definition of quantitative research in nursing

Nursing Research (NURS 3321/4325/5366)

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• Understand What Qualitative Research Is
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What is Quantitative Research?

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

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

What is the purpose of quantitative research?

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

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

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

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

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

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Differences between Qualitative & Quantitative Research

" Quantitative research ," also called " empirical research ," refers to any research based on something that can be accurately and precisely measured.  For example, it is possible to discover exactly how many times per second a hummingbird's wings beat and measure the corresponding effects on its physiology (heart rate, temperature, etc.).

" Qualitative research " refers to any research based on something that is impossible to accurately and precisely measure.  For example, although you certainly can conduct a survey on job satisfaction and afterwards say that such-and-such percent of your respondents were very satisfied with their jobs, it is not possible to come up with an accurate, standard numerical scale to measure the level of job satisfaction precisely.

It is so easy to confuse the words "quantitative" and "qualitative," it's best to use "empirical" and "qualitative" instead.

Hint: An excellent clue that a scholarly journal article contains empirical research is the presence of some sort of statistical analysis

See "Examples of Qualitative and Quantitative" page under "Nursing Research" for more information.

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Examples of Qualitative vs Quantitiative

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• Quantitative vs. Qualitative Research

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

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

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

For more information on qualitative research:

Curtis, A. & Keeler, C. (2022). An introduction to qualitative methods for the nurse researcher.  American Journal of Nursing, 122  (8), 52-56. https://doi: 10.1097/01.NAJ.0000854992.17329.51.

Noyes, J., Booth, A., Cargo, M., Flemming, K., Harden, A., Harris, J., Garside, R., Hannes, K., Pantoja, T., & Thomas, J. (2023). Chapter 21: Qualitative evidence.  In Higgins, J.P.T., Thomas, J., Chandler, J., Cumpston, M., Li, T., Page, M.J., Welch, V.A. (Eds.).  Cochrane handbook for systematic reviews of interventions version 6.4.  Cochrane.  www.training.cochrane.org/handbook

Video:  UniversityNow: Quantitative vs. Qualitative Research

Appraising Quantitative and Qualitative Research

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

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

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

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Quantitative vs Qualitative Research in Nursing: Understanding the Differences

Quantitative research in nursing: definition, advantages, and disadvantages.

Table of Contents

As a nursing professional, it is crucial to stay informed about the latest research methods and their applications in healthcare. One such method is quantitative research, which plays a significant role in evidence-based practice. In this article, we will explore the definition of quantitative research and examine its advantages and disadvantages in the nursing field.

What is Quantitative Research?

Quantitative research is a systematic approach used to gather and analyze numerical data to answer research questions or test hypotheses. It involves collecting data through structured surveys, questionnaires, or measurements, which are then analyzed using statistical techniques. This type of research aims to establish relationships, patterns, or trends in a population, allowing for generalizations and predictions.

Advantages of Quantitative Research in Nursing

Quantitative research offers several advantages that make it a valuable tool in nursing practice:

• Objective and Reliable: Quantitative research provides measurable data that can be analyzed objectively, reducing bias and subjectivity.
• Generalizability: By using large sample sizes, quantitative research findings can be generalized to larger populations, allowing nurses to make evidence-based decisions that benefit a broader range of patients.
• Replicability: The structured nature of quantitative research allows for replication of studies, enhancing the reliability and validity of findings.
• Trends and Patterns: Through statistical analysis, quantitative research can identify trends and patterns in healthcare outcomes, helping nurses understand the effectiveness of interventions or treatments.
• Data-driven Decision Making: Nurses can use quantitative research findings to inform their clinical practice, improve patient care, and contribute to healthcare policy development.

Disadvantages of Quantitative Research in Nursing

While quantitative research has many advantages, it also comes with a few limitations that nurses should be aware of:

• Limited Contextual Understanding: Quantitative research focuses on numerical data, which may not capture the complexity of nursing practice or the unique experiences of individual patients.
• Lack of In-depth Exploration: The structured nature of quantitative research often limits the ability to explore underlying reasons or motivations behind certain phenomena.
• Difficulty in Capturing Human Emotions: Quantitative research primarily deals with objective data, making it challenging to capture subjective experiences or emotions accurately.
• Cost and Time Intensive: Conducting quantitative research studies can be expensive and time-consuming due to the need for large sample sizes and complex statistical analyses.

In conclusion, quantitative research is a valuable tool in nursing that provides objective and generalizable data to guide evidence-based practice. While it has its limitations, understanding the advantages and disadvantages of quantitative research can help nurses critically evaluate research findings and apply them appropriately in their clinical settings. To stay updated on the latest research in nursing, visit reputable sources like the National Center for Biotechnology Information (NCBI) or the American Nurses Association Research Toolkit .

II. Definition of Qualitative Research

A. what is qualitative research.

Qualitative research is a method used in various disciplines, including nursing, to explore and understand complex phenomena. Unlike quantitative research, which focuses on numerical data and statistical analysis, qualitative research aims to gather rich, in-depth insights into the experiences, behaviors, and perceptions of individuals or groups.

This research approach involves collecting non-numerical data through techniques such as interviews, focus groups, observations, and document analysis. It seeks to uncover the underlying meanings, motivations, and contexts that influence human behavior and decision-making.

Qualitative research is particularly valuable in nursing as it helps nurses gain a holistic understanding of patients’ needs, perspectives, and experiences. By exploring subjective experiences and social constructs, qualitative research contributes to evidence-based practice and the development of patient-centered care.

B. Advantages and Disadvantages

Qualitative research offers several advantages and disadvantages that researchers should consider when planning their studies. Here are some key points to keep in mind:

Advantages: – In-depth insights: Qualitative research allows for a deep exploration of complex phenomena, providing rich descriptions and contextual understanding. – Flexibility: Researchers have the flexibility to adapt their methods and questions during data collection, allowing for emergent findings. – Participant perspectives: This approach enables researchers to capture participants’ perspectives, beliefs, and experiences directly. – Contextual understanding: Qualitative research emphasizes the importance of understanding social, cultural, and environmental contexts that influence behavior. – Theory development: By uncovering patterns and themes, qualitative research can contribute to the development of theories that guide future nursing practice.

Disadvantages: – Limited generalizability: Due to the small sample sizes and specific contexts often used in qualitative research, findings may not be easily generalized to larger populations. – Time-consuming: Qualitative research requires significant time and resources for data collection, transcription, coding, and analysis. – Subjectivity: The interpretation of qualitative data involves researchers’ subjectivity, potentially introducing bias. – Data management: Managing large volumes of qualitative data can be challenging, requiring careful organization and analysis techniques.

It is important to note that qualitative and quantitative research approaches are not mutually exclusive. Many studies incorporate both methods to provide a more comprehensive understanding of a research question. Researchers should consider the specific goals, research question, and resources available when deciding on the appropriate research approach.

For further reading on qualitative research in nursing, you can refer to authoritative sources such as the Journal of Nursing Research or the National Institutes of Health’s PubMed Central .

Remember, understanding qualitative research is essential for nurses who aim to contribute to evidence-based practice and improve patient care outcomes.

Differences between Quantitative and Qualitative Research in Nursing

In the field of nursing research, there are two primary approaches to gathering and analyzing data: quantitative and qualitative research. These two methods have distinct objectives, data collection techniques, analysis methodologies, and sample selection processes. Understanding the differences between quantitative and qualitative research is crucial for nurses and nursing students alike. Let’s explore these differences in detail.

A. Objectives & Goals

Quantitative Research:

• Objective: Quantitative research aims to measure and quantify data in a systematic and structured manner.
• Goal: The main goal of quantitative research is to identify patterns, relationships, and correlations between variables through statistical analysis.
• Focus: This research method emphasizes objectivity, generalizability, and the ability to make predictions or draw conclusions about a larger population.

Qualitative Research:

• Objective: Qualitative research seeks to understand and interpret phenomena from the perspective of the participants.
• Goal: The primary goal of qualitative research is to explore experiences, meanings, and social contexts surrounding a particular phenomenon.
• Focus: This research method emphasizes subjectivity, contextuality, and the generation of rich descriptions or narratives that capture the complexity of human experiences.

It’s important to note that both quantitative and qualitative research have their own strengths and limitations. Nurses often choose the most appropriate method based on the research question and desired outcomes.

B. Type of Data Collected & Analysis Techniques

• Data Collected: Quantitative research collects numerical data, such as measurements, counts, or ratings.
• Analysis Techniques: Statistical analysis methods, such as descriptive statistics, inferential statistics, and data modeling, are commonly used to analyze quantitative data.
• Data Collected: Qualitative research collects non-numerical data, such as interviews, observations, and textual materials.
• Analysis Techniques: Qualitative data analysis involves techniques like thematic analysis, content analysis, and narrative analysis. These methods aim to identify patterns, themes, and meanings within the collected data.

By using appropriate data collection methods and analysis techniques, nurses can gain valuable insights into various aspects of patient care, health outcomes, and healthcare systems.

C. Sample Selection & Sampling Methodology

• Sample Selection: Quantitative research typically involves larger sample sizes that are randomly selected to represent a target population.
• Sampling Methodology: Common sampling methods in quantitative research include random sampling, stratified sampling, and cluster sampling.
• Sample Selection: Qualitative research often involves smaller sample sizes that are purposefully selected based on specific criteria or characteristics relevant to the research question.
• Sampling Methodology: Qualitative researchers use various sampling techniques such as purposive sampling, snowball sampling, and theoretical sampling to recruit participants who can provide rich and diverse perspectives on the phenomenon under study.

Both quantitative and qualitative research approaches have their own advantages when it comes to sample selection. While quantitative research allows for generalizability, qualitative research focuses on in-depth understanding of specific contexts and experiences.

Understanding the differences between quantitative and qualitative research in nursing is essential for conducting evidence-based practice, contributing to nursing knowledge, and improving patient care. By utilizing these research methods appropriately, nurses can generate valuable insights that inform their decision-making process and enhance the overall quality of healthcare.

For more information on nursing research methodologies, you may visit the following authoritative resources:

• National Center for Biotechnology Information (NCBI)
• American Nurses Association (ANA)
• National Center for Complementary and Integrative Health (NCCIH)

Clinical Trials & Evidence-Based Practice

Clinical trials and evidence-based practice are essential components of nursing that rely on both quantitative and qualitative research methods. These research approaches play a crucial role in advancing healthcare and improving patient outcomes. Let’s explore how each method is utilized in these areas:

Quantitative Research

Quantitative research involves the collection and analysis of numerical data to identify patterns, trends, and statistical relationships. In clinical trials and evidence-based practice, quantitative research is commonly used in the following ways:

1. Efficacy and Safety Testing: Clinical trials often employ quantitative methods to determine the effectiveness and safety of new drugs, treatments, or interventions. This involves collecting data on a large sample of patients and using statistical analysis to measure outcomes.

2. Outcome Measurement: Quantitative research enables healthcare professionals to measure patient outcomes objectively. By utilizing standardized tools and assessments, researchers can gather data on variables such as symptom severity, functional status, or quality of life.

