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Evidence Based Nursing Practice

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Levels of Evidence

As the different study designs have different strengths, and weakness, they have been ranked in levels of evidence.  Simply put, the strongest designs are at the top, the weakest at the bottom.  The pyramid is a convenient symbol for this, as there are usually fewer randomized trials say, than case reports.

For an interactive version, go to:   https://library.muhealth.org/evidencepyramid/

Click on the image to see larger version. 

research design nursing study

Study Types/Designs

Case Report - a write up of the case of an individual patient; a clinical presentation.  Often the first report of a new disease or disease trend.

Case Series - a write up of the cases of several patients all undergoing similar treatment.

Case-Control Study -  a comparison of study subjects with a particular disease/risk factor (cases) to those without (controls).  These have also been called retrospective studies.  A good design for rare diseases but easy to get poor data.

Clinical Trial - an experimental study in which subjects receive an intervention.  Preferably subjects are assigned to either treatment or no treatment/placebo (see Controlled Clinical Trial).  Some trials compare multiple treatments, e.g. the subjects could be assigned to: Treatment A, Treatment B, No treatment/placebo.  The different groups are called arms.   This is the best study design for testing effect of interventions.

Cohort Study -  a group of subjects followed through time.  Cohort studies can be used to track effect of an exposure, e.g. all subjects had been exposed to lead in their housing, or they can track a cohort not exposed.  They have also been called prospective studies.  This is a strong design for determining risk and incidence. 

Controlled Clinical Trial - a Clinical Trial where there is a control group receiving a comparison treatment or no treatment/placebo.

Cross Sectional Study - a descriptive study that documents the number of people with a particular disease or risk factor.

Randomized Controlled Trial - Same as Controlled Clinical Trial, with the added benefit of the subjects being randomly assigned to treatment/no treatment arms.  This avoids selection bias as all subjects have an equal chance of being assigned to any one of the treatment/no treatment arms.  Random assignment can be accomplished using machine generated random number tables.  Assigning subjects using methods such as coin tosses or assigning even-odd numbers is considered pseudo-randomization. 

Review articles are not considered evidence .  One exception to this are Systematic Reviews - including their subset, Meta-Analysis . 

Why are Systematic Reviews included in the evidence based pantheon?  They aim for documented, exhaustive and comprehensive searching for all research on a specified topic.  Most other types of reviews either do not document their search and collection of the research nor do they verify that they have completed an exhaustive and comprehensive search. 

All things random

In evidence based practice, much is made of Randomized Control Trials (i.e. clinical trials where participants are randomized assigned to an interventions, including a control group.)  Why?   Randomized Control Trials - RCTs - can show cause and effect not just association.

However, they are not the only study design available.  This page provides a glossary (left column) of some of them.  For more info & a nifty chart, check out CEBM's Study Design site.

Making sense of it all

Study designs can be classified as descriptive or analytical .  The analytical studies have more power, or ability to predict, than descriptive studies and therefore rank higher in the evidence based world.

Descriptive studies give us a snap shot of what is happening.  Surveys, case reports, cross sectional studies (using surveys) are descriptive.  They cannot show cause and effect, but they can show prevalence or incidence.  They can also be useful in spotting trends.

Analytical studies measure the relationship between factors.  Cohort studies and randomized control trials are analytical.  They show cause and effect.

For more information or in depth definitions, see College of Veterinary Medicine, Washington State University.

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  • Volume 2, Issue 1
  • Identifying the best research design to fit the question. Part 1: quantitative designs
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  • Jackie Roberts , RN, MSc ,
  • Alba Dicenso , RN, PhD
  • School of Nursing, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada

https://doi.org/10.1136/ebn.2.1.4

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Evidence-based nursing is about applying the best available evidence to a specific clinical question. Different clinical questions require evidence from different research designs. No single design has precedence over another, rather the design chosen must fit the particular research question. 1 Questions focused on the cause, prognosis (course), diagnosis, prevention, treatment, or economics of health problems are best answered using quantitative designs, whereas questions about the meaning or experience of illness are best answered using qualitative designs. Many different quantitative and qualitative research designs exist, each with a specific purpose and with strengths and limitations. In this editorial, the most rigorous quantitative designs to address questions of prevention or treatment, causation, and prognosis will be outlined. The next editorial will describe the use of qualitative designs to address questions of meaning or experience.

Questions about the effectiveness of prevention and treatment interventions

The randomised controlled trial (RCT) is the strongest design for questions of whether healthcare interventions are beneficial (ie, do more good than harm). An RCT is a true experiment in which people are randomly allocated to receive a new intervention (experimental group) or to receive a conventional intervention or no intervention at all (control group). Because it is the play of chance alone that determines the allocation, the only systematic difference between the groups should be the intervention. Investigators follow participants forward in time (follow up) and then assess whether they have experienced a specific outcome (fig 1 ⇓ ). The 2 most important strengths of RCTs are (1) the random allocation of participants to groups, which helps to ensure that the groups are similar in all respects except exposure to the intervention, and (2) the longitudinal nature of the study, whereby exposure to the intervention precedes the development of the outcome. These 2 features ensure that any differences in outcome can be attributed to the intervention. The disadvantages of this design include the cost of conducting a trial, the long period of follow up before patients experience the outcome, and the possibility that patients who agree to participate in a trial may differ from those to whom the results would be applied (generalisability).

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Randomised controlled trial.

If you are a primary care nurse practitioner and are wondering whether you should suggest nicotine gum to help smokers to stop smoking, again you should look for evidence from RCTs. In such trials, smokers are randomly allocated to nicotine gum (experimental group) or to placebo gum, which looks and tastes like nicotine gum but contains no active ingredients (control group). They are then followed up, and data are collected and compared on the number of participants in each group who stopped smoking.

Readers of this journal will notice that all of the treatment studies that have been abstracted have been RCTs. An example from this issue is the study by Macknin (p13) on the effectiveness of zinc lozenges for cold symptoms in children. There are occasions, however, when the evaluation of an intervention using an RCT is not ethical or feasible. In this case, we must rely on a less rigorous design such as the cohort analytic study (also known as a controlled trial). This study design is similar to the RCT in that there are comparison groups who receive and do not receive an intervention and they are followed up to determine who experiences the outcome of interest. The important difference between the 2 designs is the absence of random allocation to study groups; instead, participants most often select themselves or are selected by a clinician to receive the intervention (fig 2 ⇓ ). This is an important limitation because groups may differ in ways other than exposure to the intervention. Group differences in outcomes at the end of the study may be because of differences in the groups that existed before the intervention began (baseline differences). The intervention therefore may appear to have had an effect on the outcome when, in fact, it was the initial differences in groups that influenced the outcome.

Cohort analytic study.

Continuing with the example of the school based smoking prevention programme, if schools were unhappy about being randomly allocated to groups, a cohort analytic study might be done rather than an RCT. In such a study, several schools are approached and asked if they would like to receive the innovative intervention (intervention group) or the traditional lectures (control group). Without random allocation to groups, it may be that schools that choose the innovative intervention differ from those that choose not to receive it in ways that may influence the outcome (eg, socioeconomic status or parental smoking habits). The study findings may show that students who received the innovative intervention were less likely to start smoking; however, this outcome may have been influenced by the baseline characteristics of the group rather than, or as well as, the intervention. In other words, this group may not have been as likely to smoke even if they did not receive the innovative intervention. Even if investigators document the group differences in baseline characteristics or use statistical techniques to adjust for the differences, other factors that were not considered may be responsible for differences in outcome.

Using a cohort analytic design for the nicotine gum example, smokers who want to stop smoking are offered nicotine gum and those who choose to take it (intervention group) are compared over time with those who choose not to take it (control group). Again, the major limitation of this design is that smokers who choose to take nicotine gum may differ from those who choose not to take it with respect to known and unknown baseline characteristics that may influence the outcome. Nicotine gum may appear to increase quit rates when, in fact, the increase may be because of variables such as higher motivation to stop smoking, younger age, or fewer years of smoking.

Questions about the cause of a health problem or disease

The RCT is the most rigorous design to determine whether some factor (exposure) causes an outcome. Using this design, participants are randomly allocated to be or not be exposed to a potential causative agent and then followed up to compare the number in each group who experience the outcome. In questions of causation, however, it may not be ethical or feasible to randomly allocate people to exposure to the causative agent. The next best evidence comes from cohort analytic studies. In this design, the investigator follows up people who are exposed to and not exposed to a causative agent. The major strength of RCTs and cohort analytic studies is that those entering the study have not yet experienced the outcome. The investigator is certain therefore that exposure to the causative agent (smoking) precedes the development of the outcome (lung cancer). This issue of temporality—that is, that the causative agent precedes the development of the outcome, is crucial for establishing a causal relation. 2

When the outcome of interest is rare or takes a long time to develop, neither RCTs nor cohort analytic studies may be feasible. In these circumstances, a case control design is often used. In a case control design, patients with the outcome of interest (cases) and patients without the outcome of interest (controls) are identified and then the investigator determines whether they have had previous exposure to the causative agent (fig 3 ⇓ ). The investigator is able to match the case and control patients on important variables that may influence the outcome (eg, age, sex, and other health conditions). In this way, the groups are as similar as possible and the specific effect of the causative agent on the outcome can be more confidently examined. The strengths of this design are that it allows the assessment of causation when the outcome is rare or takes a long time to develop, and that it includes a control group. The limitations are the difficulties in establishing that the exposure actually occurred before the outcome (temporality), obtaining accurate information about exposure to a causative agent which has occurred in the past (relies on accuracy of people's memory or on completeness and accuracy of medical records), and identifying a control group that is similar in all other factors that may have influenced the outcome.

Case control study.

When considering whether smoking causes lung cancer, it is unethical to randomise participants to smoke or to not smoke and then follow them up to determine who develops lung cancer; an RCT is therefore not possible. Cohort analytic studies have been done in which investigators followed up a group of smokers and a group of non-smokers, who were matched for as many other explanatory variables as possible. However, given the long time it takes before lung cancer develops, these studies took many years to complete. Case control studies are often a more feasible option when the disease in question is rare and when a cohort analytic study would be extremely large and costly to identify a sufficient number of people who develop the disease. Using a case control design for the smoking and lung cancer example, people with lung cancer are matched, for several important variables, to people without lung cancer. All participants are asked about their past smoking behaviour, and the number of smokers in each group are compared to see whether those with lung cancer were more likely to have smoked. An example of a case control study that examines a causal relation in this issue is the study by Woodward et al (p25) on whether parenting style increases hyperactivity in school aged boys.

Questions about the course of a health state or disease (prognosis)

When we are interested in the likelihood that people will experience or develop an outcome given their exposure to a disease, condition, or situation, the best design is a cohort study . An example of a prognosis question that appeared in a previous issue of Evidence-Based Nursing is whether infants who are preterm and small for gestational age are likely to have cognitive and motor delays during early childhood (Hutton et al , Jan 1998 issue, p 19). In this example, the condition is being preterm and small for gestational age. An example of a prognosis question that begins with a disease is how likely are patients with ulcerative colitis to develop bowel cancer ? In a cohort study, one group of patients who are at a uniform point in the development or exposure of the disease or condition (eg, at first onset or at initial diagnosis) (inception cohort) and free of the outcome of interest are followed up to determine who develops the outcome (fig 4 ⇓ ).

Cohort study.

In the case of lung cancer, an example of a prognosis study is to assemble a group of patients who have just been diagnosed with lung cancer and follow them up to determine when certain symptoms appear or how long patients survive.

The longitudinal nature of the cohort design ensures that the disease, condition, or situation precedes the outcome. The disadvantages of this design are the expense and time required to follow up large numbers of patients until some develop the outcome.

Single studies versus systematic reviews

Questions about the prevention or treatment of disease, and the cause or course of disease are usually addressed by more than one study. To help practitioners and health policy makers keep up with the literature related to specific topics, systematic reviews of the literature are conducted. In a systematic review, eligible research studies are viewed as a population to be systematically sampled and surveyed. Individual study characteristics and results are then abstracted, quantified, coded, and assembled into a database that, if appropriate, is statistically analysed much like other quantitative data. The statistical combination of the results of >1 study, or meta-analysis , effectively increases the sample size and results in a more precise estimate of effect than can be obtained from any of the individual studies used in the meta-analysis. Rigorous systematic reviews provide a summary of all methodologically sound studies related to a specific topic. This is much more powerful than the results of any one single study and avoids the potential of bias if one only looks at some of the studies on a particular question. 3 An example of a systematic review in this issue is the study by Tang (p18) about whether an intervention of dietary advice lowers blood cholesterol concentrations in people living in the community.

There are numerous quantitative research designs. The designs described above are the most rigorous for addressing questions about treatment, causation, and prognosis. When looking for studies related to these questions, awareness of these designs will help nurses to identify those studies and systematic reviews worth reading.

  • ↵ Mulhall A. Nursing, research, and the evidence [editorial]. Evidence-Based Nursing 1998 Jan; 1 : 4 –6. OpenUrl FREE Full Text
  • ↵ Hill AB. Principles of medical statistics (9th edition). London: Lancet, 1971:313.
  • ↵ DiCenso A , Cullum N, Ciliska D. Implementing evidence-based nursing: some misconceptions [editorial]. Evidence-Based Nursing 1998 Apr; 1 : 38 –40. OpenUrl FREE Full Text

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Nursing Research Guide: Study Designs

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Levels of Evidence and Study Designs

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Acknowledgements

I would like to thank the librarians at Dahlgren Memorial Library, Washington, DC for their kind permission to re-use content from their Evidence-Based Medicine Resource Guide .

Study Types Explained

Definitions of Study Types

 (From the Centre for Evidence Based Medicine ,  OCEBM Table of Evidence Glossary .) 

  Meta-analysis:  A statistical technique that summarizes the results of several studies in a single weighted estimate, in which more weight is given to results of studies with more events and sometimes to studies of higher quality.

Systematic Review:  The application of strategies that limit bias in the assembly, critical appraisal, and synthesis of all relevant studies on a specific topic. Systematic reviews focus on peer-reviewed publications about a specific health problem and use rigorous, standardized methods for selecting and assessing articles. A systematic review may or may not include a  meta-analysis,  which is a quantitative summary of the results.

Randomized Controlled Trial:  An epidemiological experiment in which subjects in a population are randomly assigned into groups, usually called study and control groups, to receive or not receive an experimental preventive or therapeutic procedure, maneuver, or intervention. The results are assessed by rigorous comparison of rates of disease, death, recovery, or other appropriate outcome in the study and control groups.

