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Journal of Research in Nursing

Journal of Research in Nursing

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  • Description
  • Aims and Scope
  • Editorial Board
  • Abstracting / Indexing
  • Submission Guidelines

Journal of Research in Nursing publishes research on nursing topics and themes. Original research is published with the aim of encouraging evidence-based practice and improving the quality of patient care.

It publishes quality research papers on healthcare issues that inform nurses and other healthcare professionals globally. Through linking policy, research and development initiatives to clinical and academic excellence Journal of Research in Nursing aims to support nursing and healthcare professionals in their development, for the overall benefit of quality healthcare services.

"I have used Journal of Research in Nursing extensively in the course of a recent research project and think that it provides an invaluable reference point for nurse researchers particularly for up-to-date policy related information" Professor Donna Fitzmasons, Ulster University and Belfast Health and Social Care Trust, UK

" Journal of Research in Nursing is an important journal in UK Nursing and has made a significant contribution to the transfer of knowledge with direct relevance to the whole of the nursing community. Researchers have no hesitation in contributing papers to the journal highlighting the respect Journal of Research in Nursing has as a vehicle for the dissemination of research findings. The partnership with SAGE Publications will enable this success to be taken to the world stage. I wish the journal, its editor and editorial team every success in its 're-birth' and ongoing development" Professor Brendan McCormack, Head of Division of Nursing, Queen Margaret University, Edinburgh, UK

"A rip-roaring, highly policy and practice relevant research read" Dr Ann-Marie Rafferty, King's College London, UK This journal is a member of the Committee on Publication Ethics (COPE)

The Journal of Research in Nursing is a leading peer reviewed journal that blends good research with contemporary debates about policy and practice. The Journal of Research in Nursing contributes knowledge to nursing practice, research and local, national and international health and social care policy. Each issue contains a variety of papers and review commentaries within a specific theme. The editors are advised and supported by a board of key academics, practitioners and policy makers of international standing.

The Journal of Research in Nursing will:

• Ensure an evidence base to your practice and policy development

• Inform your research work at an advanced level

• Challenge you to critically reflect on the interface between practice, policy and research

Emeritus Professor of Nursing, University of Southampton, UK
Honorary Senior Teaching Fellow, University of Glasgow and Honorary Professor, Plymouth University
Visiting Professor of Nursing, City University, UK
Clinical Lead Research and Innovation, Institute of Nursing and Midwifery Care Excellence at Nottingham University Hospitals NHS Trust, UK
Emeritus Professor of Social Science and Health, De Montfort University, UK
Senior Lecturer, International, Glasgow Caledonian University, UK
Emerita Professor of Primary Care, University of South Wales, UK
Chief Nurse Research and Development, NHS Lothian, UK
Research Associate, University of Warwick, UK
Professor of Nursing Sociology, Head of Department of Social Sciences and Social Work, Bournemouth University, UK
Professor of Nursing, University of Birmingham/United Hospitals Birmingham NHS Foundation Trust, UK
Vice President of Research, Innovation and Graduate Studies, Waterford Institute of Technology, Ireland
Professor of Nursing and Associate Dean, University of Calgary, Canada
Professor of Nursing, Director and Head of Graduate Division, Nethersole School of Nursing, The Chinese University of Hong Kong, China
Professor and Executive Vice Dean, Rory Meyers College of Nursing, New York University, USA
Executive Chair for Research at UKRI, UK
Vice-Chancellor, University of Auckland, New Zealand
Matthew Flinders Fellow and Professor of Health Services and Implementation Research in the College of Nursing and Health Sciences, Flinders University, Australia
Assistant Professor of Nursing, University of Calgary, Canada
Professor of Nursing, University of Texas Health Science Center at San Antonio, USA
Professor of Nursing, Ulster University, Northern Ireland, UK
Head of the Research Unit in Health Care, Instituto de Salud Carlos III, Madrid, Spain
Professor Emerita, University of North Carolina at Chapel Hill, USA
Adjunct Associate Professor, School of Health Sciences, Massey University, New Zealand
Adjunct Professor of Nursing, College of Health and Medicine, University of Tasmania, Australia
  • Applied Social Sciences Index & Abstracts (ASSIA)
  • British Nursing Index
  • Clarivate Analytics: Emerging Sources Citation Index (ESCI)
  • Corporate ResourceNET
  • Cumulative Index to Nursing and Allied Health Literature CINAHL
  • MasterFILE Premier
  • Periodical Abstracts
  • Psychological Abstracts
  • Standard Periodical Directory
  • TOPIC Search

Manuscript Submission Guidelines: Journal of Research in Nursing

This Journal is a member of the Committee on Publication Ethics

This Journal recommends that authors follow the Recommendations for the Conduct, Reporting, Editing, and Publication of Scholarly Work in Medical Journals formulated by the International Committee of Medical Journal Editors (ICMJE).