3. Data Analysis: Quantitative research provides a structured approach to analyze large datasets efficiently. Researchers can use statistical techniques to identify significant findings, establish correlations, or predict future outcomes.

4. Evidence Synthesis: Systematic reviews and meta-analyses, which are critical components of evidence-based practice, often rely on quantitative research. These methods involve combining and analyzing data from multiple studies to draw conclusions about the effectiveness of specific interventions or treatments.

Qualitative Research

Qualitative research involves the collection and analysis of non-numerical data, such as interviews, observations, or textual analysis. In clinical trials and evidence-based practice, qualitative research is commonly used in the following ways:

1. Exploration of Patient Experiences: Qualitative research allows nurses and healthcare professionals to gain insights into patients’ experiences, perceptions, and preferences. Through interviews or focus groups, researchers can explore the lived experiences of patients, which can inform the development of patient-centered care.

2. Understanding Context and Culture: Qualitative research helps uncover the contextual factors that influence healthcare delivery and outcomes. By examining social, cultural, and environmental influences, researchers can gain a deeper understanding of the complex interactions that impact patient care.

3. Evaluation of Interventions: Qualitative research methods are valuable in evaluating the implementation and impact of interventions in real-world settings. Researchers can collect qualitative data to assess the acceptability, feasibility, and effectiveness of new programs or interventions.

4. Identification of Emerging Themes: Qualitative research allows for the identification of emerging themes or patterns that may not be captured by quantitative methods alone. This can help generate new hypotheses or refine existing theories.

Healthcare Administration & Policymaking

In addition to clinical trials and evidence-based practice, both quantitative and qualitative research methods are also applied in healthcare administration and policymaking. Let’s explore how they contribute to these areas:

1. Data Analysis for Decision-Making: Quantitative research provides healthcare administrators with data-driven insights for decision-making. By analyzing large datasets related to patient outcomes, resource utilization, or financial indicators, administrators can identify areas for improvement and allocate resources effectively.

2. Evaluation of Healthcare Systems: Quantitative research is crucial in assessing the efficiency and effectiveness of healthcare systems. Researchers can use statistical analysis to evaluate the impact of policies, interventions, or organizational changes on patient outcomes and healthcare delivery.

3. Quality Improvement Initiatives: Quantitative research methods play a vital role in quality improvement initiatives within healthcare organizations. By collecting and analyzing data on key performance indicators, administrators can monitor progress, identify areas of concern, and implement evidence-based interventions to enhance quality of care.

1. Understanding Stakeholder Perspectives: Qualitative research helps healthcare administrators understand the perspectives and experiences of various stakeholders, including patients, healthcare providers, and policymakers. This insight can inform decision-making and policy development that aligns with the needs and values of these stakeholders.

2. Policy Evaluation: Qualitative research methods are employed to evaluate the impact of healthcare policies on different populations. By conducting interviews, focus groups, or case studies, researchers can gather data on the experiences and perceptions of individuals affected by specific policies, enabling policymakers to refine or develop new strategies.

3. Identifying Barriers and Facilitators: Qualitative research allows for a comprehensive exploration of the barriers and facilitators to effective healthcare delivery and policymaking. By understanding the contextual factors that influence implementation success, administrators can design targeted interventions to overcome barriers and enhance facilitators.

In conclusion, both quantitative and qualitative research methods play vital roles in nursing across various domains. They contribute to clinical trials, evidence-based practice, healthcare administration, and policymaking by providing valuable insights into patient outcomes, experiences, and system effectiveness. Utilizing a combination of these research approaches allows for a more comprehensive understanding of complex healthcare issues and facilitates evidence-based decision-making.

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Understanding quantitative research: part 1, juanita hoe senior clinical research associate, research department of mental health sciences, university college london, london, zoë hoare clinical trials statistician, bangor university, bangor.

This article, which is the first in a two-part series, provides an introduction to understanding quantitative research, basic statistics and terminology used in research articles. Critical appraisal of research articles is essential to ensure that nurses remain up to date with evidence-based practice to provide consistent and high-quality nursing care. This article focuses on developing critical appraisal skills and understanding the use and implications of different quantitative approaches to research. Part two of this article will focus on explaining common statistical terms and the presentation of statistical data in quantitative research.

Nursing Standard . 27, 17, 52-58. doi: 10.7748/ns.27.17.52.s65

All articles are subject to external double-blind peer review and checked for plagiarism using automated software.

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Qualitative and Quantitative Research

In general, quantitative research seeks to understand the causal or correlational relationship between variables through testing hypotheses, whereas qualitative research seeks to understand a phenomenon within a real-world context through the use of interviews and observation. Both types of research are valid, and certain research topics are better suited to one approach or the other. However, it is important to understand the differences between qualitative and quantitative research so that you will be able to conduct an informed critique and analysis of any articles that you read, because you will understand the different advantages, disadvantages, and influencing factors for each approach. 

The table below illustrates the main differences between qualitative and quantitative research. Be aware that these are generalizations, and that not every research study or article will fit neatly into these categories. 

Systematic reviews, meta-analyses, and integrative reviews are not exactly designs, but they synthesize, analyze, and compare the results from many research studies and are somewhat quantitative in nature. However, they are not truly quantitative or qualitative studies.

References:

LoBiondo-Wood, G., & Haber, J. (2010). Nursing research: Methods and critical appraisal for evidence-based practice (7 th ed.). St. Louis, MO: Mosby Elsevier

Mertens, D. M. (2010). Research and evaluation in education and psychology (3 rd ed.). Los Angeles: SAGE

Quick Overview

This 2-minute video provides a simplified overview of the primary distinctions between quantitative and qualitative research.

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The value of quantitative research in nursing

Affiliation.

• 1 Edge Hill University College, School of Health Studies, Fazakerley Hospital, Liverpool.
• PMID: 9782989

Quantitative research is an objective process used to obtain numerical data. The form of quantitative research used is influenced by current knowledge of the problem. Careful planning in the design stage is essential when undertaking quantitative research.

Publication types

• Clinical Nursing Research / methods*
• Data Interpretation, Statistical*
• Planning Techniques
• Research Design*

• Open access
• Published: 18 May 2024

Exposure to secondary traumatic stress and its related factors among emergency nurses in Saudi Arabia: a mixed method study

• Bushra Alshammari 1 ,
• Nada F Alanazi 2 ,
• Fatmah Kreedi 3 ,
• Farhan Alshammari 4 ,
• Sameer A. Alkubati 1 , 5 ,
• Awatif Alrasheeday 6 ,
• Norah Madkhali 7 ,
• Ammar Alshara 6 ,
• Venkat Bakthavatchaalam 8 ,
• Mahmoud Al-Masaeed 9 , 10 ,
• Sabah Kaied Alshammari 11 ,
• Nwair Kaied Alshammari 12 ,
• Mukhtar Ansari 13 ,
• Arshad Hussain 13 &
• Ahmed K. Al-Sadi 1  

BMC Nursing volume  23 , Article number:  337 ( 2024 ) Cite this article

Metrics details

Emergency department (ED) nurses are exposed to the risk of secondary traumatic stress (STS), which poses a threat not only to nurses’ health and psychological well-being but also adversely affects the execution of their professional duties. The quality and outcome of their nursing services are negatively affected by STS.

The purpose of this study is to comprehensively investigate the prevalence and intensity of Secondary Traumatic Stress (STS) among Emergency Department (ED) nurses. It aims to identify and analyze the socio-demographic, occupational, and psychological factors that influence the severity and variation of STS experienced by these nurses.

The study utilized a sequential explanatory mixed methods approach, including two phases. Phase 1 employed a cross-sectional study design, utilizing a convenience sample of 181 nurses to explore the levels of STS and the factors associated with it. Following this, Phase 2 was structured as a qualitative descriptive study, which involved conducting semi-structured interviews with a purposefully selected group of ten ED nurses. Data collection took place at three major hospitals in Saudi Arabia during the period from January to June 2022.

A total of 181 participants were included in the study. The mean STSS score reported by the nurses was 51 (SD = 13.23) out of the maximum possible score of 85, indicating severe STS among ED nurses. Factors associated with an increase in the levels of STS among ED nurses included being female, older in age, married, possessing higher education and experience, having a positive relationship with colleagues, receiving organisational support, and dealing with a higher number of trauma cases. Several themes emerged from the qualitative interviews including: ED Characteristics: Dual Impact on STS, Emotional Resonance and Vulnerability, Personal Life Stressors, The Ability to Cope, and Social Support.

Conclusion and implications for practice

Future strategies and interventions targeting STS should be prioritized to effectively manage its impact on ED nurses. It is crucial to develop targeted interventions that address the specific factors contributing to STS, as identified in this study. Additionally, these findings aim to enhance awareness among nursing administrators, managers, and supervisors about the critical factors associated with STS. This awareness is essential for accurately assessing and developing interventions that mitigate STS among nursing staff.

Peer Review reports

Nurses play a pivotal role in delivering healthcare services, often serving as the primary the primary and main point of contact between patients and healthcare providers [ 1 , 2 ]. They spend most of their working time directly relating to and interacting with patients. It is crucial to ensure that the nurses’ welfare is supported to enhance their professional development, quality of work, and output levels. Emergency Department (ED) nurses, in particular, work in highly demanding environments [ 3 ], where the intensity of work and the level of effort and empathy required are significantly higher. In this unit, the nurses work with patients who are, in most instances, unable to execute their basic hygienic needs and duties [ 4 ]. Frequently, ED nurses provide care for patients who have experienced traumatic events, such as accidents and injuries, and wounded and haemorrhaging victims. A majority of ED patients are traumatised by their experiences and often share this with ED nurses. As such, on a regular basis, ED nurses work and serve patients with trauma, which exposes them to the risk of trauma [ 5 , 6 ]. The Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) has broadened the definition of trauma to include indirect exposure to trauma—hearing about, witnessing, and learning about trauma—through indirect means [ 7 , 8 ]. Thus, trauma refers not only to direct trauma from an assault but also to secondary exposure to trauma. The re-conceptualisation of trauma leads to the recognition of secondary traumatic stress (STS) as a form of traumatic stress in addition to post-traumatic stress disorder (PTSD) diagnosis. PTSD is a mental health problem that occurs in people after they encounter a life-threatening experience [ 8 , 9 ]. With both PTSD and STS characterized by symptoms of intrusion, avoidance, and arousal [ 7 ]. In the period preceding DSM-5, individuals were only diagnosed with PTSD after prolonged exposure to trauma, which limited the number of people diagnosed. Many were incorrectly diagnosed as not having PTSD. The most prevalent risk of trauma exposure for ED nurses is STS [ 7 , 8 ]. STS is the result of stress caused by indirect trauma exposure. This stress dimension is acquired secondarily. The primary stress is experienced by patients who have been exposed to a traumatic event. In turn, the secondary level of stress affects the nurses who care for these patients. Nurses have a responsibility to engage patients while offering care. This includes taking their medical histories and understanding the context and nature of their injuries and accidents. Consequently, they often gather information on patients’ traumatic experiences. This exposure to patients’ traumatic stories and histories can lead to nurses experiencing STS. Understanding the level and exposure of nurses to STS is critical as its prevalence affects their psychosocial wellness and quality performance [ 10 , 11 ].