Controlled Clinical Trial:  a trial in which participants are assigned to two or more different treatment groups.  When the method of allocation is by random selection, the study is referred to as a randomized controlled trial (RCT). Non-randomized controlled trials are more likely to suffer from bias than RCTs.

Cohort study : The analytic method of epidemiologic study in which subsets of a defined population (e.g. smokers) can be identified who are, have been, or in the future may be exposed or not exposed, or exposed in different degrees, to a factor or factors hypothesized to influence the probability of occurrence of a given disease (e.g. lung cancer) or other outcome. The main feature of cohort study is observation of large numbers over a long period (commonly years) with comparison of incidence rates in groups that differ in exposure levels.

Cross-Sectional Survey : A study that examines the relationship between diseases (or other health-related characteristics) and other variables of interest as they exist in a defined population at one particular time (ie exposure and outcomes are both measured at the same time). Best for quantifying the prevalence of a disease or risk factor, and for quantifying the accuracy of a diagnostic test.

Case-control study : The observational epidemiologic study of persons with the disease (or other outcome variable) of interest and a suitable control (comparison, reference) group of persons without the disease. The relationship of an attribute to the disease is examined by comparing the diseased and nondiseased with regard to how frequently the attribute is present or, if quantitative, the levels of the attribute, in each of the groups.

Case-series : A group or series of case reports involving patients who were given similar treatment. Reports of case series usually contain detailed information about the individual patients. This includes demographic information (for example, age, gender, ethnic origin) and information on diagnosis, treatment, response to treatment, and follow-up after treatment. (NCI Dictionary)

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  • Research Study Design

Nursing Research, Step By Step, from:  American Journal of Nursing . 

This series coordinated by the Heilbrunn Family Center for Research Nursing at Rockefeller University is designed to give nurses the knowledge and skills they need to participate in research, step by step. Each column will present the concepts that underpin evidence-based practice—from research design to data interpretation. Some articles are accompanied by a podcast offering more insight and context from the author.

  • Capili, B. (2020). How does research start?  The American Journal of Nursing,  120 (10), 41–44. 10.1097/01.NAJ.0000718644.96765.b3

This article focuses on how to start the research process by identifying a topic of interest and developing a well-defined research question.

  • Capili, B. (2021). Selection of the study participants.  Th e American Journal of Nursing,  121 (1), 64–67. 10.1097/01.NAJ.0000731688.58731.05

This article is an introduction to designing study eligibility criteria and recruiting study participants. 

  • Curtis, & Keeler, C. (2021). Sampling design in nursing research.  The American Journal of Nursing ,  121 (3), 53–57. https://doi.org/10.1097/01.NAJ.0000737304.14564.51  

This column continues with a discussion of sampling design and includes a consideration of probability and nonprobability sampling methodologies.

  • Curtis, A. C., & Keeler, C. (2021). Measurement in nursing research.  The American Journal of Nursing,  121 (6), 56–60. 10.1097/01.NAJ.0000753668.78872.0f 

In this article, we explore measurement in quantitative research. We will also consider the concepts of validity and reliability as they relate to quantitative research measurement.

  • Capili, B. (2021). Selection and implementation of outcome measurements .  The American Journal of Nursing,  121 (8), 63–67. 10.1097/01.NAJ.0000767840.30291.31  

This column continues the discussion of outcome measures, focusing on questionnaire formats and guidelines for selecting and administering these measures in clinical research.

  • Capili, B. (2021). Cross-sectional studies.  The American Journal of Nursing,  121 (10), 59–62. 10.1097/01.NAJ.0000794280.73744.fe  

This article describes one type of observational study, the cross-sectional study, examining its strengths and weaknesses and discussing methods for reporting the study results.

  • Capili, B., & Anastasi, J. K. (2021). Cohort studies.  The American Journal of Nursing ,  121 (12), 45–48. https://doi.org/10.1097/01.NAJ.0000803196.49507.08  

This article describes prospective (following a group from the present into the future) and retrospective (studying a group from the past through to the present) cohort designs, examines their strengths and weaknesses, and discusses methods for reporting the study results. 

  • Keeler, & Curtis, A. C. (2022). Case-control studies.  The American Journal of Nursing ,  122 (2), 51–56. https://doi.org/10.1097/01.NAJ.0000820584.29051.80  

Like cohort studies, case–control studies connect a health outcome with a specific exposure, allowing researchers to compare the association between the two. Here, we compare cohort and case–control studies, discuss the selection of cases and controls, describe how one might evaluate whether an association exists between them, and outline potential sources of bias. We end by discussing when a case–control study might be appropriate.

  • Keeler, & Curtis, A. C. (2022). Secondary data in nursing research.  The American Journal of Nursing ,  122 (4), 58–61. https://doi.org/10.1097/01.NAJ.0000827360.84863.f1  

This article discusses the alignment of research goals with secondary data sources, explores sources of publicly available secondary data that might be of interest to nurse researchers, and outlines the costs and benefits of using secondary data.

  • Curtis, & Keeler, C. (2022). Diagnostic studies: Measures of accuracy in nursing research. The American Journal of Nursing, 122 (6), 44–49. https://doi.org/10.1097/01.NAJ.0000833928.06431.8e  

This article reviews the use of diagnostic and screening tests and tools in nursing research and clinical practice.

  • Curtis, A. C. (2022). An Introduction to qualitative methods for the nurse researcher.  The American Journal of Nursing ,  122 (8), 52–56. https://doi.org/10.1097/01.NAJ.0000854992.17329.51  

This article provides an introduction to qualitative methods in nursing research.

  • Curtis, A. & Keeler, C. (2022). Interpretive methodologies in qualitative nursing research. The American Journal of Nursing, 122  (10), 45-49. doi: 10.1097/01.NAJ.0000890224.65902.0a . 

This article, one in a series on clinical research by nurses, explores the rich tradition of interpretive qualitative research practices, including phenomenology, grounded theory, ethnography, and case study

  • Capili, B., & Anastasi, J. K. (2023). Improving the validity of causal inferences in observational studies.  The American Journal of Nursing ,  123 (1), 45–49. https://doi.org/10.1097/01.NAJ.0000911536.51764.47

This article focuses on understanding causal inferences and methods for improving their use in observational studies.

  • Capili, B., & Anastasi, J. K. (2023). Efficacy randomized controlled trials.  The American Journal of Nursing ,  123 (3), 47–51. https://doi.org/10.1097/01.NAJ.0000921808.23646.01  

This article describes the process of selecting the intervention, choosing experimental and control groups, determining study outcomes, and applying blinding and randomization.

  • Keeler, C., & Curtis, A. C. (2023). The architecture of a research study.  The American Journal of Nursing ,  123 (5), 59–62. https://doi.org/10.1097/01.NAJ.0000933952.08188.67  

This article describes the development of a research study from research question to empirical strategy.

  • Keeler, C., & Curtis, A. C. (2023). Introduction to statistical hypothesis testing in nursing research.  The American Journal of Nursing ,  123 (7), 53–55. https://doi.org/10.1097/01.NAJ.0000944936.37768.29  

This article focuses on hypothesis testing—and outlines the following five elements: (1) stating the null and alternative hypotheses, (2) calculating the appropriate test statistic, (3) interpreting the  P  value of the test statistic, (4) assessing statistical significance, and (5) interpreting the results.

  • Capili, B., & Anastasi, J. K. (2023). The cluster randomized trial study design.  The American Journal of Nursing ,  123 (9), 57–60. https://doi.org/10.1097/01.NAJ.0000978168.48569.72

Randomized clinical trials are among the highest levels of evidence researchers can use in evaluating new therapeutics or interventions. Besides classic parallel, two-group comparisons between an experimental condition and a control, another type of randomized trial is the cluster randomized trial. This study design helps evaluate the usefulness of an intervention at the population or public health level.

  • Curtis, A. C., & Keeler, C. (2023). Sample size planning in quantitative nursing research.  The American Journal of Nursing ,  123 (11), 42–46. https://doi.org/10.1097/01.NAJ.0000995360.84994.3b

Building on previous articles in this series on sampling design1 and hypothesis testing, the current installment describes how to determine an appropriate sample size for a quantitative research project, and introduces the concepts of error, power, and effect size.

Centre for Evidence-Based Medicine. (n.d.). Study designs . https://www.cebm.ox.ac.uk/resources/ebm-tools/study-designs 

This short article from the Centre for Evidence-Based Medicine, University of Oxford, gives a brief guide to the different study types and a comparison of the advantages and disadvantages.

Hess, D. R. (2004). Retrospective studies and chart reviews. Respiratory Care , 49 (10), 1171–1174. https://rc.rcjournal.com/content/49/10/1171

This article discusses retrospective studies, case series and case control studies.

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QUALitative research "is best suited for research aimed at rich description or in-depth understanding of a phenomenon, rather than determining causality; it is particularly useful in understanding the relevance of contextual features in the expression of the phenomenon. Qualitative approaches are most often chosen when little is known about a topic or when new perspectives are needed; other functions of qualitative approaches include generating hypotheses, refining theory, providing illustrative examples, creating taxonomies, and generating items for instrument development.

Relying primarily on inductive rather than deductive processes, qualitative studies generally share several “ground-up” features that differentiate them from “top-down” quantitative research. These features are driven by two central tenets: an orientation to cases rather than variables, as well as a preference for emergent rather than fixed designs."

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Four types of qualitative research design often applied to nursing research are:

  • Phenomenology - the study of human life experiences and how they appear in human consciousness
  • Grounded Theory - seeks to explain variations in social interactional and social structural problems and processes
  • Ethnography - As a research process, ethnography is a comparative method for investigating patterns of human behavior and cognition through observations and interactions in natural settings
  • Narrative Inquiry - the analysis of meaning in context through interpretation of persons' life experiences

For more details , look up these research designs in:

Encyclopedia of Nursing Research

Dictionary of Nursing Theory and Research

QUANtitative research "consists of the collection, tabulation, summarization, and analysis of numerical data for the purpose of answering research questions or hypotheses. The term quantitative research is of recent origin and is distinguished from qualitative research in design, process, and the use of quantification techniques to measure and analyze the data. The vast majority of all nursing studies can be classified as quantitative.

Quantitative research uses statistical methodology at every stage in the research process. At the inception of a research project, when the research questions are formulated, thought must be given to how the research variables are to be quantified, defined, measured, and analyzed. Study subjects are often selected for a research project through the statistical method of random sampling, which promotes an unbiased representation of the target population among the sample from whom generalizations will be made. Statistical methods are used to summarize study data, to determine sampling error, and in studies in which hypotheses are tested, to analyze whether results obtained exceed those that could be attributed to sampling error (chance) alone."

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Quantitative Research Design can be Non-Experimental (Descriptive or Correlational) or Experimental (including Quasi-Experimental).

" Observational designs are nonexperimental, quantitative designs. In contrast to experimental designs in which the investigator manipulates the independent variable and observes its effect, the investigator conducting observational research observes both the independent and dependent variables. In observational studies, variation in the independent variable may be due to genetic endowment, self-selection, or occupational or environmental exposures."

" Correlational research examines the relationships between variables, but unlike experimental or quasi-experimental studies, correlational studies lack active manipulation of the independent variable(s). Therefore, postulation of relationships among study variables in causal terms is risky. Discussion of associations in correlational studies, however, sometimes gives an indication of how likely it is that a cause-and-effect relationship might exist."

More Information from Dictionary of Nursing Theory and Research

" Quasi-experimental research is similar to experimental research in that there is manipulation of an independent variable. It differs from experimental research because there is no control group, no random selection, no random assignment, and/or no active manipulation. Quasi-experimental research is a useful way to test causality in settings when it is impossible or unethical to randomly assign subjects to treatment and control groups or to withhold treatment from some subjects."

Experimental research "involves manipulation of the principal independent variable, i.e., the actual administration of treatments or interventions that comprise the categories of the independent variable. An investigation is made of the effect of the independent variable on the dependent variable.

A true experiment is characterized by random assignment of individual subjects to the treatment conditions and a high degree of control over unwanted influence of extraneous variables and other factors that could bias the results of the study."

"True experiments have the potential to provide strong evidence about the hypothesized causal relationship between independent and dependent variables. Experiments are characterized by manipulation, control, and randomization. The quality of experiments depends on the validity of their design."

" Mixed methods research is a term associated with research that uses a combination of methods that are usually identified with qualitative research and methods that are usually identified with quantitative research. It should not be confused with the terms mixed models or mixed effects that are used in other contexts such as the analysis of variance.

It is important to understand that the use of a mixed methods approach does not make research better or more valid than the use of either a qualitative or a quantitative approach."

"In nursing research, triangulation refers to the use of multiple sources to validate findings by the nursing researcher. It involves the combination of both quantitative and qualitative research methods within a single study."

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Types of Study Designs

Study design terminology.

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Meta-Analysis A way of combining data from many different research studies. A meta-analysis is a statistical process that combines the findings from individual studies.   Example :

  • Anxiety outcomes after physical activity interventions: meta-analysis findings. Conn V. Nurs Res. 2010 May-Jun;59(3):224-31.

Systematic Review A summary of the clinical literature. A systematic review is a critical assessment and evaluation of all research studies that address a particular clinical issue. The researchers use an organized method of locating, assembling, and evaluating a body of literature on a particular topic using a set of specific criteria. A systematic review typically includes a description of the findings of the collection of research studies. The systematic review may also include a quantitative pooling of data, called a meta-analysis.   Example :

  • Complementary and alternative medicine use among women with breast cancer: a systematic review. Wanchai A, Armer JM, Stewart BR. Clin J Oncol Nurs. 2010 Aug;14(4):E45-55.

Randomized Controlled Trial A controlled clinical trial that randomly (by chance) assigns participants to two or more groups. There are various methods to randomize study participants to their groups.   Example :

  • Meditation or exercise for preventing acute respiratory infection: a randomized controlled trial. Barrett B, et al. Ann Fam Med. 2012 Jul-Aug;10(4):337-46.

Cohort Study (Prospective Observational Study) A clinical research study in which people who presently have a certain condition or receive a particular treatment are followed over time and compared with another group of people who are not affected by the condition.   Example:

  • Smokeless tobacco cessation in South Asian communities: a multi-centre prospective cohort study. Croucher R, et al. Addiction. 2012 Dec;107 Suppl 2:45-52.

Case-control Study Case-control studies begin with the outcomes and do not follow people over time. Researchers choose people with a particular result (the cases) and interview the groups or check their records to ascertain what different experiences they had. They compare the odds of having an experience with the outcome to the odds of having an experience without the outcome.   Example :

  • Non-use of bicycle helmets and risk of fatal head injury: a proportional mortality, case-control study. Persaud N, et al. CMAJ. 2012 Nov 20;184(17):E921-3.

