPs continuing professional development particularly in lower middle-income countries including for services to benefit from the specialist knowledge development of their employees and for the delivery of enhanced patient care [ 35 ].

However, whilst cancer education in nursing programmes both pre- and post-registration level is a priority [ 4 ,  36 ], online learning facilitates flexibility in learning and can be undertaken in any location at any time. Mastering digital learning can also help prepare nurses to become proficient digital users and learners which is a key skill required for modern health care settings and employment in today’s society. Face-to-face learning is often cited as being preferable to online learning and can be less time consuming for instructors [ 37 ]. However, where this is not possible other avenues of the virtual learning environment (VLE) can be utilised. It is the intent of the college moving forward to have the European School of Oncology (ESO) and the EONS Masterclass embedded within the third level of the pathway where nurses spend a week learning face to face with other HCPs as well as nurses within a European country. These Masterclasses are open every year for approximately 30 nurses from across Europe to attend for 1 week’s face-to-face teaching.

Mentorship is also a requirement to support nurses in their professional development and careers and is important to fostering learner connectivity during online education [ 38 ]. The nurses however did not engage fully with the mentorship as it was out with the college and the did not see the connection. The key role for the future of mentorship is to align to the college where there will be support throughout the learning process for both mentors and mentees. The mentorship will be embedded into the VLE and support through workshops for both the mentors and mentees will be provided to enrich the experience for both. This will also support the engagement from both parties and the need for this partnership to work. Mentoring through the college with the support of EONS specialist cancer nurses supports the relationship between early career and more experienced nurses and is important for developing the next generation of cancer nurses [ 39 ].

Nurses in our study suggested that attendance at pre-arranged support sessions should be mandatory. Providing an introductory session where employers/line managers are invited to attend with the learner they are supporting and also a final evaluation meeting to discuss how the learning is informing clinical practice would be beneficial as part of the college. The need for a structure and an agreed timetable on commencement of a learning block is imperative to the overall commitment of the nurses but also with their manager. Setting the commitment at the onset would support the overall engagement. While facilitated peer group sessions were integrated into the pilot, attendance was poor. The nurses who did attend suggested that this was mainly due to work demands and not having the support of their employer. A requirement to attend a minimum number of pre-arranged synchronous sessions would encourage peer support. It is known that peer interaction online promotes learner engagement and a sense of belonging [ 40 ]. Also, having academic or ECCN recognition for their learning instead of a certificate from EONS would benefit them for professional development within their clinical roles.

Strengths and Limitations

This evaluation has highlighted strengths and limitations of a pilot learning program for European oncology nurses. The pilot was evaluated drawing on Kirkpatrick’s framework. Kirkpatrick’s first two levels (reaction and learning) have been revealed in participants’ experiences and views on the programme and what they learned [ 23 ]. In addition, in an attempt to address participants’ learning support needs, queries posted after completion of each learning block were responded to through use of the chat box embedded in the online tools. Kirkpatrick’s third and fourth levels (behaviour and results) are more challenging to establish [ 25 ], especially in the context of different cancer care settings and various levels of cancer experience. However, some comments suggest that participants were attempting to use their learning to introduce changes to their clinical practice. A limitation was the voluntary sample, and small number of nurses who applied from specific European countries where the evidence suggests that education and training is absent. Also, not all participants engaged in the learning blocks to completion. Going forward, proactive regular engagement by the programme team with participants and managers may encourage and support opportunities for learning to be applied in participants practice being explored.

Conclusions

This evaluation, focused on a pilot programme for early career nurses, will inform strategic developments in continuing education for cancer nurses across Europe, supported by EONS.

Cancer nursing across Europe is a unique speciality and one that has seen many changes over the past 40 years [ 41 ]. As was discussed throughout the limited availability of cancer education in some EU countries, this programme illustrates the potential to deliver learning, improving access and enhancing the knowledge and capabilities of nurses providing care to people affected by cancer across Europe, going some way towards meeting the WHO priorities. The education and training of nurses specialising within cancer care has become paramount in these constantly evolving specialities. Working within specialist or non-specialist settings where people with cancer are being cared for, the environments are facing fresh challenges ahead, especially as one in two people will be diagnosed with cancer and the survival rates continue to grow [ 7 ]. As these improvements develop, ongoing education and training is essential and necessary to assist in the effective delivery of prevention, treatment and supportive care regimes. Post-pandemic, although online learning is favoured by many organisations and institutions, a blended learning approach is often preferred by participants. This was expressed by the nurses and they would have appreciated more structured built in time for online support during the first level or face to face had resources allowed. Moving forward, this evaluation will support the development of the college and the needs of nurses from across Europe.

Europe’s Beating Cancer Plan. European Commission 2022 https://ec.europa.eu/health/sites/default/files/non_communicable_diseases/docs/eu_cancer-plan_en.pdf . Accessed 23 Nov 2023

Drury A, Sulosaari V, Sharp L, de Munter J, Oldenmenger W (2023) The future of cancer nursing in Europe: addressing professional issues in education, research, policy, and practice. Eur J Oncol Nurs 63:102271–102271

Article   PubMed   Google Scholar  

Drury A, ST (2023) Preparation and evaluation of a professional development series for early-career oncology nurses in Europe. Clin J Oncol Nurs 27(1):92–97

The Royal College of Nursing (2022) CLINICAL PROFESSIONAL RESOURCE Career Pathway and Education Framework for Cancer Nursing

Directive 77/452/EEC (1977) Council Directive 77/452/EEC concerning the mutual recognition of diplomas, certificates and other evidence of the formal qualifications of nurses responsible for general care, including measures to facilitate the effective exercise of this right of establishment and freedom to provide services.in: Community E.E. 77/452. EEC. European Economic Community, Brussels

Towards Cancer Care Continuum Approach in Undergraduate Nursing Education (2024) Turku AMK. https://www.turkuamk.fi/fi/tutkimus-kehitys-ja-innovaatiot/hae-projekteja/educannurs-towards-cancer-care-continuum-approach/ . Accessed Jan 2024

Challinor JM, Alqudimat MR, Teixeira TOA, Oldenmenger WH (2020) Oncology nursing workforce: challenges, solutions, and future strategies. Lancet Oncol 21(12):e564–e574. https://doi.org/10.1016/S1470-2045(20)30605-7

Article   CAS   PubMed   Google Scholar  

Ross JG, Burrell SA (2018) Standardized patient simulation to facilitate learning in evidence-based oncology symptom management. J Nurs Educ 57(4):250–253. https://doi.org/10.3928/01484834-20180322-12

European Code of Cancer Practice (2022) https://www.europeancancer.org/2-standard/66-european-code-of-cancer-practice . Accessed 23 Nov 2023

EONS (2022) Cancer Nursing Education Framework.  https://cancernurse.eu/education/cancer-nursing-education-framework/ . Accessed Jan 2024

McInally W, Taylor V, Diez de Los Rios C, Sulosaari V, Dowling M, Trigoso E, Rodrigues Gomes SM, Cesario Dias AR, Piskorjanac S, Tanay MA, Hálfdánardóttir H (2023) Innovations in cancer nursing education across Europe. Eur J Oncol Nurs 63: 102305

Benstead K, Brandl A, Brouwers T, Civera J, Collen S, Csaba DL, De Munter J, Dewitte M, Diez de los Rios, C, Dodlek, N, Eriksen, J, G, Forget, P, Gasparatto, C, Geissler, J, Hall, C, Juan, A, Kalz, M, Kelly, R, Klis, G, Kulaksız, T, Lecoq, C, Marangoni, F, McInally, W, Oliver, K, Popovics, M, Poulios, C, Price, R, Rollo, I, Romeo, S, Steinbacher, J, Sulosaari, V, and O'Higgins, N (2023). An inter-specialty cancer training programme curriculum for Europe. Eur J Surg Oncol, 49(9):106989

Diaw M, Sibeoni J, Manolios E, Gouacide JM, Brami C, Verneuil L, Revah-Levy A (2020) The lived experience of work-related issues among oncology nurses: a metasynthesis. Cancer Nurs 43(3):200–221

Galassi A, Anwarali S, Challinor J (2023) Global challenges and initiatives in oncology nursing education. Ann Palliat Med 12(3):633–645

Sharp L, Rannus K, Olofsson A, Kelly D, Oldenmenger W (2019) Patient safety culture among European cancer nurses—an exploratory, cross-sectional survey comparing data from Estonia, Germany, Netherlands, and United Kingdom. J Adv Nurs 75(12):3535–3543