In understanding the prevalence of STS among nurses, studies have demonstrated a correlation between the nurses’ socio-demographic factors and their STS levels. However, these factors are inherently contextual. ED nurses encounter a variety of socio-demographic factors across different regions and countries [ 12 , 13 ]. Therefore, findings the relationship between socio-demographic factors and STS levels depend on variables such as health policies, cultural influences, and professional expectations within each country and region [ 12 , 13 ]. Thus, findings are formulated by analyzing dataspecific to each region and country. Unfortunately, preliminary literature analysis in the Saudi context demonstrated limited data on social factors and job satisfaction among Saudi Arabian nurses [ 6 ]. This gap in the literature guided the study’s focus on primary data collection within the Saudi Arabian context. The study was developed based on the KSA public sector healthcare industry context. Thus, the focus was on nurses working in the public healthcare industry. This focus was chosen because the public healthcare sector constitutes over two-thirds of the KSA healthcare industry. An evaluation of the KSA context indicates high exposure to STS among its nurses.

The level of STS in the Middle East is higher than in the global average. For example, studies by Kinker, Arfken and Morreale [ 14 ] and Shalabi et al. [ 15 ] which used the STSS tool, have shown that nurses in the Middle East experience greater exposure to STS compared to their counterparts in Western Europe and globally. In the Middle East, cultural perceptions often view stress, depression, and all forms of mental illness as a curse and socially unacceptable. As a result, individuals facing such challenges are often ostracized, viewed as insane, and considered unfit for society. This stigma significantly increases the likelihood of individuals not seeking help, treatment, and care when they are exposed to STS. Furthermore, seeking psychiatric assistance or counselling for traumatic experiences is frequently seen as an admission of mental instability, thus discouraging many from seeking such help [ 16 ]. This distinct cultural context makes the Middle East an especially relevant location for a study aimed at examining the impact of these perceptions on STS levels and exposure factors.

The strategic aim and contribution of the study is to help evaluate the cause of the relatively high STS among nurses in KSA. Specifically, the study aims to determine if the contributing factors and the extent of exposure to STS in KSA are consistent with those identified in the global literature. This provides a foundational basis for developing effective strategies to overcome and mitigate STS among nurses in KSA. By understanding these factors, employees and organizations can devise strategic and practical solutions to alleviate STS and reduce exposure among public sector nurses in KSA. Organizations will benefit from having more positive, committed, and productive employees, while also reducing costs associated with stress-related issues [ 17 ].

Justification for conducting a mixed methods approach

The Mixed Methods Approach allows for a more comprehensive understanding of the complex relationship between socio-demographic and work-related factors and STS. Quantitative methods can identify and measure the extent of these relationships through statistical analysis, while qualitative methods can provide deeper insights into the experiences and perceptions of ED nurses regarding STS. Qualitative findings can also validate the results obtained from quantitative methods. Given the cultural context of Saudi Arabia, qualitative methods can explore cultural factors that might influence STS. These insights are crucial for tailoring interventions and policies effectively.

Based on the identified literature gap, this study aimed to comprehensively assess the prevalence and intensity of STS among nurses working in the ED. Additionally, the study aims to identify and analyze the specific socio-demographic, occupational, and psychological factors that contribute to the variation in STS levels among these nurses.

Materials and design

Research design.

The research utilized a mixed methods sequential explanatory approach, commencing with a quantitative phase followed by a qualitative phase [ 18 ]. Phase 1: used a cross-sectional design to measure the prevalence of STS among ED nurses and the nature and extent of the relationship between ED nurses’ STS levels and their socio-demographic and work-related variables [ 19 ]. Phase 2 involved a qualitative descriptive approach, which included conducting several semi-structured interviews. These interviews were designed to enhance the understanding of the Phase 1 findings by providing a context in which the quantitative data can be better interpreted [ 18 ]. Qualitative interviews helped in gaining deeper insights into the lived experiences of individuals dealing with traumatic stress and in exploring the various factors that impact the levels of stress among nurses. Both qualitative and quantitative data were gathered and subsequently integrated to offer a comprehensive understanding of the experience of STS and how various predictors contributed to an increase in its levels.

Setting and participants

This study was conducted from January to June 2022. Phase 1 of the study used a convenience sample of ED nurses recruited from three selected governmental hospitals in Saudi Arabia: Hail General Hospital, King Khalid Hospital, and King Salman Specialist Hospital. A sample size of 181 ED nurses was determined using OpenEpi web-based calculator, Version 3.01 ( www.openepi.com ) based on the following criteria: 95% confidence level, 5% absolute precision and a population size of 340. The inclusion criterion was that the participant must be currently a registered nurse who provides direct patient care in an ED in the targeted hospitals and agreed to participate in the study. Moreover, nurses who had more than one year of experience in the ED were included. Trainees were excluded from the study.

In Phase 2 of the study, we interviewed a purposeful sample of 10 nurses who had both higher and lower scores on the STSS. Choosing nurses with varying stress scores helped understand factors contributing to higher or lower STS levels, leading to more precise research outcomes relevant to the context. Interviews were carried out until data saturation was reached, where no additional themes or subthemes were found by the participants [ 20 ]. When the terms and processes started to repeat, it indicates that a sufficient amount of data has been collected [ 21 ]. Each interview lasted for approximately 30 to 60 min.

Data collection

Questionnaires.

The questionnaire has two sections which include collecting participants’ socio-demographic characteristics, such as age, gender, ethnicity, marital status, education, experience, dependents, and income. It also gathered information on factors like career rank, shift work, weekly hours, spirituality, personal trauma history, trauma caseload, organizational support, and colleague relationships.

The second section of the questionnaire assessed STS using the English validated version of the Secondary Traumatic Stress Scale (STSS) developed by Bride et al. [ 22 ]. Since English is the official language among nurses in the intended settings, this tool was chosen. The STSS is a well-established tool with proven reliability, characterized by the Cronbach’s alpha value of 0.89 [ 23 ]. The tool includes a total of 17 different questions that measure stress using five-point, self-rating scales with responses ranging from 1 to 5, with 1 = never and 5 = very often. The questions are clustered into the three elements of STS: (i) intrusion (questions 2, 3, 6, 10, and 13), (ii) arousal (questions 4, 8, 11, 15, and 16), and (iii) avoidance (questions 1, 5, 7, 9, 12, 14, and 17) [ 24 , 25 ]. In its assessment of stress levels, the questionnaire focuses on the respondents’ experiences in the last seven days. The scores range between 17 and 85, with the higher scores indicating higher levels of STS. The STSS scores have the following interpretation: <28 indicating little or no STS, 28–37 indicating mild STS, 38–43 indicating moderate STS, 44–48 indicating high STS, and 49 and above indicating severe STS [ 24 , 26 ].

The responses were collected online via Google forms, as the study questionnaire was published online, and the respondents accessed it through a URL link that was shared with them. The questionnaire was distributed by ED directors to the nurses who met the inclusion criteria. Moreover, the questionnaire had an attached consent with a brief clarification of the study purposes and a number to contact in case of any questions. The questionnaire included an empty field where participants could indicate wish to be contacted and their preferred method of communication if they wanted to participate in the second phase of the study. The data were collected in the period between January and June 2022, thereby providing the respondents with sufficient enough time to respond to the questionnaire in the midst of their busy and tight working schedules. A reminder to complete the questionnaire was sent three weeks after the first attempt to increase response rates.

In-depth semi-structured qualitative interviews were conducted with a purposeful sample of nurses who had participated in Phase 1. The researcher used SPSS to identify and recruit nurses with the highest and lowest scores on the STSS. If these nurses did not provide their contact information or express interest in participating in the first phase, the researcher would then proceed to recruit participants with the next highest and lowest scores on the STSS.

Participants were contacted and given an information sheet that detailed the purpose and nature of the interviews, along with the consent process. Subsequently, the researcher and study participants convened at a mutually agreed-upon private venue for the interview sessions, involving only the researcher and the participant, while some interviews were conducted over the telephone as per the participants’ preferences.

The interview guide (Supplementary 1 ) was created and developed by the researchers following the initial analysis of Phase 1 and a review of relevant literature. The guide was used to capture the experiences of nurses in relation to STS while they cared for patients admitted to the ED. The following questions were asked: Can you describe a specific incident or situation in your nursing practice that you found particularly stressful or emotionally challenging? What factors or things could exacerbate or alleviate the traumatic stress that you experience? Are there any specific factors or aspects of your work environment that you believe contribute to higher or lower levels of STS (explain)? What do you think could be done to improve the well-being and mental health of nurses who frequently encounter STS? Can you recall a moment when you felt overwhelmed by STS? How did you handle it, and what support did you seek or receive? How do you manage or deal with STS in your professional capacity? The interviewer proceeded to ask further open-ended questions that were customized based on each participant’s specific responses and experiences.

The interview notes incorporated observations of participants’ body language and emotions which were also used during subsequent data analysis. Interviews were recorded using audio in a quiet and comfortable room that allowed individuals to freely express themselves without disturbances.

Ethical considerations

Ethical approval.

for the study was obtained from the Institutional Review Board (IRB), represented by the Health Cluster in Hail city (registered with the King Abdullah City for Science and Technology (KACST) in the KSA, under the registration number H-08-L-074, with approval reference H-2022-20. All the participants in this study were informed about the purpose of the study and its advantages before being asked to fill out the questionnaire. In addition, autonomy to participate in the study was guaranteed, and all information was kept confidential and used only for the purpose of scientific research. Anonymity was assured by using anonymous surveys that cannot be traced back to the respondent. The survey contained no personally identifiable information such as name or contact information. All responses were gathered and combined together and summarized in the report to further protect participants anonymity.

Data analysis

Phase 1: a cross sectional study.

The analysis approach included the use of a statistical analysis process. The study’s analysis process relied on the use of SPSS (version 26) software. In the analysis process, the findings were categorised into two main levels: the descriptive and the inferential statistics analysis. First, the descriptive analysis process enabled the analysis of the study sample–based demographics. The socio-demographic variables of the ED nurses were analyzed descriptively with the use of frequency and percentages to indicate the representation of the different population segments. Furthermore, the prevalence of the STSS variables and the presence of PTSD among the ED nurses were both descriptively analysed through the use of mean and standard deviation variables. Additionally, the study checked for the normality of the distributions using the Kolmogorov–Smirnov test and illustrated that p value greater than 0.05 indicates normal distribution of the data. Therefore, parametric statistics tests were used in this study.

Then, an independent-samples Student’s t-test was utilized to test the relationship between the STSS scores and the two categorical variables while one-way analysis of variance (ANOVA) was used to test the relationship between the STSS scores and three or more categorical variables. The obtained findings were presented in tables to ease the understanding and interpretation for readers. Factors that appear to have a statistically significant association with STSS scores were then analysed to identify the independent factors of ED nurses’ STSS using multiple linear regression. A p-value of ˂0.05 was considered statistically significant.