Please read the guidelines below then visit the Journal’s submission site http://mc.manuscriptcentral.com/jrn to upload your manuscript. Please note that manuscripts not conforming to these guidelines may be returned.

Only manuscripts of sufficient quality that meet the aims and scope of Journal of Research in Nursing will be reviewed.

There are no fees payable to submit or publish in this Journal. Open Access options are available - see section 3.3 below.

As part of the submission process you will be required to warrant that you are submitting your original work, that you have the rights in the work, that you are submitting the work for first publication in the Journal and that it is not being considered for publication elsewhere and has not already been published elsewhere, and that you have obtained and can supply all necessary permissions for the reproduction of any copyright works not owned by you.

  • What do we publish? 1.1 Aims & Scope 1.2 Article types 1.3 Writing your paper
  • Editorial policies 2.1 Peer review policy 2.2 Authorship 2.3 Acknowledgements 2.4 Funding 2.5 Declaration of conflicting interests 2.6 Research ethics and patient consent 2.8  Data
  • Publishing policies 3.1 Publication ethics 3.2 Contributor's publishing agreement 3.3 Open access and author archiving
  • Preparing your manuscript 4.1 Formatting 4.2 Artwork, figures and other graphics 4.3 Supplementary material 4.4 Reference style 4.5 English language editing services
  • Submitting your manuscript 5.1 ORCID 5.2 Information required for completing your submission 5.3 Permissions
  • On acceptance and publication 6.1 Sage Production 6.2 Online First publication 6.3 Access to your published article 6.4 Promoting your article
  • Further information

1. What do we publish?

1.1 Aims & Scope

Before submitting your manuscript to Journal of Research in Nursing , please ensure you have read the Aims & Scope .

1.2 Article Types

The  Journal of Research in Nursing  welcomes research papers and reviews on nursing, whether clinical, research, education or management topics. The contribution of the paper to, or implications for, both nursing practice and health and social care policy must be made explicit. Papers are normally restricted to a maximum of 5,000 words, excluding all elements (title page, abstract, notes, references, tables, biographical statement, etc.).

The Journal considers the following kinds of article for publication:

1.2.1 Research papers  should be presented under the following section headings:

Title Page File

JRN operates double anonymize peer review which means that all author information should be contained within a title page file (not shown to reviewers) and an author anonymised manuscript file. The title page file should include:

  • Manuscript Title
  • Running head (a short title)
  • This is required for each author: author name followed by job title and affiliation - first name in full, followed by family name, job title, department, institution and country. - <b>no other information</b>  (no  roles, academic credentials, positions of authority or emails). 
  • Correspondence information should be listed after the affiliations list in full. Write the name of one author for correspondence, their full postal address including postcode and country, tel and fax with international dialling codes, and email.
  • Declaration of interest section must appear here in the title page file to preserve anonymity.
  • All declarations of interest and funding must be outlined under the subheading “Declaration of interest” If authors have no declarations of interest to report, this must be explicitly stated. The suggested, but not mandatory, wording in such an instance is: The authors report no declarations of interest.
  • Ethical Permissions. Please include a statement regarding ethical permissions (or the reason why these were not needed).
  • Trial registration information (for interventions and observational studies) - must include the date the trial was registered in a public database, the trial start date, the registration number and the URL of the trial record.
  • Author biographies. Please include a 30-word biography for each author.

Main document file (the anonymized manuscript).

Your manuscript should not contain identifying information (note, self-citation is permitted). Please include the following elements:

Abstract - Please provide a structured abstract of no more than 200 words. The structured abstract should include the sub-headings of Background, Aims, Methods, Results and Conclusions.  Within the conclusions section please clearly state the paper’s contribution to nursing.

Keywords - six MeSH compliant keywords.