Article   PubMed   PubMed Central   Google Scholar  

de Wit H (2018) The Bologna process and the wider world of higher education: the cooperation competition paradox in a period of increased nationalism. In: Curaj A, Deca L, Pricopie R (eds) European higher education area: the impact of past and future policies. Springer, Cham. https://doi.org/10.1007/978-3-319-77407-7_2

Kelly D, Lankshear A, Wiseman T, Jahn P, Mall-Roosmäe H, Rannus K, Oldenmenger W, Sharp L (2020) The experiences of cancer nurses working in four European countries: a qualitative study. Eur J Oncol Nurs 49:101844

Wilson R, Hungerford C (2015) Mental health education and virtual learning environments (VLEs) in pre-registration nursing degrees: follow the leaders? Issues Mental Health Nurs 36(5):379–387

Article   Google Scholar  

Vicary S, Copperman J, Higgs A (2018) Social work education through distance learning: the challenges and opportunities. Soc Work Educ 37(6):685–690

The NHS Constitution (2019) The topol review: preparing the healthcare workforce to deliver the digital future. an independent report on behalf of the secretary of state for health and social sare. Health Education England

Chiang-Hanisko LD, Newman S, Dyess DP, Liehr P (2016) Guidance for using mixed methods design in nursing practice research. Appl Nurs Res 31:1–5. https://doi.org/10.1016/j.apnr.2015.12.006

O’Brien BC, Harris IB, Beckman TJ, Reed DA, Cook DA (2014) Standards for reporting qualitative research: a synthesis of recommendations. Acad Med 89(9):1245–1251

Praslova L (2010) Adaptation of Kirkpatrick’s four level model of training criteria to assessment of learning outcomes and program evaluation in higher education. Education Assess Eval Account 22(3):215–225

Caley L, Williams SJ, Spernaes I, Thomas D, Behrens D, Willson A (2021) Frameworks for evaluating education programmes and work related learning: a scoping review. J Work Learn 33(6):486–501

Campbell K, Taylor V, Douglas S (2019) Effectiveness of online cancer education for nurses and allied health professionals; a systematic review using Kirkpatrick evaluation framework. J Cancer Educ 34(2):339–356

Fernandes RAML, de Oliveira Lima JT, da Silva BH, Sales MJT, de Orange FA (2020) Development, implementation and evaluation of a management specialization course in oncology using blended learning. BMC Med Educ 6;20(1):37. https://doi.org/10.1186/s12909-020-1957-4 . 

De Brún A, Rogers L, Drury A, Gilmore B (2022) Evaluation of a formative peer assessment in research methods teaching using an online platform: a mixed methods pre-post study. Nurse Educ Today 108:105166

Ng W (2012) Can we teach digital natives digital literacy? Comput Educ 59(3):1065–1078

Stegringa S, Dunn J, Dewar AM, McCarthy A, Yates P, Beadle G (2005) Impact of an intensive nursing education course on nurses’ knowledge, confidence, attitudes, and perceived skills in the care of patients with cancer. Oncol Nurs Forum 32(2):375–381

Braun V, Clarke V (2021) One size fits all? What counts as quality practice in (reflexive) thematic analysis? Qual Res Psychol 18(3):328–352

Riley K, Schmidt D (2016) Does online learning click with rural nurses? A qualitative study. Aust J Rural Health 24(4):265–270

Giltenane M, Dowling M (2023) Student nurses’ experiences of remote learning during Covid-19 pandemic: a qualitative evidence synthesis J Adv Nurs. (in press)

Alfaleh R, East L, Smith Z, Wang SY (2023) Nurses’ perspectives, attitudes and experiences related to e-learning: a systematic review. Nurse Education Today 125:105800

Guillaume D, Troncoso E, Duroseau B, Bluestone J, Fullerton J (2022) Mobile-social learning for continuing professional development in low- and middle-income countries: integrative review. JMIR Med Educ 8(2):e32614

Merry L, Castiglione SA, Rouleau G, Létourneau D, Larue C, Deschênes MF, Gonsalves DM, Ahmed L (2023) Continuing professional development (CPD) system development, implementation, evaluation and sustainability for healthcare professionals in low- and lower-middle-income countries: a rapid scoping review. BMC Med Educ 23(1):498

Nursing Midwifery Council (2023) The code professional standards of practice and behaviour for nurses, midwives and nursing associates. https://www.nmc.org.uk/standards/code/ . Accessed 23 Dec 2023

Navarro P (2000) Economics in the cyberclassroom. J Econ Perspect 14(2):119–132

Schroeder S, Shogren M, Terras K (2021) Student connectivity in online programs: role of the nurse faculty. J Nurse Pract 17(3):329–334

Hale RL, Phillips CA (2019) Mentoring up: a grounded theory of nurse-to-nurse mentoring. J Clin Nurs 28(1–2):159–172

Trimble A, Fan S (2023) Peer student support and the formation of learning communities. Adapting to online and blended learning in higher education: supporting the retention and success of the expanded and diversified intake. Singapore, Springer Nature Singapore, pp 377–398

Chapter   Google Scholar  

European Oncology Nursing Society. EONS occupational safety survey. Available at: https://cancernurse.eu/advocacy/eons-work-on-safety/ . Accessed 25 Oct 2023

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A qualitative study of leaders’ experiences of handling challenges and changes induced by the COVID-19 pandemic in rural nursing homes and homecare services

• Malin Knutsen Glette 1 , 2 ,
• Tone Kringeland 2 ,
• Lipika Samal 3 , 4 ,
• David W. Bates 3 , 4 &
• Siri Wiig 1  

BMC Health Services Research volume  24 , Article number:  442 ( 2024 ) Cite this article

Metrics details

The COVID-19 pandemic had a major impact on healthcare services globally. In care settings such as small rural nursing homes and homes care services leaders were forced to confront, and adapt to, both new and ongoing challenges to protect their employees and patients and maintain their organization's operation. The aim of this study was to assess how healthcare leaders, working in rural primary healthcare services, led nursing homes and homecare services during the COVID-19 pandemic. Moreover, the study sought to explore how adaptations to changes and challenges induced by the pandemic were handled by leaders in rural nursing homes and homecare services.

The study employed a qualitative explorative design with individual interviews. Nine leaders at different levels, working in small, rural nursing homes and homecare services in western Norway were included.

Three main themes emerged from the thematic analysis: “Navigating the role of a leader during the pandemic,” “The aftermath – management of COVID-19 in rural primary healthcare services”, and “The benefits and drawbacks of being small and rural during the pandemic.”

Conclusions

Leaders in rural nursing homes and homecare services handled a multitude of immediate challenges and used a variety of adaptive strategies during the COVID-19 pandemic. While handling their own uncertainty and rapidly changing roles, they also coped with organizational challenges and adopted strategies to maintain good working conditions for their employees, as well as maintain sound healthcare management. The study results establish the intricate nature of resilient leadership, encompassing individual resilience, personality, governance, resource availability, and the capability to adjust to organizational and employee requirements, and how the rural context may affect these aspects.

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In 2021, essential healthcare services in 90% of the world’s countries were disrupted by the COVID-19 pandemic [ 1 ]. Healthcare services were heavily stressed and had to address unexpected issues and sudden changes, whilst still providing high quality care over a prolonged period [ 2 , 3 ]. Despite the intense focus on hospitals during this period, other parts of the healthcare system such as nursing homes and homecare services also faced extreme challenges. These included issues such as having to introduce and constantly adapt new infection control routines, as well as being given increased responsibility in caring for infected and seriously ill patients in facilities that were not built for such circumstances [ 4 , 5 , 6 , 7 ]. Mortality rates in nursing homes were especially high [ 8 ].

Resilience in healthcare is about a system’s ability to adapt to challenges and changes at different levels (e.g., organization, leaders, health personnel) to maintain high quality care [ 9 , 10 ]. During the COVID-19 pandemic, leaders and the front line were forced to rapidly adjust to keep healthcare services afloat. It has been demonstrated in previous research that effective leadership is crucial in navigating crises and building resilience within health systems [ 11 , 12 , 13 ]. Furthermore, leaders play key roles in facilitating health personnel resilience, for example, through promoting a positive outlook on change and by developing health personnels’ competencies and strengths [ 12 , 14 , 15 ]. During the COVID-19 pandemic, this role became intensified [ 16 , 17 , 18 ], and leaders’ roles in promoting resilient healthcare services were central, for example safeguarding resources, providing emotional support and organizing systems to cope with extreme stresses [ 3 , 19 ].