Phase 2: qualitative descriptive design

Thematic analysis was employed to analyze the interviews [ 27 ]. Coding was managed using NVivo qualitative data analysis software Version 12 [ 28 ]. In our qualitative analysis, we employed a structured three-phase approach: data reduction, data display, and conclusion drawing/verification [ 29 ]. . Initially, the research team conducted a detailed review of all interview transcripts, applying line-by-line coding to highlight significant phrases and identify emerging patterns. This process was enhanced by independent coding by two team members, ensuring data reliability through consensus on code assignment. During the data display phase, we organized the coded data using matrices and diagrams, which facilitated the examination of relationships and the comparison of themes across the dataset. This visual organization helped refine codes into more focused categories. In the final phase, we synthesized the data to draw meaningful conclusions, ensuring our interpretations were grounded in the participants’ experiences. Member checking was employed to validate our findings, further bolstering the credibility of our analysis. To ensure interpretative accuracy, maintain reliability, and bolster rigor, the findings were methodically discussed and validated with colleagues at every stage of the research process [ 30 ].

The Good Reporting of a Mixed Methods Study (GRAMMS) guidelines were utilized to improve the quality and transparency of the study [ 31 ]. Interviews were transcribed and independently coded by three team members (BA, FK, and FA) for dependability and confirmability. Emerging codes and themes were collectively discussed and agreed upon [ 32 ]. Member verification was carried out throughout the interview process.

Quantitative results

Demographic findings and sample validity.

A total of 181 nurses completed the questionnaire. The first findings analyzed in the study focused on the sample demographic variables as illustrated in Table  1 . Overall, 50.8% ( n  = 92) of the total participants identified themselves as being female, with 49.2% ( n  = 89) as being male. The average age of these participants was 29.9 years, ranging between 20 and 46. The majority, at 80.1% ( n  = 145), were identified as Arabs. In terms ofmarital status, 56.4% ( n  = 102) were unmarried, while 43.6% ( n  = 79) were married. Professionally, 26% had a diploma education level, while 58% and 16% Held at least a bachelor and master’s degree qualification, respectively. On earnings, the majority earn between 5000 and 10,000 Saudi Riyal (SAR) at 37%, with only 16.6% reporting to earn more than 15,000 SAR monthly income salary.

STSS scoring among participants

This study analysed the level of STS among ED nurses. The analysis relied on the scores derived from participants’ responses to 17 questions. According to STSS, the mean STS score reported by the nurses was 51.0 (SD = 13.2) out of a possible score of 85, thereby indicating severe STS among the ED nurses. A small proportion of participants (5%) reported experiencing Little to no, or moderate STS, whereas 11.6% indicated mild STS. The majority of participants disclosed experiencing high and severe levels of STS, with 27.6% reporting high levels and 50.8% reporting severe levels. Figure  1 displays the distribution of STS levels among ED nurses.

Levels of STS reported by ED nurses

Scoring of STSS subscales: intrusion, arousal, and avoidance variables

The STSS scoring examined the respective scores of the three elements of STS, namely intrusion, arousal, and avoidance. Table  2 outlines the average mean for the three elements of STSS and for the total score of STSS of the respondents in the study. For the three different STSS subscales, the analysis established that out of the highest possible score of 35, avoidance symptoms had the highest score of 20.62 (SD = 5.87), followed by the intrusion with a mean score of15.57 (SD = 3.97), and arousal with a mean score of 14.80 (SD = 4.38).

STS symptoms as reported by ED nurses

The most frequently reported avoidance symptoms included a perceived foreshortened future (76%), followed by diminished activity level (75%), avoidance of clients (68%), and inability to recall client information (62%) respectively. The remaining avoidance symptoms were reported less frequently, including emotional numbing (51%); avoidance of people, places, and things (53%), and detachment from others (56%). Among intrusion symptoms, the most commonly reported symptoms were cued psychological distress (79%), disturbing dreams about clients (69%), and sense of reliving clients’ trauma (63%) while the remaining intrusion symptoms were reported less frequently. Regarding arousal symptoms, the majority of ED nurses indicated experiencing difficulty sleeping (76%), hypervigilance (71%) and irritability (70%). Table  3 illustrates the prevalence of STS symptoms among ED nurses.

Relationship between emergency nurses’ demographics and STSS scores

Table  4 illustrates the relationship between the ED nurses’ sociodemographic characteristics and their overall STSS scores. Significant relationship were observed between the STSS scores and the variables of age, gender, years of experience, marital status, and educational level, with p-values of 0.010, 0.001, 0.001, 0.008, and 0.003, respectively. Conversely, no significant association was found between the STSS scores and the variables of ethnicity, number of dependents, and monthly income.

Relationship between emergency nurses’ work-related items and STSS scores

Table  5 shows that there were a significant relationships between the STSS scores and the variables of Trauma Case Load, ED nurses’ organisational Support, and their relationship with colleagues with p-value of 0.001, 0.027 and 0.026, respectively. However, no significant relationship was found between the STSS scores and other item.

Independent factors of secondary traumatic stress among ED nurses

Multiple linear regression shows that gender ( p  = 0.001), years of experience ( p  = 0.005), marital status ( p  = 0.013), and trauma case load ( p  = 0.007) were the independent factors of the STSS among ED nurses, see Table  6 .

Qualitative results

Sociodemographic characteristics of nurses participated in qualitative phase.

In a sample of 10 nurses included in the interviews, the mean age was 31.7 years, with an average professional experience of 9.5 years. The educational backgrounds among the nurses are diverse, with 6 holding Bachelor’s degrees, 3 possessing Diplomas, and 1 having a Master’s degree. The group was predominantly female, consisting of 8 females and 2 males. Regarding marital status, the distribution was mixed: 6 were married, 3 were single, and 1 was divorced. Among participants, five reported experiencing high levels of STS, while the other five reported low levels of stress. This diversity provided a more comprehensive understanding of the STS experience and the various factors influencing its manifestation (Table  7 ).

Findings of the interviews

Five themes emerged from the qualitative interviews: ED Characteristics: Dual Impact on STS, Emotional Resonance and Vulnerability, Personal Life Stressors, The ability to cope and Social support.

Theme 1: ED characteristics: dual impact on STS

Some nurses reported that working in the ED made them experience fewer physiological and psychological problems when providing care to patients, especially those nearing death. The nurses indicated that since their transfer to the ED, they haven’t had to establish close bonds with patients, as they care for them for a short time. In contrast, participants reported that departments like the dialysis unit, where patients need ongoing treatment over extended periods, require nurses to engage in more prolonged relationships with their patients. This dynamic presents unique emotional challenges, as observed in other specialized units like the isolation ward, highlighting the diverse impacts of different nursing environments on healthcare professionals’ well-being.

“I developed a strong connection with a patient when I was working in the ward, and I was profoundly impacted by their death. Now, in the ER, I am unable to establish relationships with patients, regardless of my desire to do so.” (Nurse 6). “I used to work in the isolation sections and built long-lasting relationships with many patients who stayed there. I was deeply affected if something happened to them. Now I feel less attached to the patients since transferring to the ER’’ (Nurse 8). “I know a colleague who works in the dialysis unit and cries every time a patient dies. Even though he is not typically sensitive, he finds it difficult to cope with these losses.” (Nurse 9).

On the other hand, some nurses find it challenging to detach emotionally from their work, highlighting the intricate nature of nursing care where emotional bonds are fundamental to the profession. This sentiment is encapsulated in the words of one nurse:

“I have encountered several shocking events that continue to weigh heavily on me. My colleagues advise professional detachment; however, I cannot comply because I believe that our emotions as nurses are essential to delivering true care” (Nurse 3). “We will continue to experience stress, and it’s unlikely and challenging to completely separate our emotions from our work as nurses.” (Nurse 4).

Responses from new nurses revealed a common struggle with distressing experiences at work. One nurse shared their difficulty in staying emotionally detached, as advised by her nurse’s colleagues, because she felt that connecting emotionally is crucial for providing proper care.

Additionally, some nurses have reported being more profoundly impacted by traumatic situations due to feelings of guilt and hopelessness. These emotions stem from the perceived low quality of care they are able to provide, which is linked to the excessive burdens and demands characteristic of ED environments

“Occasionally, I feel distressed by the thought that I could have provided more care to certain patients if I had not been so overwhelmed with other responsibilities.” (Nurse 2).

Another nurse described the challenging nature of work in the ED, particularly for those handling critical and life-threatening situations. She mentioned the difficulty of dealing with high-pressure scenarios such as resuscitations and witnessing patient deaths.

“Handling cases like resuscitations and witnessing deaths in daily bases has been tough. It’s these kinds of intense, acute events that really stick in my mind” (Nurse 5).

Theme 2: emotional resonance and vulnerability in nursing

The emotional resonance and vulnerability experienced by nurses significantly shape their professional practice and the care they provide to patients. This theme encompasses the profound impact of personal experiences, such as parenthood, and inherent personality traits, like anxiety, on nurses’ interactions with patients and their well-being. Nurses report an intensified emotional connection with patients that mirrors their own life experiences, such as the empathy felt by parent-nurses towards pediatric patients or the poignant reminder of lost loved ones when caring for elderly patients.

“In every child that comes into the ER, I see the image of my own child. Sometimes, I choose not to work with these young patients and instead ask my colleagues to take over their care.” (Nurse 1).

Another nurse also feels a strong connection to senior patients, reminiscent of her late father. She experiences a deep emotional bond with these patients says:

“Each senior man with a white beard who arrives in the ED holds a special place in my heart, reminding me of my father who has passed away—may he rest in peace. When something happens to them, it makes my heart melt with grief, and it feels as if I am experiencing the loss of my father all over again,” (Nurse 2).

Additionally, certain personality traits, such as a tendency towards anxiety, can increase vulnerability to STS. Nurses with these traits may be more prone to internalizing and reflecting on the traumatic experiences of others.

“I’ve always been a bit of a worrier. Lately, I catch myself thinking and dreaming about my patients’ struggles even after my shift is over.” (Nurse 4). “Everything I see in the hospital reflects on me at home. When my children fall ill, I live in terror that something will happen to them like what happened to a patient I saw in the hospital. There was a child who developed a fever, then had seizures and complications that might impair them for life, even though they were a normal child before. I have become obsessed and fearful that something similar will happen to my children. My husband gets upset about my excessive concern for our children, even in minor cases.” (Nurse 3).

The stress of working in high-pressure environments like the ER, compounded by the emotional intensity of caring for pediatric patients, can lead parent-nurses to become overly vigilant or anxious about their own children’s well-being, even in minor situations. This excessive concern, a possible manifestation of STS, can strain family relationships, as illustrated by instances where a spouse, such as a husband, becomes upset over what is perceived as unnecessary worry. This quotation indicates that the stress from work can spill over into their personal life, leading to a cycle where the stress from one domain exacerbates the challenges in the other.