Cross-sectional study The observation of a defined population at a single point in time or time interval. Exposure and outcome are determined simultaneously.   Example :

  • Fasting might not be necessary before lipid screening: a nationally representative cross-sectional study. Steiner MJ, et al. Pediatrics. 2011 Sep;128(3):463-70.

  Case Reports and Series A report on a series of patients with an outcome of interest. No control group is involved.   Example :

  • Students mentoring students in a service-learning clinical supervision experience: an educational case report. Lattanzi JB, et al. Phys Ther. 2011 Oct;91(10):1513-24.

Ideas, Editorials, Opinions Put forth by experts in the field.   Example :

  • Health and health care for the 21st century: for all the people. Koop CE. Am J Public Health. 2006 Dec;96(12):2090-2.

Animal Research Studies Studies conducted using animal subjects.   Example :

  • Intranasal leptin reduces appetite and induces weight loss in rats with diet-induced obesity (DIO). Schulz C, Paulus K, Jöhren O, Lehnert H. Endocrinology. 2012 Jan;153(1):143-53.

Test-tube Lab Research "Test tube" experiments conducted in a controlled laboratory setting.

Adapted from Study Designs. In NICHSR Introduction to Health Services Research: a Self-Study Course and Glossary of EBM Terms.

NOTE : Credit for the above content is given to  ***public health: General subject guide: About study designs . GSU Library Research Guides from https://research.library.gsu.edu/ph/studydesigns.

Bias  - Any deviation of results or inferences from the truth, or processes leading to such deviation. Bias can result from several sources: one-sided or systematic variations in measurement from the true value (systematic error); flaws in study design; deviation of inferences, interpretations, or analyses based on flawed data or data collection; etc. There is no sense of prejudice or subjectivity implied in the assessment of bias under these conditions.

Case Control Studies  - Studies which start with the identification of persons with a disease of interest and a  control  (comparison, referent) group without the disease. The relationship of an attribute to the disease is examined by comparing diseased and non-diseased persons with regard to the frequency or levels of the attribute in each group.

Causality  - The relating of causes to the effects they produce. Causes are termed necessary when they must always precede an effect and sufficient when they initiate or produce an effect. Any of several factors may be associated with the potential disease causation or outcome, including predisposing factors, enabling factors, precipitating factors, reinforcing factors, and risk factors.

Control Groups -  Groups that serve as a standard for comparison in experimental studies. They are similar in relevant characteristics to the experimental group but do not receive the experimental intervention.

Controlled Clinical Trials -  Clinical trials involving one or more test treatments, at least one control treatment, specified outcome measures for evaluating the studied intervention, and a bias-free method for assigning patients to the test treatment. The treatment may be drugs, devices, or procedures studied for diagnostic, therapeutic, or prophylactic effectiveness. Control measures include placebos, active medicines, no-treatment, dosage forms and regimens, historical comparisons, etc. When randomization using mathematical techniques, such as the use of a random numbers table, is employed to assign patients to test or control treatments, the trials are characterized as Randomized Controlled Trials.

Cost-Benefit Analysis  - A method of comparing the cost of a program with its expected benefits in dollars (or other currency). The benefit-to-cost ratio is a measure of total return expected per unit of money spent. This analysis generally excludes consideration of factors that are not measured ultimately in economic terms. Cost effectiveness compares alternative ways to achieve a specific set of results.

Cross-Over Studies -  Studies comparing two or more treatments or interventions in which the subjects or patients, upon completion of the course of one treatment, are switched to another. In the case of two treatments, A and B, half the subjects are randomly allocated to receive these in the order A, B and half to receive them in the order B, A. A criticism of this design is that effects of the first treatment may carry over into the period when the second is given.

Cross-Sectional Studies  - Studies in which the presence or absence of disease or other health-related variables are determined in each member of the study population or in a representative sample at one particular time. This contrasts with LONGITUDINAL STUDIES which are followed over a period of time.

Double-Blind Method -  A method of studying a drug or procedure in which both the subjects and investigators are kept unaware of who is actually getting which specific treatment.

Empirical Research  - The study, based on direct observation, use of statistical records, interviews, or experimental methods, of actual practices or the actual impact of practices or policies.

Evaluation Studies  - Works consisting of studies determining the effectiveness or utility of processes, personnel, and equipment.

Genome-Wide Association Study -  An analysis comparing the allele frequencies of all available (or a whole genome representative set of) polymorphic markers in unrelated patients with a specific symptom or disease condition, and those of healthy controls to identify markers associated with a specific disease or condition.

Intention to Treat Analysis -  Strategy for the analysis of Randomized Controlled Trial that compares patients in the groups to which they were originally randomly assigned.

Logistic Models  - Statistical models which describe the relationship between a qualitative dependent variable (that is, one which can take only certain discrete values, such as the presence or absence of a disease) and an independent variable. A common application is in epidemiology for estimating an individual's risk (probability of a disease) as a function of a given risk factor.

Longitudinal Studies  - Studies in which variables relating to an individual or group of individuals are assessed over a period of time.

Lost to Follow-Up -  Study subjects in cohort studies whose outcomes are unknown e.g., because they could not or did not wish to attend follow-up visits.

Matched-Pair Analysis -  A type of analysis in which subjects in a study group and a comparison group are made comparable with respect to extraneous factors by individually pairing study subjects with the comparison group subjects (e.g., age-matched controls).

Meta-Analysis  - Works consisting of studies using a quantitative method of combining the results of independent studies (usually drawn from the published literature) and synthesizing summaries and conclusions which may be used to evaluate therapeutic effectiveness, plan new studies, etc. It is often an overview of clinical trials. It is usually called a meta-analysis by the author or sponsoring body and should be differentiated from reviews of literature.

Numbers Needed To Treat -  Number of patients who need to be treated in order to prevent one additional bad outcome. It is the inverse of Absolute Risk Reduction.

Odds Ratio  - The ratio of two odds. The exposure-odds ratio for case control data is the ratio of the odds in favor of exposure among cases to the odds in favor of exposure among noncases. The disease-odds ratio for a cohort or cross section is the ratio of the odds in favor of disease among the exposed to the odds in favor of disease among the unexposed. The prevalence-odds ratio refers to an odds ratio derived cross-sectionally from studies of prevalent cases.

Patient Selection -  Criteria and standards used for the determination of the appropriateness of the inclusion of patients with specific conditions in proposed treatment plans and the criteria used for the inclusion of subjects in various clinical trials and other research protocols.

Predictive Value of Tests  - In screening and diagnostic tests, the probability that a person with a positive test is a true positive (i.e., has the disease), is referred to as the predictive value of a positive test; whereas, the predictive value of a negative test is the probability that the person with a negative test does not have the disease. Predictive value is related to the sensitivity and specificity of the test.

Prospective Studies  - Observation of a population for a sufficient number of persons over a sufficient number of years to generate incidence or mortality rates subsequent to the selection of the study group.

Qualitative Studies  - Research that derives data from observation, interviews, or verbal interactions and focuses on the meanings and interpretations of the participants.

Quantitative Studies  - Quantitative research is research that uses numerical analysis.

Random Allocation -  A process involving chance used in therapeutic trials or other research endeavor for allocating experimental subjects, human or animal, between treatment and control groups, or among treatment groups. It may also apply to experiments on inanimate objects.

Randomized   Controlled Trial  - Clinical trials that involve at least one test treatment and one control treatment, concurrent enrollment and follow-up of the test- and control-treated groups, and in which the treatments to be administered are selected by a random process, such as the use of a random-numbers table.

Reproducibility of Results -  The statistical reproducibility of measurements (often in a clinical context), including the testing of instrumentation or techniques to obtain reproducible results. The concept includes reproducibility of physiological measurements, which may be used to develop rules to assess probability or prognosis, or response to a stimulus; reproducibility of occurrence of a condition; and reproducibility of experimental results.

Retrospective Studies  - Studies used to test etiologic hypotheses in which inferences about an exposure to putative causal factors are derived from data relating to characteristics of persons under study or to events or experiences in their past. The essential feature is that some of the persons under study have the disease or outcome of interest and their characteristics are compared with those of unaffected persons.

Sample Size -  The number of units (persons, animals, patients, specified circumstances, etc.) in a population to be studied. The sample size should be big enough to have a high likelihood of detecting a true difference between two groups.

Sensitivity and Specificity -  Binary classification measures to assess test results. Sensitivity or recall rate is the proportion of true positives. Specificity is the probability of correctly determining the absence of a condition.

Single-Blind Method -  A method in which either the observer(s) or the subject(s) is kept ignorant of the group to which the subjects are assigned.

Time Factors  - Elements of limited time intervals, contributing to particular results or situations.

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research design nursing study

Understanding Nursing Research

  • Primary Research
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Experimental Design

Randomization vs random selection, randomized control trials (rcts), how do i tell if my article is a randomized control trial, how to limit your research to randomized control trials.

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Correlational , or non-experimental , research is research where subjects are not acted upon, but where research questions can be answered merely by observing subjects.

An example of a correlational research question could be, "What is relationship between parents who make their children wash their hands at home and hand washing at school?" This is a question that  I could answer without acting upon the students or their parents.

Quasi-Experimental Research is research where an independent variable is manipulated, but the subjects of a study are not randomly assigned to an action (or a lack of action).

An example of quasi-experimental research would be to ask "What is the effect of hand-washing posters in school bathrooms?" If researchers put posters in the same place in all of the bathrooms of a single high school and measured how often students washed their hands. The reason the study is quasi-experimental is because the students are not randomly selected to participate in the study, they just participate because their school is receiving the intervention (posters in the bathroom).

Experimental Research is research that randomly selects subjects to participate in a study that includes some kind of intervention, or action intended to have an effect on the participants.

An example of an experimental design would be randomly selecting all of the schools participating in the hand washing poster campaign. The schools would then randomly be assigned to either the poster-group or the control group, which would receive no posters in their bathroom. Having a control group allows researchers to compare the group of students who received an intervention to those who did not.

How to tell:

The only way to tell what kind of experimental design is in an article you're reading is to read the Methodologies section of the article. This section should describe if participants were selected, how they were selected, and how they were assigned to either a control or intervention group.

Random Selection means subjects are randomly selected to participate in a study that involves an intervention.

Random Assignment means subjects are randomly assigned to whether they will be in a control group or a group that receives an intervention.

Controlled Trials are trials or studies that include a "control" group. If you were researching whether hand-washing posters were effective in getting students to wash their hands, you would put the posters in all of the bathrooms of one high school and in none of the bathrooms in another high school with similar demographic make up. The high school without the posters would be the control group. The control group allows you to see just how effective or ineffective your intervention was when you compare data at the end of your study.

Randomized Controlled Trials (RCTs) are also sometimes called Randomized Clinical Trials. These are studies where the participants are not necessarily randomly selected, but they are sorted into either an intervention group or a control group randomly. So in the example above, the researchers might select had twenty high schools in South Texas that were relatively similar (demographic make up, household incomes, size, etc.) and randomly decide which schools received hand washing posters and which did not.

To tell if an article you're looking at is a Randomized Control Trial (RCT) is relatively simple.

First, check the article's publication information. Sometimes even before you open an article, you can tell if it's a Randomized Control Trial. Like in this example:

research design nursing study

If you can't find the information in the article's publication information, the next step is to read the article's Abstract and Methodologies. In at least one of these sections, the researchers will state whether or not they used a control group in their study and whether or not the control and the intervention groups were assigned randomly.

The Methodologies section in particular should clearly explain how the participants were sorted into group. If the author states that participants were randomly assigned to groups, then that study is a Randomized Control Trial (RCT). If nothing about randomization is mentioned, it is safe to assume the article is not an RCT.

Below is an example of what to look for in an article's Methodologies section:

research design nursing study

If you know when you begin your research that you're interested in just Randomized Control Trials (RCTs), you can tell the database to just show you results that include Randomized Control Trials (RCTs).

In CINAHL, you can do that by scrolling down on the homepage and checking the box next to "Randomized Control Trials"

research design nursing study

If you keep scrolling, you'll get to a box that says "Publication Type." You can also scroll through those options and select "Randomized Control Trials." 

research design nursing study

If you're in PubMed, then enter your search terms and hit "Search." Then, when you're on the results page, click "Randomized Controlled Trial" under "Article types."

If you don't see a "Randomized Controlled Trial" option, click "Customize...," check the box next to "Randomized Controlled Trial," click the blue "show" button, and then click on "Randomized Controlled Trial" to make sure you've selected it.

research design nursing study

This is a really helpful way to limit your search results to just the kinds of articles you're interested in, but you should always double check that an article is in fact about a Randomized Control Trial (RCT) by reading the article's Methodologies section thoroughly.

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Nursing Research

Levels of evidence / types of studies, research findings, literature search, quality improvement, types of studies/evidence defined, research impact -- journal impact factor.

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Levels of Evidence

Source: Nursetopia, March 2013.