Smaller, rural nursing homes and home care services are geographically dispersed and typically remote from specialized healthcare services or other nursing home and homecare services. They also tend to have reduced access to personnel due to low population density, frequently leading to the need to make independent decisions, often in complex situations [ 20 ]. Overall, rural healthcare services face different challenges than their urban counterparts [ 21 , 22 , 23 ]. The COVID-19 pandemic intensified some of these issues and created new ones which needed to be managed [ 21 , 24 , 25 ].

The research base on COVID-19 has expanded extensively the past years [ 26 ], covering areas such as clinical risks and outcomes for healthcare workers [ 27 ] and patients [ 28 ], hospital admissions [ 29 ] and healthcare utilization during the pandemic [ 30 ]. Moreover, areas like healthcare leaders' [ 16 , 17 , 31 ] and healthcare professionals’ [ 2 , 32 ] strategies to handle the pandemic challenges, and COVID related strategies’ effect on quality of care [ 33 , 34 ]. And lastly, but not exhaustively, the COVID-19 pandemic in different healthcare settings such as hospitals [ 35 ], primary healthcare services and [ 36 ] mental healthcare services [ 37 ]. However, research on rural healthcare settings, particularly leaders in rural nursing homes and homecare services, have received less attention [ 38 , 39 , 40 ]. Despite the anticipated importance of primary healthcare services in future healthcare and the prevalence of rural healthcare options [ 41 , 42 ]. Overall, there are still lessons to be learned from the COVID-19 pandemic, specifically identifying resilience promoting and inhibiting factors in different health care settings during crisis, how leaders deal with crisis management, and furthermore, to understand and draw lessons from challenges that were overcome during the pandemic[ 43 , 44 ].

Aim and research question

The aim of this study was to assess how healthcare leaders in rural primary healthcare services managed nursing homes and homecare services during the COVID-19 pandemic. Moreover, the study aimed to explore how adaptations to changes and challenges induced by the pandemic were handled by these leaders.

The research question guiding the study was: How did primary healthcare leaders in rural areas experience their leadership during the COVID-19 pandemic, and how did they adapt to the rapid onset changes demanded by the COVID-19 outbreak?

The study employed a qualitative explorative design to study in-depth, how nursing home and homecare leaders in Norwegian rural primary healthcare services experienced and addressed the extreme challenges and needs for change induced by the COVID-19 pandemic [ 45 , 46 ]. Four rural municipalities of different sizes were included in the study. Nursing home and homecare leaders at different organizational levels participated in individual interviews (See Table  1 ).

Norway is divided into 356 municipalities. These municipalities have the autonomy to administer and manage their primary healthcare services, subject to certain laws and regulations (e.g., Act on municipal health and care services [ 47 ], Act on patient and user rights [ 48 ] and Regulation on quality in nursing and care services for service provision [ 49 ]). All municipalities are obligated to offer specified healthcare services independent of their size and inhabitant number (Se Fig.  1 for a brief overview of healthcare services provided by the Norwegian municipalities, comprising nursing homes and home care services, and included municipalities).

Brief overview of healthcare services provided by the Norwegian municipalities, comprising nursing homes and home care services, and the included municipalities

Recruitment and participants

Recruitment was anchored in the municipal management. The municipal manager of health and care in 11 municipalities across the Norwegian west coast were first contacted via email, then by telephone (se Fig.  1 ). Most managers who responded to our contact were positive, but many had to decline due to time constraints related to pandemic management. Four managers agreed to data collection in their municipality with the stipulation that the nursing home- and homecare leaders wanted to participate. All levels of leaders were eligible for inclusion due to the small size of the healthcare services. We contacted the leaders of nursing homes and home care services in the four municipalities, first by email, then by telephone. Nine leaders agreed to participate. One leader declined. All included leaders were female, registered nurses (RNs), and had long and broad experiences with working as RNs either in the healthcare service they now were leaders in, or in other healthcare settings. Some leaders stated that they had continued education or Master’s degrees, but more leader specific qualifications such as leader education, training or courses were not disclosed (Table  1 . Overview of participants and setting).

Data collection

Individual interviews were conducted from November 2021 to November 2022 by the first author (MKG). Leaders in one of the municipalities (municipality B) wished to do the interview in a group interview (three leaders), which we arranged. All but one interview was conducted at the leaders’ work premises (in their offices or in meeting rooms). One leader was interviewed via Zoom due to a temporary need for increased infection precautions. All interviews were guided by a predeveloped interview guide which was based on resilience in healthcare theory [ 50 , 51 ] and contained subject such as: Success factors and challenges with handling the COVID-19 pandemic; New solutions and how new knowledge and information was handled; and Lessons learned from the pandemic.

Data analysis

The interviews were audio recorded and transcribed. The analysis followed the steps in Braun and Clarkes thematic approach [ 52 ]. This involved reading through the transcripts multiple times to find meanings related to the overall research question. Text with meaning was inserted into a Word table which provided initial codes. After the coding process, which involved creating and continuously revising codes, there were 47 codes. The codes were then organized into categories and categories were sorted into initial main themes. Themes and categories were assessed to determine whether any of them should be merged, refined, split or eliminated [ 52 ] (see Table  2 for example of the analysis process). The author team reviewed and approved categories and themes to ensure that each theme illuminated its essence [ 52 ].

We analyzed the interviews and identified three main themes and eight categories (Table  3 ). The results are presented according to identified main themes.

Navigating the role of a leader during the pandemic

Overall, the leaders seemed to have two primary focuses when they talked about how they had experienced the COVID-19 pandemic. These were their personal coping, and how they managed the organizational challenges arising throughout the pandemic period. Particularly in the beginning, they reported feelings of fear and insecurity. Leaders dreaded the consequences which could result from mistakes, such as providing wrong, or missing essential information.

“Having such a responsibility is a burden, and even though you’re not alone, you still feel like you’re the one responsible for the safety of the employees and the patients. Ensuring the safety of everyone was the priority, which is why it was critical to make sure that the protocols we were distributing were the correct ones…” (L1 nursing home municipality C)

Additionally, several leaders stated that they were concerned about personnel who had contracted COVID-19 (some of whom had serious symptoms), and even felt responsible for their situation. Leaders of two of the municipalities reported feelings of frustration, and despair, and all leaders reported long working hours. Leaders expressed that they felt that they had been “on call” for the last two years, and described long working days, with limited consideration for evenings, nights, weekends, or vacations.

A range of organizational challenges was described (e.g., dealing with a stressed economy, experiencing task overload, working within an unprepared organization and the struggle to get a hold on enough personal protective equipment. One of the most prominent challenges in the data set, was the acquisition, interpretation, and distribution of information issued by the authorities. The leaders described that new information was issued frequently along with constantly changing routines. New routines where developed, distributed, and discarded nonstop in the attempt to “get the organization in line with the state authorities”.

“There was new information issued [from the Norwegian directorate of health] almost hourly… we had more than enough to, in a way, keep up with all these procedures that came, or all the new messages that came, and these [information and routines] had to be issued out to the employees and to the next of kin…” (L1 nursing home municipality A)

Despite the difficulties related to information flow, or lack thereof, the leaders devised a range of solutions to make information more accessible to their staff (e.g., informational e-mails, developing short information sheets, making information binders, and meeting up physically to go through new routines with their employees). The data indicated that it was hard to gauge how much information to make available to their staff, who were eager for knowledge, yet still found it hard to process everything. On occasion, the leaders desired assistance or someone to assume authority, or as one leader articulated: “someone to push the red button” (L1 homecare municipality C), due to their struggles to keep up with information, regulations, and routines in the face of rapid changes.

Not surprisingly, leaders felt a heightened need to take the lead during the COVID-19 pandemic. This was a long-running crisis, and they had to be present, approachable and a source of support for their staff, while also striving to gain the employees’ understanding. For example, in one healthcare service the employees wanted more strict rules than necessary and had strong opinions on how things should be done in “in their healthcare service”, while the leader was stringent with sticking to national regulations which were less strict. Another aspect was handling disagreement with measures among employees. Often measures were not in line with the employees’ wishes, which created friction.