Theme 3: personal life stressors

External stressors in one’s personal life, such as family issues, health problems, financial challenges, or other personal difficulties, can compound the stress experienced at work. When personal resources are already strained, the additional burden of STS can be even more impactful.

“Dealing with my own family problems and money issues at home makes the stress from my job even harder to handle.” (Nurse 4). ” I am currently facing a significant emotional exhaustion and find myself unable to manage additional stressors. Following my diagnosis with Multiple Sclerosis, I am grappling with persistent feelings of fear and uncertainty about the future on a daily basis.” (Nurse 5).

Theme 4: the ability to cope

Some nurses effectively manage their emotions during patient care, employing strategies to maintain a professional demeanor in emotionally charged and potentially stressful situations, such as when delivering distressing news to families about the loss of a loved one, a diagnosis, or a tragic accident

“I requested the doctor to be the one to convey the difficult news to the patient’s family because I find it emotionally challenging. It was particularly distressing for me when one of my patients tragically lost both of their legs in a car accident, and I felt unable to communicate this heart-breaking situation to their family’’ (Nurse 10). ‘’Now, after all these years, I have developed a thick skin that shields me from the intrusion of sadness into my body” (Nurse 9).

The quotation underscores how certain nurses cultivate resilience over time to handle stressors, aptly described as “developing a thick skin.” This phrase metaphorically signifies the establishment of emotional boundaries or wall, enabling nurses to fulfil their responsibilities without permitting emotional distress, stemming from continuous exposure to traumatic situations, to affect them deeply.

Theme 5: social support

Some nurses reported that they have a strong support network within the workplace, which helps nurses cope with STS.

“One of my colleagues experienced a deeply distressing event when her brother passed away in room number 3. As a result, she has developed severe symptoms of distress whenever she is required to enter that room. Since then, we have rallied together as a team to provide her with emotional support and assistance in managing her difficulty. Additionally, we have volunteered to handle her assignments if they happen to be in that room.” (Nurse 10).

The influence of social support was clearly evident, as some nurses, who preferred to avoid working with children after becoming parents themselves, received support from their colleagues by taking those assignments from them. Additionally, a nurse who had faced a traumatic incident in a particular emergency room was supported by the supervisory team, which accommodated her by scheduling shifts in a different room. Others received assistance from doctors in communicating sensitive news to patients or their families, which are measures aimed at reducing STS. These varied forms of support play a crucial role in alleviating the impact of STS among nursing staff in ED.

Synthesis and integration

In our study’s quantitative phase, we observed significant variations in stress scores among nurses. Qualitative interviews revealed that this variation is partly due to the unique dynamics of the ED. Some nurses experienced less stress, attributing it to the brief and less emotionally involved nature of patient care in the fast-paced ED environment. In contrast, others reported higher stress levels, particularly those in critical care roles within the ED, who face high-pressure situations like resuscitations and patient deaths. These findings highlight the complexity of stress factors in emergency medical settings.

In the quantitative phase, we observed a correlation between relationships with colleagues, organizational support, and heightened levels of STS among ED nurses. The qualitative insights revealed that this relationship is multifaceted. Nurses frequently relied on their colleagues for emotional and practical support in managing the high-stress environment of the ED. This involvement included nurses sharing patient care responsibilities to alleviate individual stress burdens and actively seeking advice on strategies, like maintaining professional detachment to lessen emotional involvement with patients. Additionally, nurses often sought the assistance of doctors in communicating sensitive information or ‘breaking news’ to patients and their families, as a means to manage the emotional impact of such interactions. This collaborative approach within the healthcare team plays a crucial role in the overall management of STS in the demanding environment of the ED, highlighting the need for comprehensive support systems within healthcare settings.

Quantitatively, the higher incidence of STS among married nurses could be attributed to the additional responsibilities and pressures that often come with marital and familial commitments. This observation aligns with the qualitative accounts where nurses reported that external stressors in their personal lives, such as family issues and health problems, exacerbate the stress experienced at work. It is also reasonable to infer that many married nurses are also parents, and this role can significantly influence their emotional and psychological responses, especially in their professional interactions involving children. Parenthood inherently brings a deeper empathy and sensitivity towards children, which could intensify the emotional experiences of nurses when caring for pediatric patients or dealing with pediatric emergencies. Given the higher number of children presenting to these settings, adds an important dimension to the stress experienced by nurses, especially those who are parents. Healthcare institutions should be mindful of these dynamics and consider flexible work arrangements, comprehensive mental health support, and resources that address both work-related and personal stressors.

In the initial phase of our study, examining the relationship between the number of children and STS among nurses did not reveal a significant correlation. However, being a parent was reported to be related to higher STS. Subsequent qualitative insights indicated a notable trend: nurses who are parents, especially mothers, experienced an enhanced emotional impact when caring for pediatric patients. This underscoring the complex interplay between personal and professional roles in healthcare settings.

We noticed that the avoidance score was high when measuring STS, aligning with qualitative findings that reported the common coping strategy among nurses is the avoidance of stressors to preserve emotional stability. For instance, several nurses, particularly after becoming parents, chose to avoid working with pediatric patients. Additionally, a nurse who experienced a traumatic event in a specific area received support from the supervisory team, who responded by reassigning her to different areas. Furthermore, some nurses were assisted by doctors in delivering sensitive news to patients and their families, thus mitigating the potential trauma. This pattern of avoidance as a coping mechanism underscores the need for comprehensive strategies to address the complex emotional challenges faced by nursing staff in various healthcare settings. The increased caseload leading to heightened STS aligns with qualitative findings that reported high caseloads often result in limited time and resources for each patient. Nurses may feel that they are not providing the level of care they aspire to, which can lead to feelings of guilt and hopelessness. This emotional response is particularly pronounced in cases with poor outcomes, despite the nurse’s best efforts.

The integration of quantitative and qualitative findings in this study provides a multifaceted analysis of the experience of STS and how its levels are influenced by several factors. From the findings of this study, it is evident that the STSS prevalence levels among ED nurses in Saudi Arabia are high—95% of ED nurses experience STS with different severity. This is in accordance with Ratrout [ 11 ], who reported an approximately similar prevalence of STS (94%) among ED nurses. In this study, more than half of ED nurses experienced high to severe levels of STS, with the majority of them reporting at least one symptom of STS. The obtained findings are similar to those of previous studies [ 10 , 11 , 33 ]. A critical analysis of the existing literature indicates that there is a prevailing high exposure to and risk of STS and PTSD among ED nurses. This can be explained by the nature of the nurses’ jobs and responsibilities [ 34 ]. The ED is mandated to care for emergency situations, such as injuries caused to accident victims, unexpected death, and violence [ 35 ]. In particular, their constant interaction with new death experiences of patients in the ED with significant injuries and pain, and even the loss of patients to death under their care, is a possible trigger for developing STS [ 36 ]. This exposure necessitates the implementation of targeted support systems and resilience-building programs within healthcare settings.

Our findings indicate that some nurses in the ED experienced lower levels of STS due to a diminished attachment to patients, attributing this to the transient and less emotionally involved nature of patient care inherent in the fast-paced ED environment. This detachment is partly due to the high acuity and urgency of cases encountered in the ED, where the primary focus is on providing immediate care. Patients often do not stay in the ED for extended periods; they are either quickly transferred to other departments for further treatment or discharged. This dynamic environment, characterized by brief interactions and the rapid turnover of patients, limits nurses’ ability to establish the kind of long-term relationships that might develop in less acute settings, such as long-term care units. Conversely, our study also revealed that certain nurses, particularly those involved in critical care roles within the ED, reported experiencing higher levels of stress. This increase in stress is attributed to the high-pressure situations they frequently face, such as performing resuscitations and managing patient deaths. These findings illuminate the varied impact of the ED work environment on nurses’ experiences of stress and emotional involvement with patients. This highlights the need for tailored interventions and support strategies in the ER, acknowledging both the challenges and potential positive aspects of this unique setting. Such targeted support is essential for effectively helping nurses manage STS.

In this study, it was evident that ED nurses suffer considerably from stress avoidance, intrusion, and arousal symptoms (rated as moderate and above) when measured through the lens of STS which was constant with a study conducted in Greek and reported similar findings [ 33 ]. Among the three subscales, avoidance scored the highest. This result was clearly evident in the avoidance behaviors that nurses utilize to cope with STS, as observed in the qualitative phase of the study. This aligns with the findings of Qian [ 37 ], who reported similar observations. The findings suggest that healthcare institutions should invest in targeted training programs that focus on emotional resilience and stress management. This training could help nurses develop healthier coping mechanisms beyond avoidance.

The results showed that the most reported symptoms were psychological stress, difficulty sleeping, foreshortened future, diminished activity level, hypervigilance, and irritability, respectively. These symptoms were also reported in Ireland by Duffy et al. [ 38 ] and in USA by Dominguez-Gomez and Rutledge [ 39 ]. Nurse managers and organisations should create effective strategies to reduce and manage such symptoms and prevent their consequences.

Being female nurses was associated with increasing the levels of STS. This finding was similar to Civljak et al. [ 40 ] Ramatsipele [ 41 ] and Dominguez-Gomez and Rutledge’s [ 39 ] and contrasted with those of Mary Pappiya [ 42 ]. Although these studies were conducted in USA, the variation between them might be related to the variation in the criteria used to measure STS [ 11 ]. The existing literature reported that female nurses are more prone to stress because of the multi-role and responsibilities associated with being a wife or mother [ 43 ]. In addition, female nurses in Saudi Arabia expose to night working shift that consider difficult and, culturally unacceptable and provide more stressful situation for them [ 44 , 45 ]. Given that the nursing workforce comprises mostly female, gender-specific interventions to reduce STS is required. Therefore, our findings suggested that married nurses may be more likely to demonstrate higher levels of STS, which was consistent with the results of Lee et al. [ 46 ] and contrasted with those of Ramatsipele [ 41 ]. A popular explanation is that the higher stress can be a consequence of the role of married nurses, which involves complex and multiple responsibilities to fulfil, such as being a parents, husband/wife, housekeeper, and employee, which might increase the level of perceived stress among them [ 47 , 48 ]. Contrary, it has been reported by Jiang et al., that being married and having a stable partner could be a source of support to reduce stress [ 49 ]. However, Robles stated that being married is not an advantage if the quality of marriage is low [ 50 ].

Further, this study revealed that the levels of STS are lower in cases where nurses have a higher number of years of experience. According to Labrague [ 51 ], nurses with lower number of years of experience had significantly higher stress due to the fear of medical errors, lack of assessment skills, and fear of occupational injuries [ 51 ]. Experienced nurses deliver higher-quality care and possess the ability to adapt to uncertain, everyday situations in dynamic environments like the ED and its various challenges. These seasoned nurses can cope effectively with stress and offer social support to both their vulnerable colleagues and new nurses who are still learning to confront STS. Further research on experienced nurses’ strategies underscores the importance of structured mentorship programs to facilitate knowledge transfer and stress management, enhancing workplace support and efficiency.