Introduction - this should set the scene, including the policy context, for the research study and state the research question/ hypothesis. This should be followed by a literature review, which should quote key articles directly relevant to the study

Methodology - this should be sufficiently detailed for subsequent researchers to follow; it should reiterate the aims and hypotheses of the study and why the methodology was chosen. Copies of research tools, such as questionnaires, should be included with the manuscript

Results - full results should be submitted, including relevant tables, figures and diagrams and details of statistical analysis

Discussion - this should be as full as possible and attempt to explain the results achieved and their significance to both nursing practice and health and social care policy. Limitations to the study should be highlighted in this section

Conclusion - this section should draw together the findings of the study, how they relate to the original aims and make recommendations as to how the work can be carried forward.  The paper’s contribution to nursing must be clearly stated.

Key points - a list of four or five key points drawing out the main findings and their implications for nursing practice, health and social care policy and future research.

References - JRN follows Harvard (author, date) style referencing. References should be complete - even when citing your own previous work. Authors should write objectively and not attach ownership to their sources, so anonymizing references is not required. View the Sage Harvard guidelines to ensure your manuscript conforms to this reference style.

Please do not include unpublished data or ‘in press’ sources since we are unable to verify the appropriateness of these.

Tables - as tabulated text/ data (if any)

Figure captions - listed after the tables (if any). Figures must be supplied as separate image format files.

S tatistical analysis should meet the minimum standards of reporting statistics in clinical research (see SAMPL http://www.equator-network.org/2013/02/11/sampl-guidelines-for-statistical-reporting/ ). You may also find the editorial by Amrhein V, Greenland S, McShane B. Retire statistical significance. Nature 2019; 567: 305-7 useful.

Figures - For guidance on the preparation of illustrations, pictures and graphs in electronic format, please visit Sage’s Manuscript Submission Guidelines

Supporting documents

Interventions must be accompanied by a completed CONSORT and TiDier flowchart and checklist.

Observations must be accompanied by a completed STROBE checklist.

The contribution of the paper to, or implications for, nursing practice and health and social care policy should be made explicit .

1.2.2 Review Articles

The contribution of the paper to, or implications for, nursing practice and health and social care policy must be made explicit.

1.3 Writing your paper

The Sage Author Gateway has some general advice and on  how to get published , plus links to further resources. Sage Author Services also offers authors a variety of ways to improve and enhance their article including English language editing, plagiarism detection, and video abstract and infographic preparation.

1.3.1 Make your article discoverable

When writing up your paper, think about how you can make it discoverable. The title, keywords and abstract are key to ensuring readers find your article through search engines such as Google. For information and guidance on how best to title your article, write your abstract and select your keywords, have a look at this page on the Gateway: How to Help Readers Find Your Article Online .

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2. Editorial policies

2.1 Peer review policy

Sage does not permit the use of author-suggested (recommended) reviewers at any stage of the submission process, be that through the web-based submission system or other communication. Reviewers should be experts in their fields and should be able to provide an objective assessment of the manuscript. Our policy is that reviewers should not be assigned to a paper if:

•  The reviewer is based at the same institution as any of the co-authors

•  The reviewer is based at the funding body of the paper

•  The author has recommended the reviewer

•  The reviewer has provided a personal (e.g. Gmail/Yahoo/Hotmail) email account and an institutional email account cannot be found after performing a basic Google search (name, department and institution). 

2.2 Authorship

All parties who have made a substantive contribution to the article should be listed as authors. Principal authorship, authorship order, and other publication credits should be based on the relative scientific or professional contributions of the individuals involved, regardless of their status. A student is usually listed as principal author on any multiple-authored publication that substantially derives from the student’s dissertation or thesis.

Please note that AI chatbots, for example ChatGPT, should not be listed as authors. For more information see the policy on Use of ChatGPT and generative AI tools .

2.3 Acknowledgements

All contributors who do not meet the criteria for authorship should be listed in an Acknowledgements section. Examples of those who might be acknowledged include a person who provided purely technical help, or a department chair who provided only general support.

2.3.1 Third party submissions

Where an individual who is not listed as an author submits a manuscript on behalf of the author(s), a statement must be included in the Acknowledgements section of the manuscript and in the accompanying cover letter. The statements must:

  • Disclose this type of editorial assistance – including the individual’s name, company and level of input
  • Identify any entities that paid for this assistance
  • Confirm that the listed authors have authorized the submission of their manuscript via third party and approved any statements or declarations, e.g. conflicting interests, funding, etc.

Where appropriate, Sage reserves the right to deny consideration to manuscripts submitted by a third party rather than by the authors themselves .

2.3.2 Writing assistance

Individuals who provided writing assistance, e.g. from a specialist communications company, do not qualify as authors and so should be included in the Acknowledgements section. Authors must disclose any writing assistance – including the individual’s name, company and level of input – and identify the entity that paid for this assistance”).