The pandemic highlighted the importance of leaders taking on the task of creating a secure working environment for their employees. The leaders noted considerable anxiety among the staff, particularly in facilities that had not experienced any COVID-19 cases. Leaders came to understand the importance of tending to all wards, regardless of whether they had been affected by the infection, even though it was perceived as taxing. Overall, the leaders worked actively to make the situation in wards with infection outbreaks as best as possible. A leader from a healthcare service which had a major COVID-19 outbreak stated:

“We constantly tried to create new procedures to make it as easy as possible for them [So] that they didn’t have to think about anything. That they [didn’t have to think about] bringing food to work, that they had to [remember] this or that. That they were provided with everything they needed…” (L2 nursing home municipality C)

Another recurring topic in the dataset, was the constant challenges and changes the leaders had to overcome and adapt to during the COVID-19 pandemic. For example, there was a need to plan for all possible scenarios, particularly if they were to have a major infection outbreak among the staff (e.g., how to limit the infection outbreak, how to deal with staffing, how to arrange the wards in case of an outbreak). One healthcare service experienced such a scenario, which demanded a rapid response, when they had a major COVID-19 outbreak with over twenty infected employees almost overnight. The leaders were left with the impossible task of covering a range of shifts, and they were forced to adopt a strategy of reaching out to other healthcare services within their municipality (other wards, nursing homes, the home care services and psychiatric services) asking if they had any nurses “to spare.” Eventually, they managed to cover their staffing needs without using a temp agency.

The leaders of this nursing home also had to deal with numerous small, but important challenges such as how to deal with dirty laundry, what to do with food scraps, where to put decorations and knick-knacks, how to provide wardrobes and lunchrooms, and generally, how to handle an infection outbreak in facilities not designed for this purpose.

Leaders in all primary healthcare services implemented strategies to prevent infection or spread of infection. They introduced longer shifts, split up the personnel in teams, made cleaning routines for lunchrooms and on-call rooms, set up a temporary visiting room for next of kin, developed routines for patient visits, regularly debriefed personnel of infection routines, made temporary wardrobes, and removed unnecessary tasks from the work schedule. New digital tools were introduced, particularly for distributing instructional videos and information among employees, and to keep contact with other leaders.

Although many leaders described the situation as challenging, particularly in the beginning, many found themselves gaining increased control over the situation as time went by.

“Little by little, in some way, the routine of everyday life has become more settled… you can’t completely relax yet, but you can certainly feel a bit more organized, and more confident in your decisions, since we have been doing it for a while [ca 1 year]. (L1 nursing home municipality C)

The aftermath—management of covid-19 in rural primary healthcare services

Despite organizational as well as personal challenges, leaders’ overall impression of the COVID-19 management was positive. The leaders firmly believed that the quality of healthcare services had been preserved, and all the physical healthcare needs of the patients had been properly cared for. According to leaders, there was not a rise in adverse events (e.g., falls, wounds) and patients and next of kin were positive in their feedback. The one main concern regarding quality of care was, however, the aspect of the patients’ sociopsychological state. Patients became isolated and lonely when they could not receive visitors or had to be isolated in their rooms or their homes during COVID. Nevertheless, the leaders expressed admiration for the healthcare personnel's work in addressing psychosocial needs to the best of their capacity. Overall, the leaders were proud of how the front-line healthcare personnel had handled the pandemic, and the extraordinary effort they put in to keeping the healthcare services running.

Several leaders stated that they now felt better prepared for “a next pandemic”, but they also had multiple suggestions for organizational improvements. These suggestions included: set up a visit coordinator, develop a better pandemic plan, be better prepared nationally, develop local PPE storage sites, introduce digital supervision for isolation rooms (for example RoomMate [ 53 ]), provide more psychological help for employees who struggled in the aftermath of an infection outbreak, have designated staff on standby for emergency situations, establish clear communication channels for obtaining information and, when constructing new nursing homes and healthcare facilities, consider infection control measures.

The leaders also discussed the knowledge they had acquired during this period. Many talked about learning how to use digital tools, but mostly they talked about the experience they had gained in handling crisis:

“I believe we are equipped in a whole different way now. There’s no doubt about that. Both employees and leaders and the healthcare service in general, I think… I have no doubt about that… so… there have been lessons learned, no doubt about it….” (L1 nursing home municipality C)

Leaders also talked about what they experienced as success factors in handling the pandemic: Long shifts (11,5 h), with the same shift going 4 days in a row to avoid contacts between different shift, the use of Microsoft Teams and other communication tools to increased and ease intermunicipal cooperation, and the possibility to share experiences, making quick decisions and take action quickly, developing close cooperation with the municipality chief medical officer and the nursing home physician, the involvement of the occupational healthcare service (take the employees’ work situation seriously) and the conduct of “Risk, Vulnerability and Preparedness” analysis (a tool to identify possible threats in order to implement preventive measures and necessary emergency response). The leaders also talked about the advantages of getting input from employees (e.g., through close cooperation with the employee representatives).

The benefits and drawbacks of being small and rural during a pandemic

Aspects of being a small healthcare service within a small municipality were highlighted by several of the leaders. For example, the leader of one the smaller healthcare service included in the study, addressed the challenge of acquiring enough competent staff. To be able to fulfill their requirements for competent staff, the municipality needed to buy healthcare services from neighboring municipalities. Another drawback was that employees who had competence or healthcare education often lacked experience in infection control and infection control routines, because they had rarely or never had infectious outbreaks of any kind. This made it particularly challenging to implement infection control measures. In one of the larger municipalities in this study, they had worked targeted for years to increase the competence in their municipality by focusing on full time positions to all and educating assistants to become Licensed practical nurses (LPN). They benefited from these measures during the pandemic.

Another aspect which was emphasized as essential to survive a pandemic in a small municipality, was intermunicipal cooperation. Leaders of all four healthcare services stated that they built increased cooperation with nearby municipalities during the pandemic. Leaders from the different municipalities met often, sometimes several times a week, and helped each other, shared routines, and methods, asked each other questions, coordinated covid-19 testing and developed intermunicipal corona wards, kept each other updated on infection status locally, and relied on each other’s strengths.

“We established a very good intermunicipal cooperation within the health and care services. We helped each other. Shared both routines and procedures, and actually had Teams meetings twice a week, where I could ask questions…and… we all had different strengths in the roles we held, not all of them [group members] were healthcare personnel either, and they had a lot of questions regarding the practical [handling of the pandemic]. At the same time, they [people who were not healthcare personnel] were good at developing routines and procedures, which they shared with the rest. In other words, the cooperation between the municipalities was very good, and for a small municipality, it was worth its weight in gold”. (L1, nursing home/homecare Municipality D)

The same leader stated that they could not have managed the pandemic without support from other larger municipalities and advised closer cooperation following the pandemic as well. An advantage of being small was the ability to easily track and monitor the virus spread within the municipality. Moreover, it was easy to have close cooperation with the infectious disease physician, the municipal chief medical officer, and the nursing home physician, as one person often held several of these roles. Some leaders also had several roles themselves such as a combination of nursing home leader and homecare leader or a combination of nursing home leader and health and care manager (overseeing all health and care services in the municipality). This was perceived as both an advantage and a disadvantage. This was an advantage because they gained a full overview of the situation due to their multiple areas of responsibility, but a disadvantage because it was demanding for one person to handle everything alone, making the system vulnerable. Another challenging aspect was a lack of people to fill all the necessary roles. For example, in one municipality they did not have a public health officer (a physician in charge of the healthcare services in a municipality, and the municipal management’s medical adviser), and had to hire a private practicing physician, who was not resident in the municipality to take on this role.

The economy was also a continuous source of worry. Running a small healthcare service within a small municipality was stated as expensive because the municipalities were obligated to provide the same healthcare services as the larger municipalities, but with less income (e.g., tax payment per inhabitant). The pandemic led to new expenses such as overtime payment, and wage supplement for changed work hours. Leader had to continuously balance a sound use of resources, and responsible operation.

Table 4 provides and overview of the challenges leaders encountered, how they were handled, and leaders’ suggestions for further improvement.

We assessed how leaders in rural primary healthcare services coped with unprecedented challenges during the COVID-19 pandemic. On one hand, they had to manage personal struggles such as insecurity, guilt, and excessive workload. At the same time, they had to confront major organizational issues such as financial instability, lack of resources, and information overload. Moreover, their roles changed, and the need to lead, make more decisions and be more supportive was heightened. While adapting to these changing roles, the leaders continuously introduced new measures to handle pandemic induced challenges including development of new routines, distilled and distributed information, reorganized staffing plans and rearranged wards. Although patients’ safety and quality of care was perceived as safeguarded throughout the COVID-19 pandemic period, leaders had several suggestions for improvements in case of future crises.