The current study revealed that an increased trauma caseload significantly increases STS. Several studies have found a significant positive association between STS and the number of trauma cases admitted to the ED [ 52 , 53 ]. According to McCann and Pearlman, hearing or learning about a traumatic event can induce STS [ 54 ]. In addition, reinforcement of nurses with coping strategies should be planned to help them to improve mental wellbeing, decreases stress and improve their resilience [ 55 ]. So that, psychological support and assistance from the healthcare providers should be provided for nurses to improve their working conditions [ 56 ]. Administrators and policymakers should encourage reasonable client caseloads, which is important to reduce STSS among ED nurses [ 57 ].

This study also found that the experience of STS among nurses of different races and ethnicities differs significantly, although it was not significant after we performed the regression analysis. Cultural differences, traditions, beliefs, expectations, and behaviors can influence the level of reported stress among nurses. According to Aldwin, the cultural context shapes the types of stressors that an individual is likely to experience and the manner in which these stressors are perceived, understood, and dealt with [ 58 ].

Although extant literature has reported that work-related factors—such as weekly working hours, career rank, salary, shift work, and organisational support—played a significant role in the prevention or occurrence of STS among professionals [ 38 ], our findings show no such influences. To conclude, STSS may have a few limitations. One limitation of the study was the inability to contact certain eligible participants for the interview phase, as they did not provide their contact details in the online survey during the initial quantitative phase. We interviewed a purposeful sample of ED nurses with varying STSS scores. If a nurse was not interested in participating in the subsequent phase or had not provided contact information, we recruited those with the next highest or lowest scores, which might not have been the ideal choice for the study’s purpose. Another limitation is that during the interviews, it was noted that some nurses held misconceptions about STS, frequently focusing on the general stress and challenges of working in the ED instead. In these instances, the researcher provided clarification on the concept of STS and guided the participants back to the central topic of the interview. The researcher clarified the concept of STS and steered the participants back to the intended focus of the interview. An additional limitation of our study is the subjective nature of certain data points, such as trauma case load, organizational support, and history of trauma. These variables depend on participants’ experiences and may introduce bias into the study results. However, we mitigated this by quantifying these data using standard scales, which enhanced the reliability, comparability, and objectivity of our data analysis.

In summary, the study has demonstrated an insight into the nature of STS and its impact on nursing professionals. These messages underscore the complex dynamics of STS in healthcare settings and offer guidance for addressing this pervasive issue. Firstly, the study reveals the high prevalence of STS among ED nurses, with a significant portion experiencing severe levels of stress. This underscores the emotionally taxing environment of emergency care and the urgent need for targeted interventions to support the mental health and well-being of these essential healthcare workers. Secondly, the study identifies key demographic and occupational factors associated with higher levels of STS, including gender, marital status, years of experience, and trauma caseload. These insights can inform targeted interventions, such as providing additional support for female nurses, those with greater familial responsibilities, or staff handling a high volume of trauma cases. Thirdly, the research highlights the dual impact of the ED environment on STS, showing how the fast-paced, high-pressure setting can both mitigate and exacerbate stress levels. Nurses in the ED may experience reduced emotional attachment due to brief patient interactions, potentially lowering STS. Conversely, the critical nature of care in the ED, involving life-threatening situations and patient deaths, significantly heightens the risk of STS. This dichotomy emphasizes the need for nuanced support strategies that address the unique challenges of the ED setting. Moreover, the study points to the profound influence of personal factors, such as family-linked empathy and personal vulnerabilities, on nurses’ experiences of STS. Nurses who are parents or have strong personal connections to their patients may find these emotional bonds intensifying their stress. This finding suggests the importance of considering individual nurse’s backgrounds and personal lives when developing support and intervention programs. Additionally, the investigation into coping mechanisms and social support systems within the workplace reveals their critical role in mitigating STS. Strategies that promote professional detachment while fostering a supportive team environment can help nurses manage the emotional demands of their work more effectively.

In conclusion, the study offers vital perspectives on the challenges ED nurses face regarding STS. Healthcare institutions should implement regular training on stress recognition and coping strategies, establish peer support programs, and provide accessible professional mental health support. Policies on workload management are essential to prevent nurse overload and ensure periodic rotations to less intense environments. Enhancing the work environment with quiet spaces for breaks and ergonomic improvements can also reduce stress. Additionally, leadership training should focus on supportive practices that foster a positive work culture, complemented by systems for regular mental health assessments and resilience-building programs to equip nurses with tools to manage and mitigate the impacts of STS effectively.

Data availability

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

Abbreviations

Emergency department

• Secondary traumatic stress

Secondary traumatic stress scale

The Diagnostic and Statistical Manual of Mental Disorders 5th Edition

Post-traumatic stress disorder

Institutional Review Board

The Good Reporting of a Mixed Methods Study

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Acknowledgements

The authors express our appreciation to the Research Deanship at the University of Ha’il, Saudi Arabia, for funding this project, identified by project number RG-20 204.

This research has been funded by research Deanship at University of Ha’il Saudi Arabia through project number RG-20 204.

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Conceptualisation, B.A., N.A., SA and M.A.; methodology, B.A., N.A., N.M., F.A., F.K., V.B., SA, A.A, SKA, NKA, Am. A and M.A; software, N.A., V.B., and M.A.; validation, N.A., V.B., and M.A.; formal analysis, B.A., N.A., AKA, V.B., SA and M.A.; investigation, B.A., N.A., and M.A; writing—original draft preparation, B.A., N.A., SA and M.A.; writing—review and editing, B.A., N.A., N.M., F.A., F.K., V.B., A.A., SA, SKA, NKA, M.An, A.H, AKA, Am. A and M.A; visualisation, B.A; supervision, B.A. and SABA: Bushra AlshammariNA: Nada F AlanaziFK: Fatmah KreediFA: Farhan AlshammariSA: Sameer A. AlkubatiAA: Awatif AlrasheedayNM: Norah MadkhaliAm. A: Ammar AlsharaVB: Venkat BakthavatchaalamMA: Mahmoud Al-MasaeedSKA: Sabah Kaied AlshammariNKA: Nwair Kaied AlshammariM.An: Mukhtar AnsariAH: Arshad HussainAKA: Ahmed K. Alsadi.

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Alshammari, B., Alanazi, N.F., Kreedi, F. et al. Exposure to secondary traumatic stress and its related factors among emergency nurses in Saudi Arabia: a mixed method study. BMC Nurs 23 , 337 (2024). https://doi.org/10.1186/s12912-024-02018-4

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Competency gap among graduating nursing students: what they have achieved and what is expected of them

• Majid Purabdollah 1 , 2 ,
• Vahid Zamanzadeh 2 , 3 ,
• Akram Ghahramanian 2 , 4 ,
• Leila Valizadeh 2 , 5 ,
• Saeid Mousavi 2 , 6 &
• Mostafa Ghasempour 2 , 4  

BMC Medical Education volume  24 , Article number:  546 ( 2024 ) Cite this article

Metrics details

Nurses’ professional competencies play a significant role in providing safe care to patients. Identifying the acquired and expected competencies in nursing education and the gaps between them can be a good guide for nursing education institutions to improve their educational practices.

In a descriptive-comparative study, students’ perception of acquired competencies and expected competencies from the perspective of the Iranian nursing faculties were collected with two equivalent questionnaires consisting of 85 items covering 17 competencies across 5 domains. A cluster sampling technique was employed on 721 final-year nursing students and 365 Iranian nursing faculties. The data were analyzed using descriptive statistics and independent t-tests.

The results of the study showed that the highest scores for students’ acquired competencies and nursing faculties’ expected competencies were work readiness and professional development, with mean of 3.54 (SD = 0.39) and 4.30 (SD = 0.45), respectively. Also, the lowest score for both groups was evidence-based nursing care with mean of 2.74 (SD = 0.55) and 3.74 (SD = 0.57), respectively. The comparison of competencies, as viewed by both groups of the students and the faculties, showed that the difference between the two groups’ mean scores was significant in all 5 core-competencies and 17 sub-core competencies ( P  < .001). Evidence-based nursing care was the highest mean difference (mean diff = 1) and the professional nursing process with the lowest mean difference (mean diff = 0.70).

The results of the study highlight concerns about the gap between expected and achieved competencies in Iran. Further research is recommended to identify the reasons for the gap between the two and to plan how to reduce it. This will require greater collaboration between healthcare institutions and nursing schools.

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Introduction| Background

Nursing competence refers to a set of knowledge, skills, and behaviors that are necessary to successfully perform roles or responsibilities [ 1 ]. It is crucial for ensuring the safe and high-quality care of patients [ 2 , 3 , 4 , 5 ]. However, evaluating nursing competence is challenging due to the complex, dynamic, and multi factorial nature of the clinical environment [ 3 ]. The introduction of nursing competencies and their assessment as a standard measure of clinical performance at the professional level has been highlighted by the Association of American Colleges of Nursing [ 6 , 7 ]. As a result, AACN (2020) introduces competence assessment as an emerging concept in nursing education [ 7 ].

On the other hand, the main responsibility of nursing education is to prepare graduates who have the necessary competencies to provide safe and quality care [ 3 ]. Although it is believed that it is impossible to teach everything to students, acquiring some competencies requires entering a real clinical setting and gaining work experience [ 8 ]. However, nursing students are expected to be competent to ensure patient safety and quality of care after graduation [ 9 ]. To the extent that the World Health Organization (WHO), while expressing concern about the low quality of nursing education worldwide, has recommended investing in nursing education and considers that the future to require nurses who are theoretically and clinically competent [ 5 ]. Despite efforts, the inadequate preparation of newly graduated nursing students and doubts about the competencies acquired in line with expectations to provide safe care for entering the nursing setting have become a global concern [ 10 , 11 , 12 , 13 ]. The results of studies in this field are different. The results of Amsalu et al. showed that the competence of newly graduated nursing students to provide quality and safe care was not satisfactory [ 14 ]. Some studies have also highlighted shortcomings in students’ “soft” skills, such as technical competency, critical thinking, communication, teamwork, helping roles, and professionalism [ 15 ]. Additionally, prior research has indicated that several nursing students have an unrealistic perception of their acquired competencies before entering the clinical setting and they report a high level of competence [ 2 ]. In other study, Hickerson et al. showed that the lack of preparation of nursing students is associated with an increase in patient errors and poor patient outcomes [ 16 ]. Some studies also discussed nursing competencies separately; Such as patient safety [ 17 ], clinical reasoning [ 18 ], interpersonal communication [ 19 ], and evidence-based care competence [ 20 ].

On the other hand, the growing need for safe nursing care and the advent of new educational technologies, the emergence of infectious diseases has increased the necessity of nursing competence. As a result, the nursing profession must be educated to excellence more than ever before [ 5 , 21 , 22 ]. Therefore, the self-assessment of students’ competence levels as well as the evaluation of nursing managers about the competencies expected from them is an essential criterion for all healthcare stakeholders, educators, and nursing policymakers to ensure the delivery of safe, and effective nursing care [ 9 , 23 , 24 ].