It is not necessary to disclose use of language polishing services.

Please supply any personal acknowledgements separately to the main text to facilitate anonymous peer review.

2.4 Funding

Journal of Research in Nursing requires all authors to acknowledge their funding in a consistent fashion under a separate heading.  Please visit the Funding Acknowledgements page on the Sage Journal Author Gateway to confirm the format of the acknowledgment text in the event of funding, or state that: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. 

2.5 Declaration of conflicting interests

Journal of Research in Nursing encourages authors to include a declaration of any conflicting interests and recommends you review the good practice guidelines on the Sage Journal Author Gateway

2.6 Research ethics and patient consent

Medical research involving human subjects must be conducted according to the World Medical Association Declaration of Helsinki

Submitted manuscripts should conform to the ICMJE Recommendations for the Conduct, Reporting, Editing, and Publication of Scholarly Work in Medical Journals , and all papers reporting animal and/or human studies must state in the methods section that the relevant Ethics Committee or Institutional Review Board provided (or waived) approval. Please ensure that you have provided the full name and institution of the review committee, in addition to the approval number.

For research articles, authors must state in the methods section whether participants provided informed consent and whether the consent was written or verbal. Authors must also state whether ethical approval was required or not for the research, please also include any relevant additional ethical considerations.

Information on informed consent to report individual cases or case series should be included in the manuscript text. A statement is required regarding whether written informed consent for patient information and images to be published was provided by the patient(s) or a legally authorized representative.

Please also refer to the ICMJE Recommendations for the Protection of Research Participants

Sage acknowledges the importance of research data availability as an integral part of the research and verification process for academic journal articles.

Journal of Research in Nursing requests all authors submitting any primary data used in their research articles [“alongside their article submissions” or “if the articles are accepted”] to be published in the online version of the journal, or provide detailed information in their articles on how the data can be obtained. This information should include links to third-party data repositories or detailed contact information for third-party data sources. Data available only on an author-maintained website will need to be loaded onto either the journal’s platform or a third-party platform to ensure continuing accessibility. Examples of data types include but are not limited to statistical data files, replication code, text files, audio files, images, videos, appendices, and additional charts and graphs necessary to understand the original research. [The editor(s) may consider limited embargoes on proprietary data.] The editor(s) can also grant exceptions for data that cannot legally or ethically be released. All data submitted should comply with Institutional or Ethical Review Board requirements and applicable government regulations. For further information, please contact the editorial office at [email address].

3. Publishing Policies

3.1 Publication ethics

Sage is committed to upholding the integrity of the academic record. We encourage authors to refer to the Committee on Publication Ethics’ International Standards for Authors and view the Publication Ethics page on the Sage Author Gateway .

3.1.1 Plagiarism

Journal of Research in Nursing and Sage take issues of copyright infringement, plagiarism or other breaches of best practice in publication very seriously. We seek to protect the rights of our authors and we always investigate claims of plagiarism or misuse of published articles. Equally, we seek to protect the reputation of the journal against malpractice. Submitted articles may be checked with duplication-checking software. Where an article, for example, is found to have plagiarised other work or included third-party copyright material without permission or with insufficient acknowledgement, or where the authorship of the article is contested, we reserve the right to take action including, but not limited to: publishing an erratum or corrigendum (correction); retracting the article; taking up the matter with the head of department or dean of the author's institution and/or relevant academic bodies or societies; or taking appropriate legal action.

3.1.2 Prior publication

If material has been previously published it is not generally acceptable for publication in a Sage journal. However, there are certain circumstances where previously published material can be considered for publication. Please refer to the guidance on the Sage Author Gateway or if in doubt, contact the Editor at the address given below.

3.2 Contributor's publishing agreement

Before publication, Sage requires the author as the rights holder to sign a Journal Contributor’s Publishing Agreement. Sage’s Journal Contributor’s Publishing Agreement is an exclusive licence agreement which means that the author retains copyright in the work but grants Sage the sole and exclusive right and licence to publish for the full legal term of copyright. Exceptions may exist where an assignment of copyright is required or preferred by a proprietor other than Sage. In this case copyright in the work will be assigned from the author to the society. For more information please visit the Sage Author Gateway .