Previous research on primary healthcare services during COVID-19 support several of the findings identified here. Similar challenges requiring leaders to adapt their ways of working such as insufficient contingency plans and infection control, lack of staffing, changing guidelines and routines and challenges related to information flow were found [ 17 , 31 , 54 , 55 , 56 ]. Leader strategies to handle these challenges included reallocation of staff, providing support, provide training and distill and distribute information [ 16 , 31 , 55 , 57 ]. Some findings in this study, particularly related to the rural context, has not been found elsewhere. We found that 1) the leaders’ and healthcare services’ increased their dependency on neighboring municipalities during the pandemic and 2) we identified both the advantages and drawbacks of leaders having to function in multiple roles during the pandemic. The heightened importance of cooperation within municipalities and healthcare services in rural areas as opposed to urban areas, has however, been highlighted both before and during the pandemic [ 17 , 23 ].

The pandemic prompted organizations like the World Health Organization (WHO), International Council of Nurses (ICN), and Organization for Economic Co-operation and Development (OECD) to advocate for the advancement of more resilient healthcare services to be able to overcome current and future health system challenges [ 3 , 58 , 59 ]. To achieve the goal of resilient healthcare services, a multi-focal perspective incorporating both individual, teams and systems, is needed. This is because health system organization and leadership on all levels will impact how resilience can be built on team and individual level and thereby reinforce resilience in organizations [ 12 , 51 , 60 , 61 , 62 ].

The multiple aspects of resilient leadership

Leadership style, leaders’ facilitation for flexibility and leaders’ management of resources, competence, and equipment, will affect the resilience of health personnel and thereby the organizational resilience [ 12 , 15 , 63 ]. However, resilient leadership is affected by multiple aspects. For one, leaders inherent individual resilience will influence how and if, they lead resiliently [ 64 ]. Individual resilience is a multifaceted concept consisting of the person’s determination, persistence, adaptability and recuperative capacity, and is impacted by their personal qualities, conduct and cultural outlook [ 12 ]. Similar to previous literature [ 65 , 66 ], the current study found that leaders had to cope with personal challenges such as fear, guilt, adapting to changed roles and increased workload, while performing their everyday tasks. Literature have shown that leaders' responses to challenges can be influenced by their unique personality traits, ultimately shaping their resilience and leadership style [ 67 , 68 ]. Personal qualities needed to “lead well” have also shown to vary between rural and urban healthcare services. For example, Doshi [ 69 ] found that being social, passionate and extrovert was more important in urban areas than in rural areas. This indicate that leaders’ personality traits affect resilience in healthcare, and that resilience promoting personality traits may vary across urban and rural areas. More research is needed to study these relationships.

Although measures to increase personal resilience can be effective (e.g., mindfulness, workshops/training, therapy) [ 70 , 71 , 72 , 73 ] it is not sufficient to base resilience building on these aspects alone [ 74 ]. There is a need to consider how leaders are influenced and supported by the system they are working within to become, and act more resiliently. This includes the support leaders have in their community (e.g., peer support, leader support and proper guidance), their access to resources and their freedom to make decisions [ 60 , 75 , 76 ]. In the current study, it appeared to be a connection between leaders’ coping and the amount of support they had from colleagues. In our interpretation, leaders who talked about their cooperation with others, also talked more positively of their COVID-19 experiences (e.g., how much they had learned or what they had accomplished, rather than how pressured and anxious they were). Similar results have previously been found. For example, leaders in Marshall and colleagues’ study [ 65 ] felt isolated and struggled to make sense of the situation (COVID-19 induced challenges), while leaders in Seljemo and colleagues’ study stated that support from other managers made it easier to cope with high workloads [ 31 ]. In smaller rural healthcare settings, obtaining support can be challenging due to the limited presence of leader colleagues in close proximity [ 77 ]. Additionally, Gray & Jones [ 78 ] suggests that resilient leaders are leaders who ask for help when needed. This indicates that leaders in more isolated areas may require more effort to form connections beyond their organization, and rural healthcare systems must afford greater attention to enabling peer networking (e.g., by providing time and resources).

Through recurrent intermunicipal, online meetings, leaders in the current study attained to initiate, and preserve contact with other leaders in other healthcare settings, much more than before the COVID-19 pandemic. This was particularly important for the smallest, most rural municipalities, where one leader held many roles, and was by one leader, stated as the main reason they were able to manage the COVID-19 pandemic in their primary healthcare service. The tendency to increase intermunicipal cooperation during this period, and the overall need for smaller, rural healthcare services to cooperate with others is found in other literature [ 23 , 79 ]. However, mostly as collaboration within primary healthcare services, and not across organizations. Although recommended by leaders, it is not clear if this close contact has been maintained after the pandemic.

The governance leaders are working under will affect leaders’ possibility to lead resiliently. The governance allows for effective coordination of financing, resource generation, and service delivery activities, ensuring optimal system performance [ 80 ]. Yet, governing for resilience has proven to be a major challenge, because it requires systems to be both flexible and stable at the same time [ 76 ]. Flexibility presupposes systems’, health personnel’, and leaders’ ability to adapt to current conditions, and is essential for systems to cope with unpredictable, non-linear, and ever-changing social and environmental conditions. Conversely, stability must also be implemented to ensure that new policies are sustained and effective, and to stabilize expectations and promote coordination over time [ 76 ]. This means that leaders need flexibility to make their own decisions, as well as the stability that proper guidelines and direction provides [ 81 ]. In this study, some leaders reported experiencing chaos and loss of control when routines and guidelines lacked in the beginning of the pandemic. Similar results have been found among other healthcare leaders, as well as healthcare personnel [ 32 , 66 ]. In contrast, the leaders’ need for flexibility to be able to adapt to the everchanging work environment brought on by the pandemic (examples in Table  3 ) was demonstrated in this, and other studies [ 16 , 17 ]. It can, however, be argued that the balance between flexibility and stability is often skewed more towards flexibility in rural regions. Rural leaders must make unsupported decisions more often than urban leaders as they face higher demands and fewer available resources (such as competence, staff, and funding) [ 77 ]. This requires rural leaders to be more innovative and adaptable to current circumstances [ 23 , 69 , 77 , 79 ]. That said, the availability of resources have shown to impact a system's flexibility, often by influencing the quality of its adaptations [ 2 ].

In low-resource healthcare settings across the globe, certain adaptations made to combat pandemic challenges ended up causing damage (e.g., reuse or misuse of PPE, overexploitation of healthcare personnel and the use of unconventional treatment methods) [ 2 , 82 ]. In high resource healthcare services, as included in this study, adaptations were often described as beneficial, and potential long-lasting solutions (Table  3 ) [ 16 , 17 , 31 ]. Although not comparable to low resource healthcare services, variation in resource availability and economy between the included healthcare services was also expressed in this study. Norwegian municipalities’ income is closely tied to their tax revenue and population size [ 83 ], and regardless of income, the municipalities are required to provide specific healthcare services to their inhabitants. Thus, the financial foundation of smaller more rural municipalities is not as strong as that of larger municipalities. These inequalities were expressed as notable by both leaders and by healthcare personnel in a preceding study exploring the same primary rural healthcare services as included here [ 32 ]. Since resilience in healthcare is also highly dependent on the competence and experience of employees and leaders, the combination of resource and financial deficiencies, more often experienced in rural healthcare services than in urban healthcare services, may pose particular challenges in resilience building in rural areas [ 23 , 84 ]. This is worth exploring further, along with the rural healthcare services’ particular need to be flexible versus the potential difficulty they may have in making beneficial adaptations because of a weaker financial foundation.

Resilience and leadership style

Providing support to employees was an important leader task during the pandemic [ 55 , 66 ] and have further, been found to be particularly vital in rural areas, where employees have a smaller network of colleagues to turn to [ 84 ]. Other vital leadership tasks, recognizable from crisis leadership literature and also found in this study, were the importance of organizing, directing and implementing actions, forging cooperation, enabling work- arounds or adaptation, direct and guide and the importance of communication and dissemination of information [ 85 , 86 ]. Although charismatic leadership Footnote 1 has been found to be most valuable during crisis [ 87 ], there is an ongoing discussion of what leadership style is best suited to promote resilience in healthcare [ 11 , 14 , 66 , 88 ]. For example, both transformational and transactional leadership 1 [ 89 ] have been stated as resilience promoting leadership styles [ 15 ]. However, as found in other literature [ 66 , 88 ], the results of this study indicated that leaders oscillated between different styles during the COVID-19 pandemic period. For example, in the beginning of the pandemic when uncertainty characterized the healthcare system, leaders became stricter with rules and regulations, demonstrating an authoritative leadership style 1 . Further, stepping in, lecturing about infection control procedures and use of PPE, indicated a coaching leadership 1 style and lastly, when the leaders went against employees wishes to ensure safe maintenance of operation, it showed similarities to a transformational leadership style 1 [ 90 ]. Interestingly, leaders did not speak directly about how their leadership styles changed, and seemed unaware of their leadership style adaptation. Similarly, in Sihvola et al. [ 66 ] leaders found it surprising how novel conditions could influence their leadership style.