However, studies of nurse managers’ perceptions of the competence of newly graduated nursing students are limited and mostly conducted at the national level. Hence, further investigation is needed in this field [ 25 , 26 ]. Some other studies have been carried out according to the context and the needs of societies [ 3 , 26 , 27 , 28 ]. The results of some other studies in the field of students’ self-assessment of perceived competencies and managers’ and academic staff’s assessment of expected competency levels are different and sometimes contradictory, and there is the “academic-clinical gap” between expected and achieved competencies [ 25 , 29 , 30 ]. A review of the literature showed that this gap has existed for four decades, and the current literature shows that it has not changed much over time. The academe and practice settings have also been criticized for training nurses who are not sufficiently prepared to fully engage in patient care [ 1 ]. Hence, nursing managers must understand the expected competencies of newly graduated students, because they have a more complete insight into the healthcare system and the challenges facing the nursing profession. Exploration of these gaps can reveal necessities regarding the work readiness of nursing graduates and help them develop their competencies to enter the clinical setting [ 1 , 25 ].

Although research has been carried out on this topic in other countries, the educational system in those countries varies from that of Iran’s nursing education [ 31 , 32 ]. Iran’s nursing curriculum has tried to prepare nurses who have the necessary competencies to meet the care needs of society. Despite the importance of proficiency in nursing education, many nursing graduates often report feeling unprepared to fulfill expected competencies and they have deficiencies in applying their knowledge and experience in practice [ 33 ]. Firstly, the failure to define and identify the expected competencies in the nursing curriculum of Iran led to the absence of precise and efficient educational objectives. Therefore, it is acknowledged that the traditional nursing curriculum of Iran focuses more on lessons organization than competencies [ 34 ]. Secondly, insufficient attention has been given to the scheduling, location, and level of competencies in the nursing curriculum across different semesters [ 35 ]. Thirdly, the large volume of content instead of focusing on expected competencies caused nursing graduates challenged to manage complex situations [ 36 ]. Therefore, we should not expect competencies such as critical thinking, clinical judgment, problem-solving, decision-making, management, and leadership from nursing students and graduates in Iran [ 37 ]. Limited research has been conducted in this field in Iran. Studies have explored the cultural competence of nursing students [ 38 ] and psychiatric nurses [ 39 ]. Additionally, the competence priorities of nurses in acute care have been investigated [ 40 ], as well as the competency dimensions of nurses [ 41 ].

In Iran, after receiving the diploma, the students participate in a national exam called Konkur. Based on the results of this exam, they enter the field of nursing without conducting an aptitude test interview and evaluating individual and social characteristics. The 4-year nursing curriculum in Iran has 130 units including 22 general, 54 specific, 15 basic sciences, and 39 internship units. In each semester, several workshops are held according to the syllabus [ 42 ]. Instead of the expected competencies, a list of general competencies is specified as learning outcomes in the program. Accepted students based on their rank in the exam and their choice in public and Islamic Azad Universities (non-profit), are trained with a common curriculum. Islamic Azad Universities are not supported by government funding and are managed autonomously, this problem limits the access to specialized human resources and sufficient educational fields, and the lower salaries of faculty members in Azad Universities compared to the government system, students face serious challenges. Islamic Azad Universities must pay exorbitant fees to medical universities for training students in clinical departments and medical training centers, doubling these Universities’ financial problems. In some smaller cities, these financial constraints cause students to train in more limited fields of clinical training and not experience much of what they have learned in the classroom in practice and the real world of nursing. The evaluation of learners in the courses according to the curriculum is based on formative and summative evaluation with teacher-made tests, checklists, clinical assignments, conferences, and logbooks. The accreditation process of nursing schools includes two stages internal evaluation, which is done by surveying students, professors and managers of educational groups, and external accreditation is done by the nursing board. After completing all their courses, to graduate, students must participate in an exam called “Final”, which is held by each faculty without the supervision of an accreditation institution, the country’s assessment organization or the Ministry of Health, and obtain at least a score of 10 out of 20 to graduate.

Therefore, we conducted this comprehensive study as the first study in Iran to investigate the difference between the expected and perceived competence levels of final year nursing students. The study’s theoretical framework is based on Patricia Benner’s “From Novice to Expert” model [ 43 ].

Materials and methods

The present study had the following three objectives:

Determining self-perceived competency levels from the perspective of final year nursing students in Iran.

Determining expected levels of competency from the perspective of nursing faculties in Iran.

To determine the difference between the expected competencies from the perspective of nursing faculties and the achieved competencies from the perspective of final-year nursing students.

This study is a descriptive-comparative study.

First, we obtained a list of all nursing schools in the provinces of Iran from the Ministry of Health ( n  = 31). From 208 Universities, 72 nursing schools were randomly selected using two-stage cluster sampling. Among the selected faculties, we chose 721 final-year nursing students and 365 nursing faculties who met the eligibility criteria for the study. Final-year nursing students who consented to participate in the study were selected. Full-time faculty members with at least 2 years of clinical experience and nurse managers with at least 5 years of clinical education experience were also included. In this study, nursing managers, in addition to their educational roles in colleges, also have managerial roles in the field of nursing. Some of these roles include nursing faculty management, nursing board member, curriculum development and review, planning and supervision of nursing education, evaluation, and continuous improvement of nursing education. The selection criteria were based on the significant role that managers play in nursing education and curriculum development [ 44 ]. Non-full-time faculty members and managers without clinical education experience were excluded from the study.

The instrument used in this study is a questionnaire developed and psychometrically tested in a doctoral nursing dissertation [ 45 ]. To design the tool, the competencies expected of undergraduate nursing students in Iran and worldwide were first identified through a scoping review using the methodology recommended by the Joanna Briggs Institute (JBI) and supported by the PAGER framework. Summative content analysis by Hsieh and Shannon (2005) was used for analysis, which included: counting and comparing keywords and content, followed by interpretation of textual meaning. In the second step, the results of the first step were used to create tool statements. Then the validity of the instrument was checked by face validity, content validity (determination of the ratio and index of content validity), and validity of known groups. Its reliability was also checked by internal consistency using Cronbach’s alpha method and stability using the test-retest method. The competency questionnaire comprises 85 items covering 17 competencies across 5 domains: “individualized care” (4 competencies with 21 items), “evidence-based nursing care” (2 competencies with 10 items), “professional nursing process” (3 competencies with 13 items), “nursing management” (2 competencies with 16 items), and “work readiness and professional development” (6 competencies with 25 items) [ 45 ]. “The Bondy Rating Scale was utilized to assess the competency items, with ratings ranging from 1 (Dependent) to 5 (Independent) on a 5-point Likert scale [ 46 ]. The first group (nursing students) was asked to indicate the extent to which they had acquired each competency. The second group (nursing faculties) was asked to specify the level to which they expected nursing students to achieve each competency.

Data collection

First, the researcher contacted the deans and managers of the selected nursing schools by email to obtain permission. After explaining the aims of the study and the sampling method, we obtained the telephone number of the representative of the group of final year nursing students and also the email of the faculty members. The representative of the student group was then asked to forward the link to the questionnaire to 10 students who were willing to participate in the research. Informed consent for students to participate in the online research was provided through the questionnaires, while nursing faculty members who met the eligibility criteria for the study received an informed consent form attached to the email questionnaire. The informed consent process clarified the study objectives and ensured anonymity of respondent participation in the research, voluntary agreement to participate and the right to revoke consent at any time. An electronic questionnaire was then sent to 900 final year nursing students and 664 nursing faculties (from 4 March 2023 to 11 July 2023). Reminder emails were sent to nursing faculty members three times at two-week intervals. The attrition rate in the student group was reported to be 0 (no incomplete questionnaires). However, four questionnaires from nursing faculty members were discarded because of incomplete responses. Of the 900 questionnaires sent to students and 664 sent to nursing faculties, 721 students and 365 nursing faculty members completed the questionnaire. The response rates were 79% and 66% respectively.

Data were analyzed using SPSS version 22. Frequencies and percentages were used to report categorical variables and mean and standard deviations were used for quantitative variables. The normality of the quantitative data was confirmed using the Shapiro-Wilk and Skewness tests. An independent t-test was used for differences between the two groups.

Data analysis revealed that out of 721 students, 441 (61.20%) was female. The mean and deviation of the students’ age was 22.50 (SD = 1.21). Most of the students 577 (80%) were in their final semester. Also, of the total 365 faculties, the majority were female 253 (69.31%) with a mean of age 44.06 (SD = 7.46) and an age range of 22–65. The academic rank of most nursing faculty members 156 (21.60%) was assistant professor (Table  1 ).

The results of the study showed that in both groups the highest scores achieved by the students and expected by the nursing faculty members were work readiness and professional development with a mean and standard deviation of 3.54 (0.39) and 4.30 (0.45) respectively. The lowest score for both groups was also evidence-based nursing care with a mean and standard deviation of 2.74 (0.55) for students and 3.74 (0.57) for nursing faculty members (Table  2 ).

Also, the result of the study showed that the highest expected competency score from the nursing faculty members’ point of view was the safety subscale. In other words, faculty members expected nursing students to acquire safety competencies at the highest level and to be able to provide safe care independently according to the rating scale (Mean = 4.51, SD = 0.45). The mean score of the competencies achieved by the students was not above 3.77 in any of the subscales and the highest level of competency achievement according to self-report of students was related to safety competencies (mean = 3.77, SD = 0.51), preventive health services (mean = 3.69, SD = 0.79), values and ethical codes (mean = 3.67, SD = 0.77), and procedural/clinical skills (mean = 3.67, SD = 0.71). The other competency subscales from the perspective of the two groups are presented in Table  3 , from highest to lowest score.

The analysis of core competencies achieved and expected from both students’ and nursing faculty members’ perspectives revealed that, firstly, there was a significant difference between the mean scores of the two groups in all five core competencies ( P  < .001) and that the highest mean difference was related to evidence-based care with mean diff = 1 and the lowest mean difference was related to professional care process with mean diff = 0.70 (Table  4 ).

Table  5 indicates that there was a significant difference between the mean scores achieved by students and nursing faculty members in all 5 core competencies and 17 sub-core Competencies ( p  < .001).

The study aimed to determine the difference between nursing students’ self-perceived level of competence and the level of competence expected of them by their nursing faculty members. The study results indicate that students scored highest in work readiness and professional development. However, they were not independent in this competency and required support. The National League for Nursing (NLN) recognizes nursing professional development as the goal of nursing education programs [ 47 ] However, Aguayo-Gonzalez [ 48 ] believes that the appropriate time for professional development is after entering a clinical setting. This theme includes personal characteristics, legality, clinical/ procedural skills, patient safety, preventive health services, and mentoring competence. Personality traits of nursing students are strong predictors of coping with nursing stress, as suggested by Imus [ 49 ]. These outcomes reflect changes in students’ individual characteristics during their nursing education. Personality changes, such as the need for patience and persistence in nursing care and understanding the nurse identity prepare students for the nursing profession, which is consistent with the studies of Neishabouri et al. [ 50 ]. Although the students demonstrated a higher level of competence in this theme, an examination of the items indicates that they can still not adapt to the challenges of bedside nursing and to use coping techniques. This presents a concerning issue that requires attention and resolution. Previous studies have shown that nursing education can be a very stressful experience [ 51 , 52 , 53 ].