3.3 Open access and author archiving

Journal of Research in Nursing  offers optional open access publishing via the Sage Choice programme and Open Access agreements, where authors can publish open access either discounted or free of charge depending on the agreement with Sage. Find out if your institution is participating by visiting Open Access Agreements at Sage . For more information on Open Access publishing options at Sage please visit Sage Open Access . For information on funding body compliance, and depositing your article in repositories, please visit Sage’s Author Archiving and Re-Use Guidelines and Publishing Policies .

Please check whether you are entitled to publish open access via a deal between your institution and Sage by checking this page of Open Access Agreements.

4. Preparing your manuscript for submission

4.1 Formatting

The preferred format for your manuscript is Word. LaTeX files are also accepted. Word and (La)Tex templates are available on the Manuscript Submission Guidelines page of our Author Gateway.

4.2 Artwork, figures and other graphics

For guidance on the preparation of illustrations, pictures and graphs in electronic format, please visit Sage’s Manuscript Submission Guidelines .

Figures supplied in colour will appear in colour online regardless of whether or not these illustrations are reproduced in colour in the printed version. For specifically requested colour reproduction in print, you will receive information regarding the costs from Sage after receipt of your accepted article.

4.3 Supplementary material

This journal is able to host additional materials online (e.g. datasets, podcasts, videos, images etc) alongside the full-text of the article. For more information please refer to our guidelines on submitting supplementary files .

4.4 Reference style

Journal of Research in Nursing adheres to the Sage Harvard reference style. View the Sage Harvard guidelines to ensure your manuscript conforms to this reference style.

If you use EndNote to manage references, you can download the Sage Harvard EndNote output file .

4.5 English language editing services

Authors seeking assistance with English language editing, translation, or figure and manuscript formatting to fit the journal’s specifications should consider using Sage Language Services. Visit Sage Language Services on our Journal Author Gateway for further information.

5. Submitting your manuscript

Journal of Research in Nursing is hosted on Sage Track, a web based online submission and peer review system powered by ScholarOne™ Manuscripts. Visit http://mc.manuscriptcentral.com/jrn to login and submit your article online.

IMPORTANT: Please check whether you already have an account in the system before trying to create a new one. If you have reviewed or authored for the journal in the past year it is likely that you will have had an account created.  For further guidance on submitting your manuscript online please visit ScholarOne Online Help.

As part of our commitment to ensuring an ethical, transparent and fair peer review process Sage is a supporting member of ORCID, the Open Researcher and Contributor ID . ORCID provides a unique and persistent digital identifier that distinguishes researchers from every other researcher, even those who share the same name, and, through integration in key research workflows such as manuscript and grant submission, supports automated linkages between researchers and their professional activities, ensuring that their work is recognized.

The collection of ORCID iDs from corresponding authors is now part of the submission process of this journal. If you already have an ORCID iD you will be asked to associate that to your submission during the online submission process. We also strongly encourage all co-authors to link their ORCID ID to their accounts in our online peer review platforms. It takes seconds to do: click the link when prompted, sign into your ORCID account and our systems are automatically updated. Your ORCID iD will become part of your accepted publication’s metadata, making your work attributable to you and only you. Your ORCID iD is published with your article so that fellow researchers reading your work can link to your ORCID profile and from there link to your other publications.

If you do not already have an ORCID iD please follow this link to create one or visit our ORCID homepage to learn more.

5.2 Information required for completing your submission

You will be asked to provide contact details and academic affiliations for all co-authors via the submission system and identify who is to be the corresponding author. These details must match what appears on your manuscript. At this stage please ensure you have included all the required statements and declarations and uploaded any additional supplementary files (including reporting guidelines where relevant).

5.3 Permissions

Please also ensure that you have obtained any necessary permission from copyright holders for reproducing any illustrations, tables, figures or lengthy quotations previously published elsewhere. For further information including guidance on fair dealing for criticism and review, please see the Copyright and Permissions page on the Sage Author Gateway .

6. On acceptance and publication

6.1 Sage Production

Your Sage Production Editor will keep you informed as to your article’s progress throughout the production process. Proofs will be sent by PDF to the corresponding author and should be returned promptly.  Authors are reminded to check their proofs carefully to confirm that all author information, including names, affiliations, sequence and contact details are correct, and that Funding and Conflict of Interest statements, if any, are accurate.

6.2 Online First publication

Online First allows final articles (completed and approved articles awaiting assignment to a future issue) to be published online prior to their inclusion in a journal issue, which significantly reduces the lead time between submission and publication. Visit the Sage Journals help page for more details, including how to cite Online First articles.