On one side, these results, suggest that an adaptive leadership style can be necessary during crisis. On the other side, this and other studies [ 31 , 54 ] indicate that leaders need more knowledge on crisis leadership, for example, to be made aware of the potential need to oscillate between different leadership styles during a crisis, and the possible subsequent challenges. For example, a study conducted by Boyle og Mervin [ 91 ] found that being a “nurse leader” (all leaders in this study were nurses), showed challenging because the leaders were judged as a peer rather than a leader. This can cause challenges, particularly when stepping into an authoritative leadership style. Such conflicts were not reported in this study, however, these are all aspects which should be given more attention when investigating resilience in healthcare and leadership styles [ 88 ]. Furthermore, it is crucial to acquire further understanding on the distinctions between leading in rural and urban areas, and how various leadership approaches may be impacted by managing tight-knit employee teams, which is often the case in small rural nursing home and homecare services. And finally, there is a need to provide a deeper understanding of the factors that promote or impede resilience in rural primary healthcare services, and the influence of the contextual aspects on resilience in healthcare.

Limitations

This study has limitations which need to be addressed. A larger number of included primary healthcare leaders over a wider geographical area and across boarders would have provided a broader view of leader experiences during the COVID-19 pandemic. However, it was very difficult to get leaders to take time to reflect during this crisis. This study does provide insight into a variety of different municipalities of different sizes, organization and locations in the Norwegian context, providing a variety of rural primary healthcare leaders experiences during the pandemic. Interviews were conducted in different ways (focus group, digital and individually) this could have influenced leaders description of their experiences. Furthermore, interviews were held at different points throughout the pandemic phases, leading to a mix of leaders with both current and reflective experiences of navigating the pandemic. This should be taken into consideration when reading the results.

By exploring nursing home and home care leaders’ experiences with the COVID-19 pandemic in rural areas, we found that the leaders met a range of rapid onset challenges of different nature, many of which demanded fast decisions and solutions. Leaders handled these challenges and changes in a variety of ways in their different contexts. In addition to health system challenges, leaders also had to cope with rapidly changing roles, while managing their own and employees’ insecurities. This study’s results demonstrate the intricate nature of resilient leadership, encompassing individual resilience, personality, governance, resource availability, and the capability to adjust to organizational and employee requirements. In addition, there may be differences between how resilience in healthcare is built and progresses in rural healthcare services versus urban contexts. Further research to understand the interplay between these aspects is needed, and it is critical to consider context.

Availability of data and materials

Data are available from the corresponding author upon reasonable request.

Charismatic leadership : influence and persuasion of others to help the fulfill their mandate, also in face of adversity; Transformational leadership: pushing to work and think in new ways; Authoritative leadership : the leader in control, low autonomy; Coaching leadership : the leader support employee’s skill advancement; Transactional leadership : exchange of rewards for fulfilling expectations.

Abbreviations

International Council of Nurses

Licensed practical nurse

Organization for Economic Co-operation and Development

Personal protective equipment

Registered Nurse

The World Health Organization

WHO. COVID-19 continues to disrupt essential health services in 90% of countries WHO2021 [Available from: https://www.who.int/news/item/23-04-2021-covid-19-continues-to-disrupt-essential-health-services-in-90-of-countries .

Malin Knutsen G, Kristiana L, Siri W, et al. Resilience perspective on healthcare professionals’ adaptations to changes and challenges resulting from the COVID-19 pandemic: a meta-synthesis. BMJ Open. 2023;13(9):e071828.

Article   Google Scholar  

OECD. Ready for the Next Crisis? Investing in Health System Resilience. 2023.

Book   Google Scholar  

Franzosa E, Gorbenko K, Brody AA, et al. “At home, with care”: lessons from New York City home-based primary care practices managing COVID-19. J Am Geriatr Soc. 2021;69(2):300–6.

Article   PubMed   Google Scholar  

Franchini L, Varani S, Ostan R, et al. Home palliative care professionals perception of challenges during the Covid-19 outbreak: a qualitative study. Palliat Med. 2021;35(5):862–74.

Damian AJ, Gonzalez M, Oo M, Anderson D. A national study of community health centers’ readiness to address COVID-19. J Am Board Fam Med. 2021;34(Suppl):S85-s94.

Zhao S, Yin P, Xiao LD, et al. Nursing home staff perceptions of challenges and coping strategies during COVID-19 pandemic in China. Geriatric Nursin. 2021;42(4):887–93.

Aalto UL, Pitkälä KH, Andersen-Ranberg K, et al. COVID-19 pandemic and mortality in nursing homes across USA and Europe up to October 2021. Eur Geriatr Med. 2022;13(3):705–9.

Article   PubMed   PubMed Central   Google Scholar  

Wiig S, Aase K, Billett S, et al. Defining the boundaries and operational concepts of resilience in the resilience in healthcare research program. BMC Health Serv Res. 2020;20(1):330.

Wiig S, Fahlbruch B. Exploring Resilience - An Introduction. In: Wiig S, Fahlbruch B, editors. Exploring Resilience : a scientific journey from practice to theory. Springer briefs in applied sciences and technology : safety management. Springer Open: Cham; 2019. p. 1–3.

Google Scholar  

Barasa E, Mbau R, Gilson L. What is resilience and how can it be nurtured? A systematic review of empirical literature on organizational resilience. Int J Health Policy Manag. 2018;7(6):491–503.

Bowman A. Leadership and resilience: where the literature stands. J Leadersh Stud. 2022;16(2):33–41.

Akerjordet K, Furunes T, Haver A. Health-promoting leadership: an integrative review and future research agenda. J Adv Nurs. 2018;74(7):1505–16.

Eliot JL. Resilient leadership: the impact of a servant leader on the resilience of their followers. Adv Dev Hum Resour. 2020;22(4):404–18.

Ree E, Ellis LA, Wiig S. Managers’ role in supporting resilience in healthcare: a proposed model of how managers contribute to a healthcare system’s overall resilience. Int J Health Governance. 2021;26(3):266–80.

Lyng HB, Ree E, Wibe T, Wiig S. Healthcare leaders’ use of innovative solutions to ensure resilience in healthcare during the Covid-19 pandemic: a qualitative study in Norwegian nursing homes and home care services. BMC Health Serv Res. 2021;21(1):878.

Ree E, Wiig S, Seljemo C, et al. Managers’ strategies in handling the COVID-19 pandemic in Norwegian nursing homes and homecare services. Leadership in Health Services. (ahead-of-print). 2022;200–18.

Saleem J, Ishaq M, Zakar R, et al. Experiences of frontline Pakistani emigrant physicians combating COVID-19 in the United Kingdom: a qualitative phenomenological analysis. BMC Health Serv Res. 2021;21(1):291.

Glette MK, Bates DW, Dykes PC, et al. A resilience perspective on Healthcare Personnels’ Experiences of Managing the COVID-19 Pandemic: A qualitative study in Norwegian nursing homes and come care services. BMC Health Services Research. 2023 (in review).

Smedt SED, Mehus G. Sykepleieforskning i rurale områder i Norge; en scoping review (English title: Nursing research in rural areas in Norway; a scoping review). Norsk tidsskrift for helseforskning. 2017;13;2:1–27.

W P, L R. Rural, remote and at risk: Why rural health services face a steep climb to recovery from Covid-19. Nuffield Trust; 2020.

van Pijkeren N, Msc P, Wallenburg I, et al. Caring peripheries: How care practitioners respond to processes of peripheralisation. Sociologia Ruralis. 2023;64:64–81.

van de Bovenkamp H, van Pijkeren N, Ree E, et al. Creativity at the margins: a cross-country case study on how Dutch and Norwegian peripheries address challenges to quality work in care for older persons. Health Policy. 2023;127:66–73.