  • Study Design 101 Tutorial by George Washington University. Describes different study designs.
  • Presenting research to clinicians: strategies for writing about research findings Nurse Researcher 2006. Vol. 13, Iss. 4; p. 66 (9 pages) Marilyn H Oermann, Elizabeth A Galvin, Judith A Floyd, Janna C Roop
  • Translating research into evidence-based nursing practice and evaluating effectiveness Coopey, M & Nix, MP Journal of Nursing Care Quality (2006) 21(3), 195-202.
  • The integrative review: updated methodology
  • How to undertake a literature search: a step-by-step guide Watson, M. (2020). How to undertake a literature search: A step-by-step guide. British Journal of Nursing (Mark Allen Publishing), 29(7), 431-435. https://doi.org/10.12968/bjon.2020.29.7.431
  • Differentiating Between Research and Quality Improvement Gregory, K. (2015). Differentiating Between Research and Quality Improvement. The Journal of Perinatal & Neonatal Nursing, 29 (2), 100-102. doi: 10.1097/JPN.0000000000000107.
  • What is a Systematic Review? As defined by the Cochrane Consumer Network, A systematic review summarises the results of available carefully designed healthcare studies (controlled trials) and provides a high level of evidence on the effectiveness of healthcare interventions. Judgments may be made about the evidence and inform recommendations for healthcare. Source: Cochrane Consumer Network
  • Randomized Controlled Trial A study design that randomly assigns participants into an experimental group or a control group. As the study is conducted, the only expected difference between the control and experimental groups in a randomized controlled trial (RCT) is the outcome variable being studied. Source: Study Design 101, GWU
  • Cohort Study A study design where one or more samples (called cohorts) are followed prospectively and subsequent status evaluations with respect to a disease or outcome are conducted to determine which initial participants exposure characteristics (risk factors) are associated with it. As the study is conducted, outcome from participants in each cohort is measured and relationships with specific characteristics determined. Source: Study Design 101, GWU
  • Case Control Study A study that compares patients who have a disease or outcome of interest (cases) with patients who do not have the disease or outcome (controls), and looks back retrospectively to compare how frequently the exposure to a risk factor is present in each group to determine the relationship between the risk factor and the disease. Source: Study Design 101
  • Case Report An article that describes and interprets an individual case, often written in the form of a detailed story. Case reports often describe: Unique cases that cannot be explained by known diseases or syndromes Cases that show an important variation of a disease or condition Cases that show unexpected events that may yield new or useful information Cases in which one patient has two or more unexpected diseases or disorders Case reports are considered the lowest level of evidence, but they are also the first line of evidence, because they are where new issues and ideas emerge. This is why they form the base of our pyramid. A good case report will be clear about the importance of the observation being reported. Source: Study Design 101
  • Expert Opinion defined by Merriam-Webster Dictionary a belief or judgment about something given by an expert on the subject
  • A tutorial on pilot studies: The what, why and how Thabane, L., Ma, J., Chu, R., Cheng, J., Ismaila, A., Rios, L. P., . . . Goldsmith, C. H. (2010). A tutorial on pilot studies: The what, why and how. BMC Medical Research Methodology, 10(1), 1-1. doi:10.1186/1471-2288-10-1
  • Understanding research impact: A review of existing and emerging tools for nursing. Wimmer, E. N., Rethlefsen, M. L., Jarvis, C., & Shipman, J. P. (2016). Understanding research impact: A review of existing and emerging tools for nursing. Journal of Professional Nursing, 32(6), 401-411. 10.1016/j.profnurs.2016.05.005
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Resources listed on these guides are compiled by librarians at the R.A. Williams Library. We accept content recommendations, and after review, may include suggested resources on a guide. Our time is limited, so we generally do not reply to unsolicited recommendations from individuals not affiliated with AdventHealth University or notify them regarding whether or not we have linked to suggested content.

Determining the level of evidence: Nonexperimental research designs

Affiliation.

  • 1 Amy Glasofer is a nurse scientist at Virtua Center for Learning in Mt. Laurel, N.J., and Ann B. Townsend is an adult NP with The Nurse Practitioner Group, LLC.
  • PMID: 33953103
  • DOI: 10.1097/01.NURSE.0000731852.39123.e1

To support evidence-based nursing practice, the authors provide guidelines for appraising research based on quality, quantity, and consistency. This article, the second of a three-part series, focuses on nonexperimental research designs.

Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.

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Library Research Guides - University of Wisconsin Ebling Library

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Nursing Resources : Types of Research within Qualitative and Quantitative

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Aspects of Quantative (Empirical) Research

♦   Statement of purpose—what was studied and why.

  ♦   Description of the methodology (experimental group, control group, variables, test conditions, test subjects, etc.).

  ♦   Results (usually numeric in form presented in tables or graphs, often with statistical analysis).

♦   Conclusions drawn from the results.

  ♦   Footnotes, a bibliography, author credentials.

Hint: the abstract (summary) of an article is the first place to check for most of the above features.  The abstract appears both in the database you search and at the top of the actual article.

Types of Quantitative Research

There are four (4) main types of quantitative designs: descriptive, correlational, quasi-experimental, and experimental.

samples.jbpub.com/9780763780586/80586_CH03_Keele.pdf

Types of Qualitative Research

http://wilderdom.com/OEcourses/PROFLIT/Class6Qualitative1.htm

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  • Last Updated: Nov 30, 2023 2:31 PM
  • URL: https://researchguides.library.wisc.edu/nursing
  • Open access
  • Published: 21 February 2024

Usefulness of pedagogical design features of a digital educational resource into nursing home placement: a qualitative study of nurse educators’ experiences

  • Monika Ravik   ORCID: orcid.org/0000-0002-1490-9341 1 ,
  • Kristin Laugaland   ORCID: orcid.org/0000-0003-3451-2584 2 ,
  • Kristin Akerjordet   ORCID: orcid.org/0000-0002-4300-4496 2 , 3 ,
  • Ingunn Aase   ORCID: orcid.org/0000-0002-0243-6436 2 &
  • Marianne Thorsen Gonzalez   ORCID: orcid.org/0000-0003-1208-5470 1  

BMC Nursing volume  23 , Article number:  135 ( 2024 ) Cite this article

Metrics details

The rapid advancement of technology-enhanced learning opportunities has resulted in requests of applying improved pedagogical design features of digital educational resources into nursing education. Digital educational resources refers to technology-mediated learning approaches. Efficient integration of digital educational resources into nursing education, and particularly into clinical placement, creates considerable challenges. The successful use of digital educational resources requires thoughtful integration of technological and pedagogical design features. Thus, we have designed and developed a digital educational resource, digiQUALinPRAX, by emphasizing pedagogical design features. The nurse educators’ experiences of the usefulness of this digital educational resource is vital for securing improved quality in placement studies.

To obtain an in-depth understanding of the usefulness of the pedagogical design features of a digital educational resource, digiQUALinPRAX, in supporting nurse educators’ educational role in nursing home placements in the first year of nursing education.

An explorative and descriptive qualitative research design was used. Individual semi-structured interviews were conducted with six nurse educators working in first year of a Bachelor’s of Nursing programme after using the digital educational resource, digiQUALinPRAX, during an eight-week clinical placement period in nursing homes in April 2022.

Two main categories were identified: (1) supporting supervision and assessment of student nurses and (2) supporting interactions and partnerships between stakeholders.

The pedagogical design features of the digiQUALinPRAX resource provided nurse educators with valuable pedagogical knowledge in terms of supervision and assessment of student nurses, as well as simplified and supported interaction and partnership between stakeholders.

Peer Review reports

Contributions of the paper

What is already known.

The educational role in clinical placement education poses substantial challenges for nurse educators, such as tailoring pedagogical approaches to the learning needs and abilities of individual students.

Digital educational resources are increasingly used in clinical placement education in nursing to enhance student learning.

To improve the quality of clinical placement learning for student nurses, attention should be paid to the design, development, and use of digital educational resources.

What this paper adds

This paper adds that nurse educators experienced that pedagogical design features of a digital educational resource, digiQUALinPRAX, provided them with valuable knowledge in supervising and assessing student nurses in clinical placement education in nursing homes.

This paper further adds that nurse educators experienced that the pedagogical design features of the digital educational resource, digiQUALinPRAX, were supportive and enhanced their role by providing possibilities for interaction and partnership between stakeholders in nursing home placement.

Nursing homes hold great potential as clinical learning arenas for first year student nurses; thus, improved quality in these clinical placement studies is crucial [ 1 ]. To provide optimal and high-quality clinical placement education and benefit from the nursing home learning potential, nurse educators play a key role in their supervision and assessment approaches [ 2 ]. Thus, nurse educators’ pedagogical approaches during clinical placement education entails meeting different levels of students’ individual learning needs and preparedness for learning [ 3 ]. From this perspective, nurse educators’ competence, engagement, pedagogical practice and experience might motivate or demotivate student nurses early on in their education, both directly and indirectly, for their future careers working with elderly in the nursing home context [ 4 ]. However, in nursing homes as an important learning context, recruiting registered nurses filling roles as students’ clinical supervisors is often a challenge [ 5 , 6 ].

Nonetheless, supervising student nurses during placement education in nursing homes is reported to be a low priority among nurse educators [ 5 ]. Additionally, nurse educators in nursing homes frequently lack the formal preparation to fulfil their educational role at the expected educational level [ 5 , 7 ], and are often hired to act as nurse educators for a short time during placement education [ 5 ]. Consequently, part-time nurse-educators will lead to a lack of continuity in student follow-ups [ 5 ]. Thus, addressing improved quality in clinical supervision and assessment in the Bachelor’s of Nursing Education Programs is vital [ 8 , 9 ].

Tailoring pedagogical approaches to students’ individual learning needs pose substantial challenges for nurse educators [ 10 ]. Thus, supporting and enhancing nurse educators’ proficiency in supervising student nurses during placement education in nursing homes for pedagogical purposes has been suggested; this should be done using digital educational resources [ 8 ]. The present study responds to this request.

The use of digital educational resources has been increasingly developed owing to the extensively available and easily accessible internet connection [ 11 ]. These resources could be electronic (e-learning), mobile (m-learning), and online and game-based learning [ 12 , 13 , 14 , 15 ]. Digital educational resources are innovative educational approaches to provide knowledge in an interactive and flexible environment, thus facilitating personalised learning and improved understanding [ 16 , 17 ]. Digital educational resources aimed at ensuring that student nurses have appropriate learning opportunities and that experiences are increasingly being used [ 18 , 19 , 20 , 21 , 22 ].

However, integrating digital educational resources in various educational institutions goes beyond easy and flexible access to these learning resources. Koehler and Mishra [ 23 ] underline the need to effectively utilise these resources for educational purposes. Thus, there is a need for educators to improve their understanding of using digital educational resources when teaching, supervising, and assessing to optimally enhance students’ learning experiences [ 23 , 24 ]. Nurse educators are often underconfident and unable to optimally use digital resources, and thus are unable to understand how to modify their pedagogical approaches digitally [ 10 , 16 , 17 , 25 ]. A recent review has reported that digital educational resources in nursing education often lacks anchoring in pedagogical theories [ 26 ]. Consequently, this will directly affect the quality of education provided to student nurses [ 16 ]. To compensate for the above mentioned shortcomings, we designed and developed a digital educational resource, digiQUALinPRAX. This resource aims to support nurse educators in developing suitable and theoretically anchored pedagogical knowledge that is adapted to student nurses during nursing home placement [ 8 ]. The co-creative process informed the educational content, design, and functionality of the digiQUALinPRAX resource, which were informed by and grounded in learning theory and principles, in line with Koehler and Mishra’s [ 23 ] ‘Technological pedagogical and content knowledge’ framework. Technological knowledge refers to knowledge of the technological characteristics, whereas pedagogical knowledge refers to how students learn best, and content knowledge refers to the domain-specific subject matter that is being taught and learned [ 23 ]. Koehler and Mishra [ 23 ] emphasise the necessity of interrelatedness and dynamic interplay between content and pedagogical and technological knowledge to effectively cater to students’ learning needs. Here, technological pedagogical knowledge refers to knowledge about the use of technology to optimally implement pedagogical approaches (i.e. the use of digital educational resources as a vehicle for the learning outcomes and experiences desired by an educator) [ 23 ].

This study aimed to obtain an in-depth understanding of how nurse educators experienced the usefulness of the pedagogical design features of the digiQUALinPRAX resource to support their role in nursing home placements. Experiences enables the identification and addressing of any issues that require improvement before the final version of a digital educational resource is released, resulting in a better pedagogical experience for nurse educators [ 27 ]. When exploring experiences about digital educational resources, experiencing educators’ feedback is crucial. This is because they have the pedagogical competence and experience necessary to create resources that align with curriculum goals [ 28 ].

The current study applied an explorative and descriptive qualitative research design. This is appropriate for investigating an unexplored subject descriptively, along with its characteristics [ 29 ]. The study is part of a larger research project [ 8 ] that developed the digiQUALinPRAX resource. The digiQUALinPRAX resource was co-created with key stakeholders (i.e. student nurses, nurse educators, registered nurse mentors, e-learning designers and researchers) to enhance quality in nursing home placements, including the support and enhancement of the nurse educators’ role. For a detailed description of the overall co-creative development process, see Laugaland et al. [ 30 ].

Educational placement context

In Norway, becoming a registered nurse requires the successful completion of a 3-year Bachelor’s curriculum programme (180 credits), developed in accordance with the European Directive [ 31 ] and national regulations [ 32 ]. Half of this nursing education programme in Norway and elsewhere in Europe comprises of the clinical placement component [ 31 , 32 ]. As part of their professional responsibilities, the qualified and experienced registered nurses fulfilled the role of registered nurse mentors for students during their clinical placements. They focused on mentorship rather than actively teaching and developing the students’ competencies, indicating that mentoring by registered nurses was service-led rather than educationally driven. Although these registered nurse mentors possessed appropriate qualifications, they lacked formal academic educator competencies. Meanwhile, nurse educators bridged the gap between academic and placement knowledge. They possessed pedagogical knowledge and played a vital role in supporting, supervising and assessing student nurses. Nurse educators, who hail from the academic setting, bear the pivotal responsibility for the final decision of whether students pass or fail. They support, supervise and assist students and their registered nurse mentors during clinical placement and take care of the collaboration between these two stakeholders. The clinical experience for student nurses was set up through a collaborative effort between nurse educators from the university setting and registered nurse mentors in the clinical setting. In this collaboration, nurse educators were crucial to facilitating clinical learning experiences by securing optimal learning situations in the nursing homes in line with the educational learning outcomes. In these learning situations, the registered nurse mentors served as facilitators, mentors and role models. They also consistently provided valuable insight from their professional experiences, offered daily mentoring, and delivered feedback. This collaboration between the stakeholders aimed to help students in bridging the gap between the knowledge gained in the university setting and their clinical experiences in the nursing homes.

The digiQUALinPRAX resource being experienced in the study

The digiQUALinPRAX resource (Fig.  1 ) is a password-protected learning management system named Canvas (website), a technology that is used to plan, implement, and assess learning processes [ 33 ]. The overall educational aim of the digiQUALinPRAX resource was to enhance quality in nursing home placements by addressing students’ learning and the mentorship practices of educators and registered nurses (i.e. supervision and assessment). Nurse educators and registered nurse mentors, in turn, utilised this resource to enhance their teaching strategies, coordinate clinical placement activities, and ensure meaningful and enriching learning experiences for their students. The digiQUALinPRAX resource was designed to support the collaborative efforts of the stakeholders, fostering a dynamic and effective learning environment within the entire context of clinical placement education in nursing homes.

The digiQUALinPRAX resource consists of several core components as design features (i.e. interactive components, content components , and resource components ). The interactive components entailed features such as file sharing and messaging (through a dialogue forum), enabling stakeholders to interact with each other during the placement period. The dialogue forum provided a digital room where nurse educators and registered nurse mentors could provide written feedback on students’ assignments submitted through the digital educational resource.