Of course, there is no consensus on the definition of professionalism and the results of studies in this field are different. For example, Akhtar et al. (2013) identified common viewpoints about professionalism held by nursing faculty and students, and four viewpoints emerged humanists, portrayers, facilitators, and regulators [ 54 ]. The findings of another study showed that nursing students perceived vulnerability, symbolic representation, role modeling, discontent, and professional development are elements that show their professionalism [ 55 ]. The differences indicate that there may be numerous contextual variables that affect individuals’ perceptions of professionalism.

The legal aspects of nursing were the next item in this theme that students needed help with. The findings of studies regarding the legal competence of newly graduated nursing students are contradictory reported that only one-third of nurse managers were satisfied with the legal competence of newly graduated nursing students [ 56 , 57 ]. Whereas the other studies showed that legality was the highest acquired competence for newly graduated nursing students [ 58 , 59 ]. However, the results of this study indicated that legality may be a challenge for newly graduated nursing students. Benner [ 43 ] highlighted the significant change for new graduates in that they now have full legal and professional responsibility for the patient. Tong and Epeneter [ 60 ] also reported that facing an ethical dilemma is one of the most stressful factors for new graduates. Therefore, the inexperience of new graduates cannot reduce the standard of care that patients expect from them [ 60 ]. Legal disputes regarding the duties and responsibilities of nurses have increased with the expansion of their roles. This is also the case in Iran. Nurses are now held accountable by law for their actions and must be aware of their legal obligations. To provide safe healthcare services, it is essential to know of professional, ethical, and criminal laws related to nursing practice. The nursing profession is accountable for the quality of services delivered to patients from both professional and legal perspectives. Therefore, it is a valuable finding that nurse managers should support new graduates to better deal with ethical dilemmas. Strengthening ethical education in nursing schools necessitates integrating real cases and ethical dilemmas into the curriculum. Especially, Nursing laws are missing from Iran’s undergraduate nursing curriculum. By incorporating authentic case studies drawn from clinical practice, nursing schools provide students with opportunities to engage in critical reflection, ethical analysis, and moral deliberation. These real cases challenge students to apply ethical principles to complex and ambiguous situations, fostering the development of ethical competence and moral sensitivity. Furthermore, ethical reflection and debriefing sessions during clinical experiences enable students to discuss and process ethical challenges encountered in practice, promoting self-awareness, empathy, and professional growth. Overall, by combining theoretical instruction with practical application and the use of real cases, nursing schools can effectively prepare future nurses to navigate ethical dilemmas with integrity and compassion.

However, the theme of evidence-based nursing care was the lowest scoring, indicating that students need help with this theme. The findings from studies conducted in this field are varied. A limited number of studies reported that nursing students were competent to implement evidence-based care [ 61 ], while other researchers reported that nursing students’ attitudes toward evidence-based care to guide clinical decisions were largely negative [ 20 , 62 ]. The principal barriers to implementing evidence-based care are lack of authority to change patient care policy, slow dissemination of evidence and lack of time at the bedside to implement evidence [ 10 ], and lack of knowledge and awareness of the process of searching databases and evaluating research [ 63 ]. While the European Higher Education Area (EHEA) framework and the International Council of Nurses Code of Ethics introduce the ability to identify, critically appraise, and apply scientific information as expected learning outcomes for nursing students [ 64 , 65 ], the variation in findings highlights the complexity of the concept of competence and its assessment [ 23 ]. Evidence-Based Nursing (EBN) education for nursing students is most beneficial when it incorporates a multifaceted approach. Interactive workshops play a crucial role, providing students with opportunities to critically appraise research articles, identify evidence-based practices, and apply them to clinical scenarios. Simulation-based learning further enhances students’ skills by offering realistic clinical experiences in a safe environment. Additionally, clinical rotations offer invaluable opportunities for students to observe and participate in evidence-based practices under the guidance of experienced preceptors. Journal clubs foster a culture of critical thinking and ongoing learning, where students regularly review and discuss current research articles. Access to online resources such as databases and evidence-based practice guidelines allows students to stay updated on the latest evidence and best practices. To bridge the gap between clinical practice and academic theory, collaboration between nursing schools and healthcare institutions is essential. This collaboration can involve partnerships to create clinical learning environments that prioritize evidence-based practice, inter professional education activities to promote collaboration across disciplines, training and support for clinical preceptors, and continuing education opportunities for practicing nurses to strengthen their understanding and application of EBN [ 66 ]. By implementing these strategies, nursing education programs can effectively prepare students to become competent practitioners who integrate evidence-based principles into their clinical practice, ultimately improving patient outcomes.

The study’s findings regarding the second objective showed that nursing faculty members expected students to achieve the highest level of competence in work readiness and professional development, and the lowest in evidence-based nursing care competence. The results of the studies in this area revealed that there is a lack of clarity about the level of competence of newly graduated nursing students and that confusion about the competencies expected of them has become a major challenge [ 13 , 67 ]. Evidence of nurse managers’ perceptions of newly graduated nursing student’s competence is limited and rather fragmented. There is a clear need for rigorous empirical studies with comprehensive views of managers, highlighting the key role of managers in the evaluation of nurse competence [ 1 , 9 ]. Some findings also reported that nursing students lacked competence in primary and specialized care after entering a real clinical setting [ 68 ] and that nursing managers were dissatisfied with the competence of students [ 30 ].

The results of the present study on the third objective confirmed the gap between expected and achieved competence requirements. The highest average difference was related to evidence-based nursing care, and the lowest mean difference was related to the professional nursing process. The findings from studies in this field vary. For instance, Brown and Crookes [ 13 ] reported that newly graduated nursing students were not independent in at least 26 out of 30 competency domains. Similar studies have also indicated that nursing students need a structured program after graduation to be ready to enter clinical work [ 30 ]. It can be stated that the nursing profession does not have clear expectations of the competencies of newly graduated nursing students, and preparing them for entry into clinical practice is a major challenge for administrators [ 13 ]. These findings can be explained by the Duchscher transition shock [ 69 ]. It is necessary to support newly graduated nursing students to develop their competence and increase their self-confidence.

The interesting but worrying finding was the low expectations of faculty members and the low scores of students in the theme of evidence-based care. However, nursing students need to keep their competencies up to date to provide safe and high-quality care. The WHO also considers the core competencies of nurse educators to be the preparation of effective, efficient, and skilled nurses who can teach the evidence-based learning process and help students apply it clinically [ 44 ]. The teaching of evidence-based nursing care appears to vary across universities, and some clinical Faculties do not have sufficient knowledge to support students. In general, it can be stated that the results of the present study are in line with the context of Iran. Some of the problems identified include a lack of attention to students’ academic talent, a lack of a competency-based curriculum, a gap between theory and clinical practice, and challenges in teaching and evaluating the achieved competencies [ 42 ].

Strengths and limitations

The study was conducted on a national level with a sizable sample. It is one of the first studies in Iran to address the gap between students’ self-perceived competence levels and nursing faculty members’ expected competency levels. Nevertheless, one of the limitations of the study is the self-report nature of the questionnaire, which may lead to social desirability bias. In addition, the COVID-19 pandemic coinciding with the student’s first and second years could potentially impact their educational quality and competencies. The limitations established during the outbreak negatively affected the nursing education of students worldwide.

Acquiring nursing competencies is the final product of nursing education. The current study’s findings suggest the existence of an academic-practice gap, highlighting the need for educators, faculty members, and nursing managers to collaborate in bridging the potential gap between theory and practice. While nursing students were able to meet some expectations, such as value and ethical codes, there is still a distance between expectations and reality. Especially, evidence-based care was identified as one of the weaknesses of nursing students. It is recommended that future research investigates the best teaching strategies and more objective assessments of competencies. The findings of this study can be used as a guide for the revision of undergraduate nursing education curricula, as well as a guide for curriculum development based on the development of competencies expected of nursing students. Nursing managers can identify existing gaps and plan to fill them and use them for the professionalization of students. This requires the design of educational content and objective assessment tools to address these competencies at different levels throughout the academic semester. This significant issue necessitates enhanced cooperation between healthcare institutions and nursing schools. Enhancing nursing education requires the implementation of concrete pedagogical strategies to bridge the gap between theoretical knowledge and practical skills. Simulation-based learning emerges as a pivotal approach, offering students immersive experiences in realistic clinical scenarios using high-fidelity simulators [ 70 ]. Interprofessional education (IPE) is also instrumental, in fostering collaboration among healthcare professionals and promoting holistic patient care. Strengthening clinical preceptorship programs is essential, with a focus on providing preceptors with formal training and ongoing support to facilitate students’ clinical experiences and transition to professional practice [ 71 ]. Integrating evidence-based practice (EBP) principles throughout the curriculum cultivates critical thinking and inquiry skills among students, while technology-enhanced learning platforms offer innovative ways to engage students and support self-directed learning [ 72 ]. Diverse and comprehensive clinical experiences across various healthcare settings ensure students are prepared for the complexities of modern healthcare delivery. By implementing these practical suggestions, nursing education programs can effectively prepare students to become competent and compassionate healthcare professionals.

Data availability

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

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The authors extend their gratitude to all the nursing students and faculties who took part in this study.

This article is part of research approved with the financial support of the deputy of research and technology of Tabriz University of Medical Sciences.

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Majid Purabdollah

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Department of Medical-Surgical Nursing, School of Nursing and Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran

Vahid Zamanzadeh

Department of Medical Surgical Nursing, Faculty of Nursing and Midwifery, Tabriz University of Medical Sciences, Tabriz, Iran

Akram Ghahramanian & Mostafa Ghasempour

Department of Pediatric Nursing, School of Nursing and Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran

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Purabdollah, M., Zamanzadeh, V., Ghahramanian, A. et al. Competency gap among graduating nursing students: what they have achieved and what is expected of them. BMC Med Educ 24 , 546 (2024). https://doi.org/10.1186/s12909-024-05532-w

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Mixed Methods in Nursing Research : An Overview and Practical Examples

Ardith z. doorenbos.

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

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

Introduction

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

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

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

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

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

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

An Example : Understanding the Pain Management Experience Among American Indians

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

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

Using Mixed Methods to Overcome Barriers to Research

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

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

Role of quantitative data

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

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

Role of qualitative data

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

Role of (qualitative) indigenous methodologies

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

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

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

Benefits of Triangulation Design: Multilevel Model

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

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

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

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

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

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

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

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

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

Qualitative and Quantitative Data Collection Procedures

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

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

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

Qualitative and Quantitative Data Analysis

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

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

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

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

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

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

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

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

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

Acknowledgments

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

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