Melvin SC, Wiggins C, Burse N, et al. The role of public health in COVID-19 emergency response efforts from a Rural health perspective. Prev Chronic Dis. 2020;17:E70.

Segel JE, Ross HI, Edwards JL, et al. The unique challenges facing rural providers in the COVID-19 pandemic. Popul Health Manag. 2020;24(3):304–6.

Teixeira da Silva JA, Tsigaris P, Erfanmanesh M. Publishing volumes in major databases related to Covid-19. Scientometrics. 2021;126(1):831–42.

Article   CAS   PubMed   Google Scholar  

Gholami M, Fawad I, Shadan S, et al. COVID-19 and healthcare workers: a systematic review and meta-analysis. Int J Infect Dis. 2021;104:335–46.

Article   CAS   PubMed   PubMed Central   Google Scholar  

Ferguson J, Rosser JI, Quintero O, et al. Characteristics and outcomes of coronavirus disease patients under nonsurge conditions, Northern California, USA, March-April 2020. Emerg Infect Dis. 2020;26(8):1679–85.

Helgeland J, Telle KE, Grøsland M, et al. Admissions to Norwegian hospitals during the COVID-19 pandemic. Scandinavian J Pub Health. 2021;49(7):681–8.

Moynihan R, Sanders S, Michaleff ZA, et al. Impact of COVID-19 pandemic on utilisation of healthcare services: a systematic review. BMJ Open. 2021;11(3):e045343.

Seljemo C, Wiig S, Røise O, Ree E. The role of local context for managers’ strategies when adapting to the COVID-19 pandemic in Norwegian homecare services: a multiple case study. BMC Health Serv Res. 2023;23(1):492.

Glette MK, Bates DW, Dykes PC, et al. A resilience perspective on healthcare personnels’ experiences of managing the COVID-19 pandemic: a qualitative study in Norwegian nursing homes and come care services. BMC Health Serv Res. 2023;23(1):1177.

Iness AN, Abaricia JO, Sawadogo W, et al. The effect of hospital visitor policies on patients, their visitors, and health care providers during the COVID-19 pandemic: a systematic review. Am J Med. 2022;135(10):1158-67.e3.

Füszl A, Bouvier-Azula L, Van den Nest M, et al. Provision of safe patient care during the COVID-19 pandemic despite shared patient rooms in a tertiary hospital. Antimicrob Resist Infect Control. 2022;11(1):61.

Mohammadinia L, Saadatmand V, Khaledi Sardashti H, et al. Hospital response challenges and strategies during COVID-19 pandemic: a qualitative study. Front Public Health. 2023;11:1167411.

Samdal GB, Alpers LM, Sekse RJT, et al. Barriers and facilitators for leading nursing homes through the COVID-19 pandemic: a focus group study in Norway. Nurs Open. 2023;10(11):7154–67.

Abbas MJ, Kronenberg G, McBride M, et al. The early impact of the COVID-19 pandemic on acute care mental health services. Psychiatr Serv. 2021;72(3):242–6.

Nessler K, Van Poel E, Willems S, et al. The response of primary care practices in rural and urban settings in Poland to the challenges of the COVID-19 pandemic. Ann Agric Environ Med. 2022;29(4):575–81.

Anaraki NR, Mukhopadhyay M, Karaivanov Y, et al. Living and working in rural healthcare during the COVID-19 pandemic: a qualitative study of rural family physicians’ lived experiences. BMC Prim Care. 2022;23(1):335.

Pavloff M, Labrecque ME, Bally J, et al. Rural home care nursing during COVID-19. Can J Nurs Res. 2023;55(4):486–93.

OECD. Realising the Potential of Primary Health Care. OECD; 2020.

The World Bank. Rural population (% of total population) 2018. Available from: https://data.worldbank.org/indicator/SP.RUR.TOTL.ZS . Cited 2023 18.12.

Ellis LA, Churruca K, Clay-Williams R, et al. Patterns of resilience: a scoping review and bibliometric analysis of resilient health care. Saf Sci. 2019;118:241–57.

Scott A, Braithwaite J, Melbourne Uo. Is COVID-19 opening the fault lines in our healthcare system? : Institute of Applied Economic and Social Research.; 2020 [Available from: http://nla.gov.au/nla.obj-2931172550 .

Creswell JW. Research design : qualitative, quantitative, and mixed methods approaches. 5th ed. ed. Los Angeles, Calif: SAGE; 2018.

Holloway I, Galvin K. Qualitative research in nursing and healthcare: Wiley Blackwell; 2017.

Lov om kommunal helse-og omsorgstjeneste (english title: Act on municipal health and care services), LOV-2011–06–24–30 (2011).

Lov om pasient- og brukerrettigheter (English title: Act on patient and user rights), LOV-1999-07-02-63.

Forskrift om kvalitet i pleie- og omsorgstjenestene (English title: Regulation on quality in nursing and care services for service provision), FOR-2003–06–27–792 (2003).

Hollnagel E, . Making Healthcare resilient: From safety-I to Safety-II. In: Hollnagel E, Braithwaite J, Wears RL, editors. Resilient health care. Ashgate studies in resilience engineering. 1. Farnham, Surrey, England: Ashgate; 2013.

Wiig S, Fahlbruch B. Exploring Resilience – An Introduction. In: Wiig S, Fahlbruch B, editors. Exploring Resilience: A Scientific Journey from Practice to Theory. Cham: Springer International Publishing; 2019. p. 1–5.

Chapter   Google Scholar  

Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3:77–101.

Sensio. RoomMate. Available from: https://www.sensio.io/no/produkter/roommate?utm_term=roommate&utm_campaign=S%C3%B8k+%7C+Produkter&utm_source=adwords&utm_medium=ppc&hsa_acc=5538158809&hsa_cam=20506326432&hsa_grp=159856433744&hsa_ad=672316590141&hsa_src=g&hsa_tgt=kwd-28346982&hsa_kw=roommate&hsa_mt=p&hsa_net=adwords&hsa_ver=3&gclid=EAIaIQobChMI3rHE6qPpgwMVOVKRBR124QjJEAAYASAAEgKR5vD_BwE .  Cited 2024 19.01.

Alakeely M, Almutari A, Masud N, Altulaihi B. Preparedness of primary health care leaders during COVID-19 outbreak, Riyadh, Saudi Arabia: a qualitative study. Risk Manag Healthc Policy. 2021;14:4339–51.

Skagerström J, Fernemark H, Nilsen P, et al. Challenges of primary health care leadership during the COVID-19 pandemic in Sweden: a qualitative study of managers’ experiences. Leadersh Health Serv. 2023;36(3):389–401.

Dale JN, Morken T, Eliassen KE, et al. Preparedness and management during the first phase of the COVID-19 outbreak - a survey among emergency primary care services in Norway. BMC Health Serv Res. 2022;22(1):896.

Karreinen S, Paananen H, Kihlström L, et al. Living through uncertainty: a qualitative study on leadership and resilience in primary healthcare during COVID-19. BMC Health Serv Res. 2023;23(1):233.

ICN. ICN President calls for resilient health systems at UN High Level Meeting on Pandemic Prevention, Preparedness and Response: ICN; 2023 [updated 21.09.23. Available from: https://www.icn.ch/news/icn-president-calls-resilient-health-systems-un-high-level-meeting-pandemic-prevention .

World Health Organization. Building health systems resilience for universal health coverage and health security during the COVID-19 pandemic and beyond: a brief on the WHO position. Geneva: WHO; 2021. Available from: https://www.who.int/publications/i/item/WHO-UHL-PHC-SP-2021.02 .

Sagan A, Webb E, Rajan D, et al. Health system resilience during the pandemic: it’s mostly about governance. Eurohealth. 2021;27(1):10–5.

Wiig S, Lyng HB, Greenfield D, Braithwaite J. Care in the future—reconciling health system and individual resilience. Int J Qual Health Care. 2023;35(4):mzad082.

Tsandila-Kalakou F, Wiig S, Aase K. Factors contributing to healthcare professionals’ adaptive capacity with hospital standardization: a scoping review. BMC Health Serv Res. 2023;23(1):799.

Fagerdal B, Lyng HB, Guise V, et al. Exploring the role of leaders in enabling adaptive capacity in hospital teams - a multiple case study. BMC Health Serv Res. 2022;22(1):908.

Gröschke D, Hofmann E, Müller ND, Wolf J. Individual and organizational resilience—Insights from healthcare providers in Germany during the COVID-19 pandemic. Front Psychol. 2022;13:965380.