Furthermore, the content components of the digiQUALinPRAX resource consisted of three content modules, including practical, educational, and contextual knowledge relevant for clinical placement in nursing homes. The three content modules were organized with different topics by the following titles: (1) Preparation to the clinical placement; (2) To study and supervise in clinical placementt; and (3) assessment of professional nursing competence. The first content module contained literature on pre-placement information, addressing the nursing home as a learning arena, role expectations, and schedule of the placement period. This content module further included a fixed time structure with predefined meetings. Additionally, an overview of the students’ theoretical educational content before placement and thus, their expected level of professional competence, was provided. The second content module contained literature on how to study, learn, and provide appropriate mentoring. This module provided examples of learning situations, as well as a description of students’ competence domains. These were tailored to accommodate the students’ learning objectives and mentoring activities. The use of reflection as a learning strategy was emphasized in this module. During the eight-week placement period, students had to write several reflection papers about various topics. The module further facilitated possibilities for nurse educators to provide written feedback on the reflection papers to stimulate and enhance students’ reflection skills. The third content module focused on assessment practices and provided information about formal and formative assessments. This was done by thoroughly describing the assessment forms through exemplifying how they could be used based on one specific patient situation. The formal assessment documents were all available directly in the digiQUALinPRAX resource.

The resource components of the digiQUALinPRAX resource consisted of practical, educational, and context-specific resources. These resources were illustrations, podcasts, video lectures, reflective activities, case-related activities, and resources to support nurse educators’ educational roles. Additional resources were study requirements, advice, and summaries of the core components.

figure 1

Core components of the digiQUALinPRAX resource

Study sample and recruitment

The target group for this study was nurse educators who were employees at one university in Norway, at which the digiQUALinPRAX was explored. The inclusion criterion was nurse educators having used the digiQUALinPRAX resource during an eight-week clinical placement period in nursing homes.

A purposive sampling strategy [ 34 ] was applied to recruit participants. After obtaining approval from the Vice-Dean of the Faculty of Health Sciences, potential nurse educators were sent recruitment e-mails. The e-mails contained general study information and a waiver of consent. Invitations were sent openly to nurse educators who had a supervisory responsibility to student nurses in nursing home placement. Six nurse educators consented to participate and received complete verbal information about the study. We considered these six nurse educators to be a representative sample [ 35 ] because they had used the digiQUALinPRAX resource during an eight-week placement period.

Research context

One week before the clinical placement period, the digiQUALinPRAX resource was precented and made accessible to the stakeholders (i.e. nurse educators, student nurses and registered nurse mentors) involved in the overall study. All stakeholders had access to the digiQUALinPRAX resource throughout the eight-week clinical placement period. As the target group in this study, the nurse educators were the only stakeholders possessing pedagogical knowledge and thus played a vital role in supporting, supervising, and assessing student nurses during their placements using the digiQUALinPRAX resource. Furthermore, they were responsible for collaborating with registered nurse mentors in their supervision of student nurses and in the use of the digiQUALinPRAX resource.

Data collection

Individual qualitative interviews with the six nurse educators were conducted for data collection. Data from individual interviews are valuable when the insight and understanding of participants’ perceptions, experiences, thoughts, and suggestions with respect to a given subject are of interest [ 29 ]. The qualitative nature of our research design, employing an in-depth exploration of the experiences of nurse educators, warranted a focus on detailed and context-specific insight rather than a large sample size [ 35 ]. The selected sample size was determined through a careful balance between power of information and the specific group of nurse educators with unique experience characteristics, which contribute to the depth of the analysis and results [ 35 ]. The nurse educators’ interviews were arranged in an academic nursing setting immediately after the eight-week clinical placement period in nursing homes for first year student nurses. Data were collected by the first author in April 2022.

A semi-structured interview guide was employed, addressing themes such as supervision and assessment possibilities, partnership, interaction and communication opportunities, and knowledge provided by the digital educational resource (see Supplementary File 1 ). Participants were offered opportunities to speak freely about their experiences, with follow-up questions where appropriate. Owing to COVID-19 restrictions, all interviews were conducted through a virtual platform via ZOOM using video and sound. This interview format encouraged two-way communication, allowing for conversations on relevant themes [ 29 ]. The interviews were audio recorded and lasted between 56 and 99 min. The six nurse educators provided rich information on their experienced usefulness of the pedagogical design features of the digiQUALinPRAX resource. The more information the participants held relevant to the actual study, the lower the number of participants needed [ 35 ].

Data analysis

All audio files were transcribed verbatim, resulting in text describing spoken words from the audio files underpinning the analysis, as recommended by Halcomb and Davidson [ 36 ]. After transcription of the audio files, text data were analysed using systematic text condensation in line with Malterud [ 37 ] (e.g. an explorative and descriptive method for thematic analysis that addresses the characteristics and essence of the subject being studied). NVivo software [ 38 ] version 12 was used for data analysis.

Data analysis was inductive; the text was re-read for a general overview and to familiarise the researchers with the content. Preliminary themes were captured in the first phase of the analysis. In the second phase, meaning units were identified and organised in relation to each of the themes captured in phase one. This data extraction approach entailed the decontextualization of the text: to be separated into parts or segments and removed from the belonging context [ 37 ]. Each meaning unit was coded and sorted into code groups. These were created in relation to each theme and provided a platform for the next phase of the analysis, in which a deeper meaning of experience was sought. In the third phase, the code groups were divided into sub-groups; the meaning units in the sub-groups were rewritten into condensates [ 37 ]. I–form was chosen to optimally represent the participants’ views, and their own words were used to maintain the original terminology. After completing the condensates, illustrative quotations (translated into English) were selected. Adjustments were made to provide a clearer understanding of the statements. In the fourth phase, the decontextualised text was recontextualised and synthesised; that is, parts were put into a new context while being true to the text from which the data were extracted. The condensed text from each sub-group within the code groups ‘went beyond’ the condensates, and new interpretive descriptions about the subject being studied were generated, to be presented in a third-person format [ 37 ]. Throughout the analysis, the first and last authors discussed the codes, sub-categories, and categories until reaching consensus. The recontextualisation resulted in two categories and five sub-categories.

To ensure the trustworthiness of this qualitative study, credibility, dependability, transferability, and confirmability were considered

[ 39 ]. Credibility was ensured in this study using an interview guide to establish consistency in the data collection process. Furthermore, video recordings (ZOOM) and transcription of the interviews verbatim helped ensure an accurate and complete representation of the nurse educators’ responses. Dependability was ensured by describing data collection and analysis in detail. NVivo was used to organise and visualise the data. Moreover, nurse educators’ arguments were quoted to show the links between the findings and data. To enhance the transferability, detailed descriptions of the research process were provided. Investigator triangulation was applied, where the first and last authors engaged in discussions and revisited the transcripts to ensure that the interpretations were supported by the data transcripts. The first and last authors held regular meetings to discuss the data analysis and ensure confirmability. Nurse educators were selected to provide in-depth data. Few participants were needed; information power was attained owing to the sample specificity and quality of dialogue [ 35 ].

Ethical considerations

This study was approved by the Norwegian Centre for Research Data (2018/61,309 and 489,776) and the university included prior to data collection. According to national regulations, approval from a medical ethical committee (Regional Committees for Medical and Health Research Ethics) to collect this type of data was not necessary. The study was conducted in accordance with the ethical principles of the Declaration of Helsinki [ 40 ]. The consolidated criteria for reporting qualitative research (COREQ) guideline was used to report the study. All participants received written and verbal information about the study, including the voluntary nature of participation and the right to withdraw from the study. All participants provided written informed consent, while non-participants refused to take part in the study. To ensure confidentiality, participants’ characteristics such as age, sex, educational background, and years of experience in placement education supervision were not provided. All data were anonymised and securely stored to ensure confidentiality and protect private information.

The qualitative analysis of nurse educators’ experiences in relation to the pedagogical design features of the developed digiQUALinPRAX resource resulted in perceptions and reflections of the following key categories: (1) supporting supervision and assessment of student nurses and (2) supporting interaction and partnership between stakeholders (Table  1 ).

Supporting supervision and assessment of student nurses

Nurse educators experienced that the pedagogical design features of the digiQUALinPRAX resource allowed for supporting supervision and assessment in terms of giving students feedback on their written assignments, encouraging their reflections and facilitating summative assessments of their study progression.

Offering possibilities to provide students feedback on their written assignments (directly in the dialogue forum)

Nurse educators positively experienced the interactive component of the digiQUALinPRAX resource as providing possibilities for giving written feedback on students’ written submissions in the dialogue forum, both from nurse educators and registered nurse mentors. Moreover, nurse educators experienced the digiQUALinPRAX resource to be useful as it forced them to provide feedback on all the students’ written assignments. However, they found it challenging to provide written feedback via the dialogue forum because it was not possible to simultaneously review students’ submissions while providing written feedback through the digiQUALinPRAX resource.

I had to go in and out of the dialogue forum when written feedback was provided on students’ submissions to read the text of the submissions. (Informant 4)

Offering possibilities to encourage students’ reflections

Nurse educators experienced the digiQUALinPRAX resource to be useful in terms of guiding specific topics for the reflection papers that were written and submitted by student nurses during placement, stating that it contributed to a more common focus on student learning during placement. They also positively experienced that the digiQUALinPRAX resource ensured that the topics of the reflection papers were not arbitrary and dependent on the individual nurse educators’ personal recommendations and preferences, which helped them provide more consistent supervision with a focus on student learning.

Learning focus became more common for student nurses because the digital educational resource guided them in terms of the topics that they should write about. (Informant 5)

Furthermore, nurse educators experienced the digiQUALinPRAX resource-led reflection papers written by students as a useful source of information. Specifically, these papers allowed nurse educators to gain valuable insights into each student’s learning and knowledge levels, enabling them to identify areas requiring further attention for learning and development. They experienced such papers as providing them with a clear understanding of the aspects that they should focus on and providing feedback to students. This approach enabled them to help correct misunderstandings and fill gaps in students’ academic and professional knowledge.

The use of the digiQUALinPRAX resource was experienced by nurse educators to help both inexperienced and experienced nurse educators when supervising students in nursing home placements and guiding reflection group meetings. Inexperienced nurse educators were helped to understand the concept and purpose of reflection and how to encourage students to engage in reflective processes. They further faced experienced educators as helping them obtain a better structure for the reflection group meeting, focusing on the reflection group towards the real education levels and learning outcomes. Nurse educators experienced that the use of the digiQUALinPRAX resource in reflection group meetings resulted in a superior focus on students’ learning processes. Moreover, supervision became more student- rather than teacher-centred.

I became more like a facilitator than a nurse educator in the reflection group meetings because the digital educational resource-led questions helped me encourage the students to reflect amongst themselves and with me as an educator. (Informant 1)

Nurse educators experienced the digiQUALinPRAX resource-led pedagogical materials as useful in influencing students’ engagement and verbal activity during reflection group meetings.

The case is great to work on together with the students. Additionally, the students enjoyed working on the case, they became actively engaged. (Informant 4)

Nurse educators experienced that digiQUALinPRAX resource-led pedagogical materials, such as cases, care plans, and reflection questions, served as a foundation for the reflection group meetings and consequently, facilitated students’ development of professional understanding and competence about the nursing profession.

Facilitating provision of summative assessments of students’ study progression

Several nurse educators experienced that using digiQUALinPRAX resource-led single patient situations as the basis for providing summative student assessments restricted the ability to comprehensively assess student progression on all items of the assessment form.

Sufficient data were unavailable to provide summative assessments of student progression using only one patient situation. (Informant 2)

Some nurse educators included multiple patient situations as the basis for providing summative student assessments, even though this was not guided by the digiQUALinPRAX resource; they experienced this to be beneficial for ensuring comprehensive coverage of all items on the assessment form. The nurse educators felt that this allowed students to demonstrate their study progress and identify areas of improvement.

It was unproblematic that the varied assessment items were written based on different patient situations because they provided more information about the student’s progression. (Informant 1)
Students completed the assessment based on several patient situations to show their knowledge well enough. (Informant 6)

Nurse educators experienced their role in summative assessment meetings as more constructive when registered nurse mentors completed the digiQUALinPRAX resource-led assessment form prior to the summative assessment meetings. This was because they adopted a cautious approach during assessment meetings as the registered nurse mentors’ verbal participation increased when they filled in their digiQUALinPRAX resource-led student evaluation form prior to the assessment. Specifically, nurse educators regarded it as a positive experience when registered nurse mentors provided clear verbal feedback on areas where students required further progress during the placement study.

Registered nurse mentors’ threshold for being verbally engaged during summative assessment situations was lowered because they had completed the digital-educational resource-led assessment form prior to the assessment meetings (Informant 1) .
Registered nurse mentors who had prepared themselves by writing in the digital educational resource-led assessment form were more verbally engaged during the summative assessment meetings. (Informant 6)

The registered nurse mentors’ clear and precise communication of students’ areas that required improvement during the placement was experienced positively by the nurse educators, as it provided them with a clear focus on what to prioritise when further supervising the students’ progress.

When the registered nurse mentor completed the digital-educational resource-led assessment form and was verbally engaged during the summative assessment meeting, the student’s next steps became clear. (Informant 2)

Supporting interaction and partnership between stakeholders

Nurse educators experienced that the interactive digiQUALinPRAX resource design contributed to increased support for interactions and establishing partnerships between stakeholders through stimulating communication and cooperation between stakeholders.

Simplifying and supporting interactions and cooperation between the stakeholders

Nurse educators experienced that the digiQUALinPRAX resource-led timeline enabled them to schedule equal in-person supervision group meetings with students during their clinical placement. Further, they experienced interactions and cooperation with students as important for encouraging students to engage in appropriate and meaningful learning processes and as a feature of conducting accurate student assessments during placements.

I established closer contact with the students because I used the digital education resource. (Informant 6)

Additionally, nurse educators experienced their cooperation with registered nurse mentors to have improved because of the use of the digiQUALinPRAX resource; that is, the registered nurse mentors contacted nurse educators more during clinical placement compared with before. As part of the appropriate student supervision, nurse educators emphasised the importance of a proper relationship between the clinical placement setting and various registered nurse mentors.

The threshold for the registered nurse mentors to contact me as an educator was lowered owing to the use of the digital educational resource. (Informant 1)

Simplifying and stimulating communication using the dialogue forum

Nurse educators experienced the dialogue forum usage to be unclear, and gave feedback on how they could appropriately use the dialogue forum (i.e. the digiQUALinPRAX resource-led interactive component that facilitates communication between the stakeholders during the placement).