Marshall F, Gordon A, Gladman JRF, Bishop S. Care homes, their communities, and resilience in the face of the COVID-19 pandemic: interim findings from a qualitative study. BMC Geriatr. 2021;21(1):102.

Sihvola S, Kvist T, Nurmeksela A. Nurse leaders’ resilience and their role in supporting nurses’ resilience during the COVID-19 pandemic: a scoping review. J Nurs Manag. 2022;30(6):1869–80.

Haver A, Akerjordet K, Furunes T. Wise emotion regulation and the power of resilience in experienced hospitality leaders. Scand J Hosp Tour. 2014;14(2):152–69.

Kumari K, Ali SB, Batool M, et al. The interplay between leaders’ personality traits and mentoring quality and their impact on mentees’ job satisfaction and job performance. Front Psychol. 2022;13:937470.

Doshi D. Improving leadership of health services in rural areas: exploring traits and characteristics. Int J Healthcare Manag. 2020;13(sup1):183–91.

McKinley N, Karayiannis PN, Convie L, et al. Resilience in medical doctors: a systematic review. Postgrad Med J. 2019;95(1121):140–7.

Cleary M, Kornhaber R, Thapa DK, et al. The effectiveness of interventions to improve resilience among health professionals: a systematic review. Nurse Educ Today. 2018;71:247–63.

Huey CWT, Palaganas JC. What are the factors affecting resilience in health professionals? A synthesis of systematic reviews. Med Teach. 2020;42(5):550–60.

Joyce S, Shand F, Tighe J, et al. Road to resilience: a systematic review and meta-analysis of resilience training programmes and interventions. BMJ Open. 2018;8(6):e017858.

Khalili H, Lising D, Kolcu G, et al. Advancing health care resilience through a systems-based collaborative approach: Lessons learned from COVID-19. J Interprof Care. 2021;35(6):809–12.

Kaul V, Shah VH, El-Serag H. Leadership during crisis: lessons and applications from the COVID-19 pandemic. Gastroenterology. 2020;159(3):809–12.

Beunen R, Patterson J, Van Assche K. Governing for resilience: the role of institutional work. Curr Opinion Environ Sustainability. 2017;28:10–6.

van de Bovenkamp H, van Pijkeren N, Ree E, et al. Creativity at the margins: a cross-country case study on how Dutch and Norwegian peripheries address challenges to quality work in care for older persons. Health Policy. 2022;127:66–73.

Gray D, Jones K. The resilience and wellbeing of public sector leaders. Int J Pub Leadership. 2018;14(3):138–54.

Bish M, Kenny A, Nay R. A scoping review identifying contemporary issues in rural nursing leadership. J Nurs Scholarsh. 2012;44(4):411–7.

Sagan A, Webb E, Azzopardi-Muscat N, et al. Health systems resilience during COVID-19. Lessons for building back better. Health policy series. 2021; 56:[1–136 pp.]. Available from: https://eurohealthobservatory.who.int/publications/i/health-systems-resilience-during-covid-19-lessons-for-building-back-better .

Grote G. Leadership in Resilient Organizations. In: Wiig S, Fahlbruch B, editors. Exploring Resilience : a scientific journey from practice to theory. 1. Springer Open: Cham; 2019. p. 59–67.

Poon YSR, Lin YP, Griffiths P, et al. A global overview of healthcare workers’ turnover intention amid COVID-19 pandemic: a systematic review with future directions. Human Resources Health. 2022;20(1):70.

NOU: 2022: no 10. Inntektssystemet for kommunene (English title: The revenue system for the municipalities). Oslo: Ministry of Local Government and Rural Affairs

Matheson C, Robertson HD, Elliott AM, et al. Resilience of primary healthcare professionals working in challenging environments: a focus group study. Br J Gen Pract. 2016;66(648):e507–15.

Boin A, Kuipers S, Overdijk W. Leadership in times of crisis: a framework for assessment. Int Rev Pub Administration. 2013;18(1):79–91.

Baker EL, Irwin R, Matthews G. Thoughts on adaptive leadership in a challenging time. J Public Health Manag Pract. 2020;26(4):378–9.

Ali BJ, Anwar G. Administrative crisis: the role of effective leadership styles in crisis management international journal of advanced engineering. Manag Sci. 2021;7(6):31–41.

Tvedt IM, Tommelein ID, Klakegg OJ, Wong J-M. Organizational values in support of leadership styles fostering organizational resilience: a process perspective. Int J Manag Proj Bus. 2023;16(2):258–78.

Grote G. Leadership in Resilient Organizations. In: Wiig S, Fahlbruch B, editors. Exploring Resilience: A Scientific Journey from Practice to Theory. Cham: Springer International Publishing; 2019. p. 59–69.

Jasper L. Building an adaptive leadership style. Strategic Finance. 2018;99(9):54–61.

Boyle TJ, Mervyn K. The making and sustaining of leaders in health care. J Health Organ Manag. 2019;33(2):241–62.

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Acknowledgements

The authors would like to thank participating leaders for their contribution to the study. We would also like to acknowledge Ole-Jørn Borum for graphical design on fig. 1 .

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MKG, SW, TK, and DWB was involved in discussions regarding the project’s development. MKG conducted interviews and led the analysis of the transcribed data. The manuscript was a collaborative effort between MKG, SW, TK, DWB and LS, where all authors provided feedback. The author team approved the manuscript before submission.

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The study was approved by the Norwegian Agency for Shared Services in Education and Research (SIKT) in 2022 and provides the ethical approval, information security and privacy services as a part of the HK-dir (Norwegian Directorate for Higher Education and Skills). An informed consent form was signed by all leaders prior to the interviews, and information about the aim of the study and their right to redraw was repeated immediately before the interviews started.

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Dr. Bates reports grants and personal fees from EarlySense, personal fees from CDI Negev, equity from ValeraHealth, equity from Clew, equity from MDClone, personal fees and equity from AESOP, personal fees and equity from Feelbet-ter, equity from Guided Clinical Solutions, and grants from IBM Watson Health, outside the submitted work. Dr. Bates has a patent pending (PHC-028564 US PCT), on intraoperative clinical decision support. The other authors report no competing interests.

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Glette, M.K., Kringeland, T., Samal, L. et al. A qualitative study of leaders’ experiences of handling challenges and changes induced by the COVID-19 pandemic in rural nursing homes and homecare services. BMC Health Serv Res 24 , 442 (2024). https://doi.org/10.1186/s12913-024-10935-y

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• PMCID: PMC10999080
• DOI: 10.1186/s12912-024-01877-1

Background: Missed nursing care occurs globally, and the consequences are severe for the patients when fundamental care needs are not fulfilled, nor delivered in a person-centred way. This study aimed to investigate the occurrence and cause of missed nursing care, and the relationship between registered nurses' and nursing assistants' perceptions of missed nursing care, in a surgical care context.

Methods: A quantitative study was performed using the MISSCARE survey, measuring missed nursing care and associated reasons, in three surgical wards with registered nurses and nursing assistants as the participants (n = 118), during May-November in 2022. The MISSCARE survey also covers background data such as job satisfaction and intention to leave. The survey was distributed paper-based and the response rate was 88%.

Results: Aspects of nursing care rated to be missed the most were 'attending interdisciplinary care conferences', 'turning patient every 2 h', 'ambulation 3 times per day or as ordered', and 'mouth care'. Differences between registered nurse and nursing assistant ratings were detected for eight out of 24 items, where registered nurses rated more missed nursing care. The uppermost reasons for missed nursing care were 'inadequate number of staff' and 'unexpected rise in patient volume and/or acuity on the unit'. Registered nurses and nursing assistants rated differently regarding six of 17 items. Almost every fourth staff member (24.6%, n = 29) had the intention to leave within a year in the present department.

Conclusions: The occurrence of missed nursing care is frequent in the surgical context, and in combination with a high number of staff members intending to leave their employment, poses a hazard to patient safety. Registered nurses, holding higher educational levels, reported more missed care compared with the nursing assistants. The main reason for missed nursing care was an inadequate number of staff. These findings support a warranted investment in nursing within the organisation. The results can be used to form strategies and interventions, to reduce nurse attrition and optimise competence utilisation, and to achieve safe person-centered fundamental care.

Keywords: Fundamentals of Care; Missed nursing care; Patient safety; Quantitative study; Reasons for missed nursing care; Surgical care.

© 2024. The Author(s).