Clarifications about the use of the dialogue forum should have been made because we were not used to making discussions in this forum. (Informant 1)

However, the nurse educators considered that the dialogue forum should only provide possibilities for communication between the varied stakeholders included in the supervision collaboration: the students, registered nurse mentors, and nurse educators. Nurse educators experienced this as a necessity for a dialogue forum that also fosters transparency and open communication between the nurse educator and their student group, such as an information channel providing possibilities for a nurse educator to disseminate the same information to all students in the student group simultaneously.

It is out of question sending information to students individually that can be disseminated to all students. (Informant 5)

Nurse educators experienced it that it was necessary for a dialogue forum to provide possibilities for confidentiality (e.g. as an alternative to emails for stakeholder communication). Moreover, confidentiality was not ensured in cases where students might not pass their placement. Students’ exclusion from the forum was requested when discussions solely between the educator and registered nurse mentor might be necessary.

I cannot raise challenging student situations in a dialogue forum if the student has access to the digital room. (Informant 3)

The current study aimed to explore and describe how nurse educators experienced the usefulness of the pedagogical design features of the digiQUALinPRAX resource from their perspective. Nurse educators’ positive experiences regarding the digital educational resource highlighted the pedagogical design features as unique features, improving their supervision and assessment of student nurses during clinical placement education in nursing homes. These findings align with those of previous studies suggesting that pedagogical design is essential for creating digital educational resources [ 26 ]. This is an important finding, as pedagogical design features are often overlooked in the technologies designed to enhance and support clinical placement education in Bachelor’s nursing programmes [ 26 , 41 ].

Nurse educators experienced the interactive communication features of the digiQUALinPRAX resource as a valued component, as it enhanced their ability to provide written feedback on students’ submissions for their learning processes. This finding is also important, as earlier research [ 42 , 43 ] has revealed that many students received insufficient written feedback on their submissions from nurse educators during clinical placement education. This inappropriate feedback may have a negative influence on students’ learning experiences, whereas it might hinder them in their ability to identify areas in which they need to improve and further study to close their gap in knowledge [ 43 ]. Hence, feedback plays a crucial role in supporting students in understanding their strengths and weaknesses, thereby helping them achieve their learning outcomes [ 44 , 45 , 46 ].

Providing written feedback on student submissions was also important for nurse educators in our study. File sharing, as an interactive part of the digiQUALinPRAX resource, enabled the nurse educators to gain insights into the students’ knowledge levels and provide feedback based on their individual learning needs. This aligns with the sociocultural learning perspective, which underscores Vygotsky’s [ 46 ] theory of learning and development. According to this theory, interactions with more proficient persons can help the learner advance to the next level of knowledge and understanding within their zone of proximal development.

Our findings also revealed that nurse educators experienced that scheduled digiQUALinPRAX resource-led submissions contributed to students receiving frequent feedback. This finding is in line with the results of Bosse et al. [ 47 ], who emphasised the benefits of receiving frequent feedback, as it led to better learning outcomes. Moreover, this illustrates that considering integrating pedagogical design features when developing digital educational resources is valuable in stimulating nurse educators to facilitate students’ learning processes.

Nurse educators noted that pedagogical design features of the digiQUALinPRAX resource helped them encourage students to actively engage in reflective thinking, both verbally and in writing. Reflective thinking involves critically analysing experiences, considering one’s thoughts and emotions and examining the broader context [ 48 ]. Improved learning through reflective-thinking processes among students has also been considered in prior research, showing that it can deepen the comprehension of learning objectives and increase the awareness of decision-making in clinical reasoning [ 49 , 50 ]. This indicates the importance of possessing reflective thinking skills, not only in improving self-directed learning but also in delivering high-quality patient care [ 48 , 51 ].

The study findings indicated that pedagogical design features of the digiQUALinPRAX resource facilitated a shift in the nurse educators’ role in reflection group meetings. The shift entailed moving from being nurse educators who often communicated their knowledge to assuming the role of facilitators who guided discussions and encouraged students’ reflections and critical thinking. This pedagogical approach prioritises a student-centred learning model, enabling student nurses to construct their understanding actively rather than passively receiving the presented information [ 49 , 50 ]. This finding is important because nurse educators often fail to involve students in reflective-thinking activities during their educational process, resulting in a lack of student participation and difficulties in comprehending learning objectives [ 6 , 48 , 52 , 53 , 54 , 55 ]. Regarding this issue, Dalsmo et al. [ 52 ] revealed that nurse educators were often ‘invisible’ in students’ learning processes during nursing home placement, hindering students’ ability to participate fully and comprehend the learning objectives.

Nurse educators positively experienced that pedagogical design features of the digiQUALinPRAX resource encouraged registered nurse mentors to provide a written assessment concerning both the strengths and weaknesses of student progression prior to summative assessment meetings, resulting in registered nurse mentors becoming more verbal during the meetings. Several studies have reported that nurse educators experience challenges in assessment meetings because of registered nurse mentors’ silence [ 42 , 52 , 56 ]. When nurse educators in our study experienced that registered nurse mentors wrote and verbalised what was expected from the students to work on during the remaining placement study, they were given opportunities to gear their student supervision towards the learning needs to focus on. From this perspective, nurse educators experienced that pedagogical design features of the digiQUALinPRAX resource facilitated both themselves and the registered nurse mentor to develop a common understanding regarding students’ learning needs. Previous research has revealed that educators and registered nurse mentors often have different expectations regarding students’ learning needs during placement studies [ 56 , 57 ]; thus, creating a common understanding among the stakeholders is crucial for effective student supervision.

Having a clear structure in the form of a timeline was a distinct pedagogical design feature of the digiQUALinPRAXresource that enhanced nurse educators’ student supervision abilities. They reported that the timeline specifying the number of physical meetings to be held during the placement period (and when they occurred) contributed to nurse educators being able to organise physical meeting frequency more equally. This is a valuable pedagogical design feature of the digiQUALinPRAX resource because dissatisfaction among students with their nurse educators’ physical presence in follow-ups during placement studies has been reported [ 3 , 6 ]. Further, the nurse educators experienced the timeline-defined specific topics for the reflection papers positively, ensuring that the topics did not become dependent on individual nurse educators’ preferences. In Ravik et al. [ 42 ], nurse educators requested greater consensus among themselves to enhance student supervision. Differences among nurse educators might be perceived as unjust by students and could account for some students learning more than others during placement studies because they receive more personalised attention from their nurse educators [ 58 ]. Therefore, including timeline-defined physical meetings for nurse educators and defined topics of the reflection papers might help address this issue. Both Cant et al. [ 3 ] and Laugaland et al. [ 8 ] reported that inconsistency between educators hinders improvements in students’ learning. Moreover, it was deemed essential for nurse educators to be physically present during clinical placement to ensure that they maintained suitable communication with registered nurse mentors. These findings are consistent with those of previous studies, suggesting that appropriate relationships and communication between stakeholders are critical for creating a supportive and collaborative learning environment for students [ 3 ].

Nurse educators positively experienced the inclusion of interactive design features in the form of a dialogue forum. This forum played a vital role in facilitating interactions between students and the stakeholders involved in overseeing and supervising students during their nursing home placement. Previous research supports the notion that this interactive design feature, integrated into digital educational resources, is essential for effectively implementing and utilising technology to enhance student supervision [ 20 , 42 , 59 ]. Notably, the presence of such dialogue forums, which enables interaction among stakeholders, has been reported as an indicator of satisfaction with digital educational resources [ 20 ]. This underscores the importance of fostering a sense of belonging within a learning community, which has been recognised as vital to student nurses’ placement learning experiences [ 60 ]. Even though the nurse educators highlighted the importance of a dialogue forum contributing to openness between all stakeholders during student supervision, they pointed out that the dialogue forum should be available for the nurse educator and registered nurse mentor only, allowing for confidential dialogues in challenging situations. Therefore, the interactive dialogue forum can create an atmosphere where nurse educators and registered nurse mentors can share concerns, exchange perspectives, and collaboratively develop strategies to address the challenges faced by students [ 42 ]. This is in line with previous research suggesting that open and confidential communication among stakeholders contributes to finding common ground and fostering productive resolutions [ 57 ].

Limitations and future research directions

Some limitations should be considered when interpreting the results of this study. Individual interviews were conducted by the first author, who was also involved in the design and development of the digital educational resource, digiQUALinPRAX. However, the first author was unknown to the participants, and lived and worked in another part of the country. Additionally, the participants were encouraged to frankly share their experiences and opinions regarding the use of digital educational resources. Despite the small sample size, the rich information that they provided allowed for the in-depth feedback and experiences we had aimed for in this study. It is, however, important to acknowledge that while the results may provide valuable insight into the experiences of the nurse educators, transferability to broader populations may be limited. Qualitative research is needed to explore and deepen these findings from the perspectives of student nurses and registered nurse mentors for the improvement of digiQUALinPRAX. Moreover, quantitative research is essential to providing knowledge about the effectiveness of digiQUALinPRAX in measuring and assessing student learning. Additionally, to broaden the applicability of the current study, it is recommended to explore the results across diverse healthcare educational settings, such as hospital settings for second- or third-year students. It is also suggested to explore revisions to the digital educational resource that would enable its adaptation to other internships within nursing education. This expanded exploration may contribute to the transferability of the results and enhance the broader relevance of the study’s implications.

Conclusions

The nurse educators gave in-depth information on how they experienced the usefulness of the pedagogical design features of the digiQUALinPRAX resource, developed to support their role in nursing home placements. The digiQUALinPRAX resource was experienced to display several positive pedagogical design features for enhancing the supervision and assessment of student nurses, while also promoting possibilities for interactions and partnerships among stakeholders. Notably, its inclusion of a timeframe was experienced as beneficial for ensuring greater consistency among nurse educators in student supervision. Additionally, its resource design facilitated student feedback, enabled nurse educators to better understand students’ current knowledge levels as well as their need for further supervision and learning. Furthermore, it was experienced as positive that pedagogical design features of the digiQUALinPRAX encouraged nurse educators to engage students in the reflective-thinking processes. Moreover, it was positively experienced that pedagogical design features of the digiQUALinPRAX contributed to registered nurse mentors becoming more verbal in assessment meetings, which also positively contributed to nurse educators’ further supervision of students during nursing home placement.

Data availability

To access the data in this study, please contact the corresponding author.

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Acknowledgements

We would like to thank all the participants who made the study possible. Thanks to Ingrid Espegren Dalsmo, UiA and NETTOPP-UIS, Department for Development of Digital Learning Tools, for their valuable participation and contribution in design and development of Fig.  1 .

This study was supported by the Research Council of Norway (RCN) (Grant number 273558). The funder had no role in the design of the project, data collection, analysis, interpretation of data or writing and publication of the manuscript.

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All authors conceptualised the study and developed the interview guides. MR conducted the data collection and designed and developed Fig.  1 . MR and MTG conducted the data analysis and interpretation, as well as drafted and revised the manuscript. KL, KA, and IA provided critical revisions for important intellectual content. All authors reviewed and approved the manuscript.

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This study was approved by the Norwegian Centre for Research Data (2018/61309 and 489776) and the university included prior to data collection. According to national regulations, approval from a medical ethical committee (Regional Committees for Medical and Health Research Ethics) to collect this type of data was not necessary. The study was conducted in accordance with the ethical principles of the Declaration of Helsinki [ 40 ]. The consolidated criteria for reporting qualitative research (COREQ) guideline was used to report the study. All participants received written and oral information about the study, including voluntary nature of participation, and the right to reject or withdraw from the study. All participants provided written informed consent. To ensure confidentiality, participants’ characteristics such as age, sex, educational background, and years of experience in placement education supervision were not provided. All data were anonymised and securely stored to ensure confidentiality and protect private information.

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Ravik, M., Laugaland, K., Akerjordet, K. et al. Usefulness of pedagogical design features of a digital educational resource into nursing home placement: a qualitative study of nurse educators’ experiences. BMC Nurs 23 , 135 (2024). https://doi.org/10.1186/s12912-024-01776-5

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Impact of a complex health services intervention in long-term care nursing homes on 3-year overall survival: results from the CoCare study

  • Klaus Kaier 1 ,
  • Boris A. Brühmann 2 ,
  • Stefan Fetzer 3 ,
  • Rieka von der Warth 2 &
  • Erik Farin-Glattacker 2  

BMC Health Services Research volume  24 , Article number:  203 ( 2024 ) Cite this article

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The Coordinated medical Care (CoCare) project aimed to improve the quality of medical care in nursing homes by optimizing collaboration between nurses and physicians. We analyze the impact of the CoCare intervention on overall survival.

The effect of time-varying treatment on 3-year overall survival was analyzed with treatment as time-varying covariate within the entire cohort. To reduce bias due to non-random assignment to treatment groups, regression adjustment was applied. Therefore, age, sex, and level of care were used as potential confounders.

The study population consisted of 8,893 nursing home residents (NHRs), of which 1,330 participated in the CoCare intervention. The three-year overall survival was 49.8% in the entire cohort. NHRs receiving the intervention were associated with a higher survival probability compared to NHRs of the control group. In a univariable cox model with time-dependent treatment, the intervention was associated with a hazard ratio of 0.70 [95%CI 0.56–0.87, p  = 0.002]. After adjustment for age, sex and level of care, the hazard ratio increased to 0.82 but was still significant [95%CI 0.71–0.96, p  = 0.011].

The analysis shows that optimizing collaboration between nurses and physicians leads to better survival of NHRs in Germany. This adds to the already published favorable cost-benefit ratio of the CoCare intervention and shows that a routine implementation of optimized collaboration between nurses and physicians is highly recommended.

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Introduction

In the last three decades, the number of people cared for in nursing homes (NHs) has risen sharply. Almost 800,000 people are currently receiving full-time inpatient care [ 1 ]. Many nursing home residents (NHRs) are multimorbid, have complex care needs and take multiple medications [ 2 , 3 , 4 , 5 , 6 ]. This, combined with a shortage of qualified staff, makes it increasingly difficult to provide adequate medical care. The care provided in nursing homes is already generally perceived as inadequate [ 7 , 8 , 9 , 10 , 11 , 12 , 13 ].

Underuse and misuse of medical services among NHRs have been linked to a shortage of interprofessional cooperation, communication and documentation between doctors and nurses [ 14 , 15 , 16 ]. In particular, nurse preparedness and physician attitudes (e.g. professionalism, responsiveness) were found to be of paramount importance for interprofessional communication [ 17 ]. Other important factors for successful cooperation between GPs and nurses are mutual trust, more contacts, fixed agreements and regular rounds [ 18 ]. A change of the resident’s family GP to reduce the number of GPs providing care may also be useful, as well as a link to an outpatient clinic in the absence of specialist care [ 19 ].

However, implementation of the necessary measures is often hampered by inadequate infrastructure and lack of or poor communication between physicians and nurses [ 20 , 21 ]. In Germany, NHs have to organize cooperation with general practitioners (GPs) and specialists themselves, which leads to a high level of bureaucracy in NHs and not to a more efficient distribution of resources [ 22 ]. Compared to other countries, this is a very German specific problem. While German GPs may visit NHs as part of their main work, countries like the Netherlands and France introduced the specialization of a nursing home GP [ 23 ]. In addition, the institutional separation of health and long-term care insurance due to interface problems leads to increased under- and inappropriate supply for care for NHRs [ 24 ]. From the perspective of health and long-term insurance funds, the institutional separation of health and long-term care insurance leads to incentives to shift costs from one side to the other.

The Coordinated Medical Care (CoCare) project is designed to improve the coordination of medical care in German long-term care hospitals by optimising collaboration between nurses and physicians. The present study examines the impact of the CoCare intervention on 3-year survival among the participants of the study. This prospective, nonrandomized study is based on German insurance data, and includes a total of 8,893 residents in NHs, of which 1,330 participated in the CoCare intervention.

A detailed overview of the study was published previously as a study protocol [ 10 ], as well as the results of the economic evaluation of CoCare [ 7 ].

Briefly, the CoCare intervention included the following elements: A team of GPs provided care to NHRs. The assignment of nursing homes was non-random. As described in more detail before [ 7 ], the intervention was administered in 35 NHs in the administrative districts of Stuttgart, Karlsruhe, and Freiburg. The 280 NHs forming the control group were recruited from another administrative district (Tübingen), which was chosen to mirror the intervention districts in number of physicians, inhabitants, and similarity in counties. GPs were allowed to treat any patient on behalf of another GP and were available by telephone out of medical treatment hours. Specialists made regular visits, at least quarterly, coordinated by GPs and accompanied by nursing staff. A coordinated medication management was implemented. Medication plans were written by GPs and reviewed quarterly. A project-specific remuneration plan includes a number of additional billing options for the participating physicians and thus significantly weakens the ceiling on costs that prevails in the German outpatient sector. For example, a project-specific surcharge was paid for joint nurse GP patient visits (€10) and joint nurse specialist patient visits (€15) or medication checks with a coordinated medication management (€10). In addition, interpatient activities such as telephone standby outside normal practice hours (€50) were remunerated separately. Communication and cooperation between physicians and nurses was improved through the appointment of study coordinators (“CoCare coordinators”) at each participating NH. CoCare coordinators were in charge of tasks, such as documentation, preparation, and follow-up of onsite physician visits. In addition, structured processes between physicians and nurses were facilitated, such as standard operating procedures for unplanned events (e.g. crisis management). Finally, treatment procedures (e.g. regarding pain) were structured and developed for participating specialists and GPs.

Details regarding the selection of intervention group NHs and control group NHs were published previously [ 7 , 10 ]. Briefly, all participants in the present study had to be in a NH at least 90 days before inclusion. Dementia was an exclusion criterion. In addition, all patients that met the inclusion criteria and resided in an intervention group NH were offered to participate, provided they signed an informed consent. Patients living in a control group NH did not need to provide informed consent.

April 1st 2017 was defined as day 0 in the survival analyses. Follow-up regarding overall survival was available until April 30 2020 for the entire study population using information from participating health insurance funds. Start of the intervention (the day when informed consent was provided) took place between October 2017 and March 2020).

All statistical analyses were performed with Stata 17 (StataCorp, Texas, USA). Between-group differences among baseline characteristics were analyzed using unpaired t-test and chi-squared test. In order to outline 3-year survival within different subgroups, the Kaplan-Meier method was applied to calculate 3-year survival probabilities and median survival. In subgroups where median survival times were not measurable, parametric survival analyses with a Weibull distribution were applied to estimate median survival. The effect of time-varying treatment on mortality was analyzed with intervention as time-varying covariate within the entire cohort. To reduce bias due to non-random assignment to intervention groups, regression adjustment was applied. Therefore, age, sex and level of care were used as potential confounders. In Germany, the level of care may be interpreted as the level of dependency. There are different levels of care, which determine, among other things, how much financial support a patient receives from the statutory long-term care insurance. To determine level of care, an assessment is carried out, which evaluates the individual’s ability to perform everyday activities and the level of support required. As a higher level of care translates into more financial support from the statutory long-term care insurance, the level of care may change frequently over time when the degree of care dependency increases. Therefore, we used the latest level of care at the beginning of the observation period (April 1st 2017) as a time-fixed covariate. The regression model chosen was a cox regression model in which the multilevel structure of the data was taken into account by specifying cluster-robust standard errors at the NH level. To graphically illustrate the impact of the time-varying treatment on overall survival, the Simon–Makuch method was applied with a 12- and a 21 months landmark [ 25 ]. A 12 month landmark may be seen as the lower bound of potential landmarks, as roughly 10% of patients in the intervention group already started the intervention at month 12. Month 21, on the contrary, represents the median time to intervention which is usually chosen [ 26 , 27 ]. To outline the effect of treatment over time, we employed the flexible parametric regression model, stpm2 command in Stata, where the hazard ratio was estimated and plotted as a function of time [ 28 ]. To identify potential subgroup effects, Cox regression models with interaction between time-varying treatment and sex, age, or levels of care were specified. For age and levels of care, restricted cubic splines were used to model the non-linear interaction between the intervention and age (or level of care). Then, the partpred command in Stata was used to obtain estimates of the hazard ratio for the intervention as a function of age (or level of care) [ 29 ].

The characteristics of the study population ( N  = 8,893) are shown in Table  1 . NHRs of the intervention group ( N  = 1,330) were younger ( p  < 0.001), more often male ( p  = 0.004), and had a lower level of care compared to NHRs of the control group (see Table  1 for details). On average, the start of the intervention was 20 months after the start of the study period. See Figure S1 for a visualization of the timing of the introduction of the intervention.

The three-year overall survival was 49.77% [95%CI 48.73-50.80%] in the entire cohort. Looking at the different age groups, (expected) differences in survival rates emerge: While 86% of patients aged < 65 were still alive after three years, the 3-year survival rate in the oldest group was only 28% (see Fig.  1 ). Detailed survival probabilities and median survival times can be found in Table S1 and Figure S2 . Regarding the care status, a similar picture emerges: Patients with a care level of 0 or 1 have a survival probability of 86% and a median survival time of more than 4 years. For patients with a higher care level, the probability of survival decreases accordingly to a median survival time of only 2 years for patients with care level 5. Interestingly, male and female patients had comparable survival probabilities over the entire study period (Table S1 ). Looking at the survival probabilities of the sexes within the age groups separately, however, a completely different picture emerges. As can be seen in Table S2 , women, as expected, have higher survival probabilities and longer median survival times when compared to men at the same age. Since the proportion of women increases disproportionately in the older age groups, the age difference is not visible when simply looking at the cohort as a whole (Table S1 ).

figure 1

Kaplan-Meier plot of overall survival according to age

NHRs of the intervention group were associated with a higher survival probability compared to NHRs of the control group. In a univariable cox model with time-dependent treatment, the intervention was associated with a hazard ratio of 0.70 [95%CI 0.56–0.87, p  = 0.002]. After adjustment for age, sex and level of care, the hazard ratio decreased to 0.82 but was still significant [95%CI 0.71–0.96, p  = 0.011]. As shown in Table  2 , male sex, high age and a higher level of care were associated with inferior survival in our multivariable cox regression model.

As shown in Fig.  2 , Simon–Makuch plots illustrate the steadily higher survival probabilities of the NHRs of the intervention group compared to those of the control group.

figure 2

Simon–Makuch plots with landmark periods of 12-months ( A ) and 21-months ( B )

Interactions between intervention and the confounders were tested but found insignificant ( p  = 0.181, p  = 0.226, p  = 0.320 for sex, age and level of care, respectively). Although no significant interaction was found, visualizations of the nonlinear relationship between age or level of care and the treatment effects are shown in Figure S3 . Regarding the interaction with sex, female NHRs [HR 0.78, 95%CI 0.64–0.95, p  = 0.014] tend to benefit more from the intervention than male NHRs [HR 0.93, 95%CI 0.78–1.09, p  = 0.358]. Inspection of the effect of the intervention over time shows no relevant trend (see Figure S4 ).

The analysis shows that the CoCare intervention leads to better survival of NHRs in Germany. Previous analyses have already shown the favorable cost-benefit ratio of the intervention with respect to healthcare costs. Specifically, the total cost of medical service use was reduced by €468.56 ( p  < 0.001) per NHR per quarter [ 7 ], meaning that the benefit of the intervention – avoided hospital admissions – clearly exceeded the cost of additional outpatient billings [see [ 7 ] for details]. When a new intervention is superior in both outcomes and cost savings, it is called an economically “dominant” strategy. In fact, very few interventions fall into this category; the most common scenario is that a new strategy improves outcomes at a higher cost. Therefore, the routine implementation of optimized collaboration between nurses and physicians is highly recommended.

In view of the substantial effects of the intervention, the individual components of the intervention are to be discussed in order to enable at least partial implementation of what saves lives and reduces costs.

From the perspective of NHRs, the CoCare intervention provided above all more services. In general, NHRs have a high prevalence of a variety of health problems [ 30 ]. Particularly needed are physiotherapists (91%), psychiatrists/neurologists (89.3%), dentists (73.7%) and urologists (71.3%) [ 31 ], whose lack causes health problems and increased hospitalizations. With a billable service catalogue for physicians and treatment guidelines for nurses, the CoCare intervention started here. Furthermore, the hurdle for NHs to contact GPs was greatly reduced in CoCare, because of their increased availability, regular visits and meetings as well as indication-specific case conferences. This ensured that GPs were often contacted at an early stage, or even in unclear situations.

From the perspective of nurses, the CoCare intervention meant more knowledge and skills to do the right thing at the right moment. Nurses are the first point of medical contact for NHRs. This is often an excessive demand in terms of content [ 32 ]. Therefore, treatment pathways were developed for the CoCare intervention (pain, challenging behavior, polypharmacy and transition from curative to palliative care) and were distributed among nursing staff. A subsidized CoCare coordinator in each NH was in charge of documentation, preparation and follow up of on-site physician visits, which lead to more productive meetings.

From the perspective of the treating GPs, the CoCare intervention primarily meant more direct and closer contact with patients and stronger networking in the NHs. This is particularly evident in the example of polypharmacy. The potentially inappropriate use of medications is common, avoidable and often associated with negative consequences for patients [ 33 ]. Therefore, competent and careful medication management is required for complex medication care. In the CoCare intervention, this was carried out jointly by GPs and nursing staff at regular intervals during joint ward rounds. The formation of teams of physicians helped to stand-in for other GPs and allocate NH visits. Last but not least, the project-specific remuneration plan includes a number of additional billing options for participating physicians and thus significantly weakens the ceiling on costs that prevails in the German outpatient sector. We believe that the project-specific surcharges have been instrumental in improving the intensity and quality of care.

Although the study was limited to Germany, one might argue the results are also of relevance for other countries, in which similar questions are likely to arise with the ageing of the population. Especially the German institutional separation of health and long-term care insurance and it’s impact on the inappropriate supply for care for NHRs is likely to be present in a lot of European countries. According to the European Commission, only a minority of countries (Denmark, Ireland and Portugal) are organized in a way which integrates health and long-term care. In most countries, however, the institutional separation between health and long-term care is described as the same problematic vertical division of responsibilities as we observe it in Germany [ 34 ].

Limitations

In interpreting our findings, a number of limitations have to be taken into consideration. As a major limitation, no randomization was possible, since this is a study in a real-world setting. Instead, regression adjustment was applied. Thereby, adjusted hazard ratios may be interpreted as ‘true’ intervention-related effects if all parameters that are relevant for the decision and the outcome are used for the risk adjustment. Unfortunately, there can be no guarantee that all relevant parameters are part of the model. In fact, the administrative data set lacks relevant medical information (such as comorbidities) and information regarding level of care may be incomplete and/or only available with a considerable time delay. Obviously, a considerable amount of information regarding level of care may be missing, since the number of NHRs with a level of care of 1 or not yet assigned is higher than the numbers reported in the official care statistic [ 1 ]. Unfortunately, no imputation of these potentially missing values could be conducted due to the absence of codes indicating that these information were missing. In addition, there may be additional unobserved differences between the intervention and control groups. An example of this would be general frailty. This is often neglected in studies due to the complexity of its collection. For example, if patients in the intervention group have better characteristics that have not yet been observed - such as less frailty. The analysis would tend to overestimate the effect of the intervention. A further limitation to the conclusion that the intervention reduces costs and saves lives at the same time is, that only healthcare costs were considered in the analysis [ 7 ]. Whether there are higher, lower, or neutral effects in terms of NH costs depends largely on whether the additional life expectancy gained through NHRs is spent in higher levels of care or whether the intervention also leads to a delay in the progression of care intensity. Unfortunately, the design of the intervention does not enable us to distinguish between the two influential factors (1) better nurse-physician collaboration, and (2) greater consumption of outpatient healthcare. Most of the billing options in the project-specific remuneration plan increases both (1) nurse-physician collaboration and (2) outpatient healthcare consumption at the same time. In addition, the exclusion criteria of dementia and a stay of less than three months substantially limit the external validity of the results. Dementia in particular is omnipresent in long-term inpatient care and our results do not allow us to draw conclusions about the effect of the CoCare intervention on patients with dementia. To answer this question, further research is needed. Finally, we believe that the intervention is most appropriate on the NH level. That is why the intervention was rolled out at the NH level. As individual consent was necessary to participate in the intervention, however, we cannot exclude possible spillover effects. If there were such spillover effects at the NH level, there could be a systematic underestimation of the intervention effect, since control patients also benefit indirectly from the intervention.

Data availability

The datasets used and/or analysed during the current study available from the corresponding author on reasonable request.

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Acknowledgements

The article processing charge in BMC Heath Services Research was funded by the German Research Foundation (DFG) and the Albert Ludwig University of Freiburg in the funding program Open Access Publishing.

Open Access funding enabled and organized by Projekt DEAL. This research was funded by the Innovation Committee of the Federal Joint Committee (G-BA) supported by the Innovation Fund. Proposal-ID: NVF1_2016–080. The funding body has had no role in the design of the study or collection, analysis, or interpretation of data or in writing the manuscript.

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Study concept and design: KK, BAB, EFG. BAB conducted the data collection, BAB and KK were responsible for the data management. Statistical analysis: KK. Drafting of the manuscript: KK and SF. Revision of the manuscript: BAB, RW and EFG. All authors contributed to interpretation of the data, read and approved the final version of the manuscript.

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Informed consent of each participant (resident/relative/caregiver/physician) is obtained in writing by the nursing staff before the recruited person completes any questionnaire. Ethics approval of this study was granted by the ethics committee at the Chamber of Physicians of the State of Baden-Wuerttemberg (Reference number: B-F-2017-127; 14.11.2017) as well as by the ethics committee at the University of Freiburg Medical Centre (Reference number: 333/17; 03.08.2017). All experiments were performed in accordance with relevant guidelines and regulations (such as the Declaration of Helsinki).

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Kaier, K., Brühmann, B.A., Fetzer, S. et al. Impact of a complex health services intervention in long-term care nursing homes on 3-year overall survival: results from the CoCare study. BMC Health Serv Res 24 , 203 (2024). https://doi.org/10.1186/s12913-024-10635-7

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Qualitative Methods in Health Care Research

Vishnu renjith.

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

Renjulal Yesodharan

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

Judith A. Noronha

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

Elissa Ladd

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

Anice George

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

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

Introduction

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

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

Qualitative Research

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

Significance of Qualitative Research

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

Differences between Quantitative and Qualitative Research

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

Differences between quantitative and qualitative research

Qualitative Research Questions and Purpose Statements

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

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

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

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

Review of the Literature

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

Reflexivity

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

Types of Qualitative Research Designs

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

Narrative research

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

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

Phenomenological research

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

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

Grounded Theory Research

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

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

Ethnographic research

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

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

Historical research

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

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

Case study research

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

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

Sampling in Qualitative Research

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

Convenience sampling

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

Purposive sampling

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

Snowball sampling

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

Intensity sampling

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

Deciding the Sample Size

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

Data Collection in Qualitative Research

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

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

Data Analysis in Qualitative Research

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

Computer-Assisted Qualitative Data Analysis Software (CAQDAS)

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

Reporting Guidelines

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

Critical Appraisal of Qualitative Research

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

Ethical Issues in Qualitative Research

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

Rigor in Qualitative Research

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

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

Conclusions

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

Financial support and sponsorship

Conflicts of interest.

There are no conflicts of interest.

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75196 - Nursing and Midwifery Research (RN)

Academic year 2023/2024.

  • Docente: Patrizia Di Giacomo
  • Credits:: 3
  • Language: Italian
  • Teaching Mode: Traditional lectures
  • Campus: Bologna
  • Corso: Second cycle degree programme (LM) in Nursing and Midwifery Sciences (cod. 8488)
  • Teaching resources on Virtuale

Course Timetable

from Nov 29, 2023 to Jan 18, 2024

Learning outcomes

At the end of the course the student must be able to investigate the nursing and midwifery, organizational and educational processes related to the evolution of population health problems, health and social systems and specific professionalization paths.

Course contents

Prerequisites:

The contents of the modules on OBSTETRICS AND NURSING BASED ON SCIENTIFIC EVIDENCE and on Medical Statistics applied to health care.

Training Goals

At the end of the module the student has to achieve these goals/target:

knowledge and skills related to the research process and to the main study designs;

tools and methods for choosing and developing the thesis topic and the subsequent elaboration.

The student has to be able to:

Identify possible research problems and hypotheses in the field of nursing and midwifery

Identify and apply research findings

Develop research projects

Program/Course

Introduction

Identify problems from which it is possible to formulate research questions in the field of nursing and midwifery

The importance of research in nursing and midwifery

Aims and areas of nursing and midwifery research

The research process

The quantitative research process and its phases

Hypotheses/research questions (PICOS) and research variables

The rationale of the study and bibliographic research

The main research designs and their characteristics: descriptive, observational and experimental

The research protocol: drafting and design

Data collection and the main data collection tools

Study authorization paths

Guidelines for reporting studies

Organizational research

The research project

Develop a research project

Readings/Bibliography

Gaeta L. (2010) Critical reading of clinical studies, Aras editions, Fano

Polit, DF & Beck, CT(2018) trad it by Palese A. Fundamentals of Nursing Research. 2 Ed. McGraw Hill, Milan

Teaching methods

lectures, presentation of problems in plenary, individual/pair and group exercises

Assessment methods

The student will have to develop and present their own project complete search of the following documents:

- The complete protocol

- The synopsis

- The data collection tool(s).

- The information sheet for the patient or participants (if appropriate)

- the study consent form

The documents described above must be sent via email 10 days before the exam date.

The evaluation will be carried out taking into account the following aspects:

- originality and completeness of the project;

- clinical-care problem/question;

- hypotheses/questions and variables consistent with the problem;

- background bibliographic research;

- methodology for testing hypotheses/answering questions;

- instruments;

- planned statistical analyses;

- action plans with timing consistent with the conduct of the research.

The final mark is expressed out of 30 points according to the following graduation:

30 cum laude, excellent implementation of the research protocol completes with all the required documentation, respect for delivery times.

24-30, complete implementation of the research protocol, compliance with delivery times.

18-23, sufficient implementation of the research protocol, compliance with delivery times.

< 18 insufficient

The evaluation will be averaged with the evaluations of the other modules making up the Integrated Course

Teaching tools

In classroom: PC and video projector, flipchart,

Office hours

See the website of Patrizia Di Giacomo

Good health and well-being

This teaching activity contributes to the achievement of the Sustainable Development Goals of the UN 2030 Agenda.

IMAGES

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  2. Nursing Research: Designs and Methods

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  5. Clinical Study Design Part 1

  6. Phenomenological Research Design

COMMENTS

  1. Study Design and Methodology

    E-Reserves MUHC Nurse Residency MUHC Evidence Based Practice Model Levels of Evidence As the different study designs have different strengths, and weakness, they have been ranked in levels of evidence. Simply put, the strongest designs are at the top, the weakest at the bottom.

  2. Clinical research study designs: The essentials

    Introduction. In clinical research, our aim is to design a study, which would be able to derive a valid and meaningful scientific conclusion using appropriate statistical methods that can be translated to the "real world" setting. 1 Before choosing a study design, one must establish aims and objectives of the study, and choose an appropriate target population that is most representative of ...

  3. An overview of research designs relevant to nursing: Part 1

    PMID: 17653437 DOI: 10.1590/s0104-11692007000300022 Abstract Evaluation Studies as Topic Nursing Research / methods* This three part series of articles provides a brief overview of relevant research designs in nursing. The first article in the series presents the most frequently used quantitative research designs.

  4. Identifying the best research design to fit the question. Part 1

    Evidence-based nursing is about applying the best available evidence to a specific clinical question. Different clinical questions require evidence from different research designs. No single design has precedence over another, rather the design chosen must fit the particular research question.1 Questions focused on the cause, prognosis (course), diagnosis, prevention, treatment, or economics ...

  5. Study designs: Part 1

    The study design used to answer a particular research question depends on the nature of the question and the availability of resources. In this article, which is the first part of a series on "study designs," we provide an overview of research study designs and their classification. The subsequent articles will focus on individual designs.

  6. An overview of the qualitative descriptive design within nursing research

    Qualitative descriptive designs are common in nursing and healthcare research due to their inherent simplicity, flexibility and utility in diverse healthcare contexts. However, the application of descriptive research is sometimes critiqued in terms of scientific rigor.

  7. Quantitative research: Designs relevant to nursing and healthcare

    It outlines some strengths and weaknesses of the designs, provides examples to illustrate the different designs and examines some of the relevant statistical concepts. The paper concludes with a brief discussion about the place of quantitative research in nursing.

  8. Nursing Research Guide: Study Designs

    Study Designs - Nursing Research Guide - Subject Guides at University of Rochester Medical Center Nursing Research Guide: Study Designs Quick Access Clinical Question Types Using PICO (T) Study Designs Journals Books Levels of Evidence and Study Designs Click the image to enlarge it. Click the image to enlarge it. Acknowledgements

  9. Types of Study Designs

    Types of Study Designs - Nursing Research Guide - Research Guides at University of Kansas Medical Center Nursing Research Guide A guide for conducting nursing research at KUMC. Please refer to your textbook and/or faculty member with more information on these topics.

  10. Research Study Design

    Nursing Research, Step By Step, from: American Journal of Nursing. This series coordinated by the Heilbrunn Family Center for Research Nursing at Rockefeller University is designed to give nurses the knowledge and skills they need to participate in research, step by step.

  11. Case Study Research Design in Nursing : Clinical Nurse Specialist

    Case Study Research Design in Nursing Siedlecki, Sandra L. PhD, RN, APRN-CNS, FAAN Author Information Clinical Nurse Specialist: 11/12 2020 - Volume 34 - Issue 6 - p 250-256 doi: 10.1097/NUR.0000000000000554 Buy Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved. Related Articles

  12. Research Design & Methodology

    Four types of qualitative research design often applied to nursing research are: Phenomenology - the study of human life experiences and how they appear in human consciousness Grounded Theory - seeks to explain variations in social interactional and social structural problems and processes

  13. An overview of the qualitative descriptive design within nursing research

    Her research interests are in the area of self-harm and suicide and she has a particular interest and expertise in mixed-methods and qualitative research designs. Catherine McCabe (PhD, MSc, BNS, RNT, RGN) is an Associate Professor in General Nursing at the School of Nursing and Midwifery, Trinity College Dublin.

  14. Research Guides: Nursing Resources: Study Designs

    Nursing Resources : Study Designs Identifying the Study Design The type of study can generally be worked at by looking at three issues: Q1. What was the aim of the study? To simply describe a population (PO questions) = descriptive To quantify the relationship between factors (PICO questions) = analytic. Q2.

  15. Types of Clinical Study Designs

    Test-tube Lab Research "Test tube" experiments conducted in a controlled laboratory setting. Adapted from Study Designs. In NICHSR Introduction to Health Services Research: a Self-Study Course and Glossary of EBM Terms. NOTE: Credit for the above content is given to ***public health: General subject guide: About study designs. GSU Library ...

  16. Experimental Design

    Experimental Design - Understanding Nursing Research - Research Guides at Texas A&M University-Corpus Christi Understanding Nursing Research Experimental Design Correlational, or non-experimental, research is research where subjects are not acted upon, but where research questions can be answered merely by observing subjects.

  17. Case Study Research Design in Nursing

    Case Study Research Design in Nursing Clin Nurse Spec. Nov/Dec 2020;34(6):250-256. doi: 10.1097/NUR.0000000000000554. Author Sandra L Siedlecki 1 Affiliation 1 Author Affiliation: Senior Nurse Scientist, Department of Nursing Research and Innovation, Cleveland Clinic, Ohio. PMID: 33009110 DOI: 10.1097 ...

  18. AHU Resource Guides: Nursing Research: Types of Research Studies

    A study design that randomly assigns participants into an experimental group or a control group. As the study is conducted, the only expected difference between the control and experimental groups in a randomized controlled trial (RCT) is the outcome variable being studied. Source: Study Design 101, GWU. A study design where one or more samples ...

  19. Determining the level of evidence: Nonexperimental research designs

    To support evidence-based nursing practice, the authors provide guidelines for appraising research based on quality, quantity, and consistency. This article, the second of a three-part series, focuses on nonexperimental research designs. Determining the level of evidence: Nonexperimental research designs Nursing. 2021 Feb 1;51(2):62-65 . doi ...

  20. Types of Research within Qualitative and Quantitative

    Nursing Resources : Types of Research within Qualitative and Quantitative Aspects of Quantative (Empirical) Research ♦ Statement of purpose—what was studied and why. ♦ Description of the methodology (experimental group, control group, variables, test conditions, test subjects, etc.).

  21. Research designs: Nursing

    When conducting research, a research design is chosen, which is the overall strategy used to organize the study in order to answer the research question. The two broad approaches to research design are quantitative and qualitative. There are also mixed-method designs, which combine both quantitative and qualitative into one research study.

  22. Development of a nomogram for predicting acute pain among patients

    The Journal of Clinical Nursing publishes research and developments relevant to all areas of nursing practice- community, geriatric, ... Design. A prospective observational study. Methods. A total of 352 patients undergoing abdominal operations from June 2022 to December 2022 participated in this investigation. A nomogram was developed for ...

  23. Usefulness of pedagogical design features of a digital educational

    Design. The current study applied an explorative and descriptive qualitative research design. This is appropriate for investigating an unexplored subject descriptively, along with its characteristics [].The study is part of a larger research project [] that developed the digiQUALinPRAX resource.The digiQUALinPRAX resource was co-created with key stakeholders (i.e. student nurses, nurse ...

  24. Using clinical simulation to assess a new ...

    The study was approved by Health Service (RGS4918) and University (HRE2021-0692) Human Research Ethics Committees. Informed consent was obtained from participants. The primary research site and simulation facility was the children's hospital located in Perth WA.

  25. Impact of a complex health services intervention in long-term care

    The Coordinated medical Care (CoCare) project aimed to improve the quality of medical care in nursing homes by optimizing collaboration between nurses and physicians. We analyze the impact of the CoCare intervention on overall survival. The effect of time-varying treatment on 3-year overall survival was analyzed with treatment as time-varying covariate within the entire cohort.

  26. Qualitative Methods in Health Care Research

    The three major domains of COREQ are the 'research team and reflexivity', 'study design', and 'analysis and findings'.[44,45] ... Nursing Research: Generating and Assessing Evidence for Nursing Practice. [Google Scholar] 2. Sorrell JM. Qualitative research in clinical nurse specialist practice. Clin Nurse Spec. 2013; 27:175-8.

  27. Nursing and Midwifery Research (RN) 2023/2024

    knowledge and skills related to the research process and to the main study designs; tools and methods for choosing and developing the thesis topic and the subsequent elaboration. ... (2018) trad it by Palese A. Fundamentals of Nursing Research. 2 Ed. McGraw Hill, Milan. Articles of interest will be indicated by the teacher during the lesson

  28. UC Davis medical school ranked among the nation's best for NIH research

    Nadine A Yehya. [email protected]. Phone: 916-734-9036. The Blue Ridge Institute for Medical Research ranked UC Davis School of Medicine among the nation's leading medical schools in terms of NIH grants. The school had a record of $209 million in NIH funding.

  29. Why do male nurses choose to work in foreign countries? A ...

    This study employed a qualitative and inductive research design. Sixteen Chinese male nurses working in Eastern and Western Japan were recruited using convenience and snowball sampling methods and were interviewed via video calls. ... nurses in developed countries facing issues such as ageing populations and nursing shortages. Implications for ...