6.3 Access to your published article

Sage provides authors with online access to their final article.

6.4 Promoting your article

Publication is not the end of the process! You can help disseminate your paper and ensure it is as widely read and cited as possible. The Sage Author Gateway has numerous resources to help you promote your work. Visit the Promote Your Article page on the Gateway for tips and advice.

7. Further information

Any correspondence, queries or additional requests for information on the manuscript submission process should be sent to the Journal of Research in Nursing editorial office as follows:

[email protected]

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Evidence-Based Practice and Nursing Research

Evidence-based practice is now widely recognized as the key to improving healthcare quality and patient outcomes. Although the purposes of nursing research (conducting research to generate new knowledge) and evidence-based nursing practice (utilizing best evidence as basis of nursing practice) seem quite different, an increasing number of research studies have been conducted with the goal of translating evidence effectively into practice. Clearly, evidence from research (effective innovation) must be accompanied by effective implementation, and an enabling context to achieve significant outcomes.

As mentioned by Professor Rita Pickler, “nursing science needs to encompass all manner of research, from discovery to translation, from bench to bedside, from mechanistic to holistic” ( Pickler, 2018 ). I feel that The Journal of Nursing Research must provide an open forum for all kind of research in order to help bridge the gap between research-generated evidence and clinical nursing practice and education.

In this issue, an article by professor Ying-Ju Chang and colleagues at National Cheng Kung University presents an evidence-based practice curriculum for undergraduate nursing students developed using an action research-based model. This “evidence-based practice curriculum” spans all four academic years, integrates coursework and practicums, and sets different learning objectives for students at different grade levels. Also in this issue, Yang et al. apply a revised standard care procedure to increase the ability of critical care nurses to verify the placement of nasogastric tubes. After appraising the evidence, the authors conclude that the aspirate pH test is the most reliable and economical method for verifying nasogastric tube placement at the bedside. They subsequently develop a revised standard care procedure and a checklist for auditing the procedure, conduct education for nurses, and examine the effectiveness of the revised procedure.

I hope that these two studies help us all better appreciate that, in addition to innovation and new breakthrough discoveries, curriculum development and evidence-based quality improvement projects, though may not seem so novel, are also important areas of nursing research. Translating evidence into practice is sound science and merits more research.

Cite this article as: Chien, L. Y. (2019). Evidence-based practice and nursing research. The Journal of Nursing Research, 27 (4), e29. https://doi.org/10.1097/jnr.0000000000000346

  • Pickler R. H. (2018). Honoring the past, pursuing the future . Nursing Research , 67 ( 1 ), 1–2. 10.1097/NNR.0000000000000255 [ PubMed ] [ CrossRef ] [ Google Scholar ]
  • Open access
  • Published: 03 July 2024

The impact of evidence-based nursing leadership in healthcare settings: a mixed methods systematic review

  • Maritta Välimäki 1 , 2 ,
  • Shuang Hu 3 ,
  • Tella Lantta 1 ,
  • Kirsi Hipp 1 , 4 ,
  • Jaakko Varpula 1 ,
  • Jiarui Chen 3 ,
  • Gaoming Liu 5 ,
  • Yao Tang 3 ,
  • Wenjun Chen 3 &
  • Xianhong Li 3  

BMC Nursing volume  23 , Article number:  452 ( 2024 ) Cite this article

269 Accesses

Metrics details

The central component in impactful healthcare decisions is evidence. Understanding how nurse leaders use evidence in their own managerial decision making is still limited. This mixed methods systematic review aimed to examine how evidence is used to solve leadership problems and to describe the measured and perceived effects of evidence-based leadership on nurse leaders and their performance, organizational, and clinical outcomes.

We included articles using any type of research design. We referred nurses, nurse managers or other nursing staff working in a healthcare context when they attempt to influence the behavior of individuals or a group in an organization using an evidence-based approach. Seven databases were searched until 11 November 2021. JBI Critical Appraisal Checklist for Quasi-experimental studies, JBI Critical Appraisal Checklist for Case Series, Mixed Methods Appraisal Tool were used to evaluate the Risk of bias in quasi-experimental studies, case series, mixed methods studies, respectively. The JBI approach to mixed methods systematic reviews was followed, and a parallel-results convergent approach to synthesis and integration was adopted.

Thirty-one publications were eligible for the analysis: case series ( n  = 27), mixed methods studies ( n  = 3) and quasi-experimental studies ( n  = 1). All studies were included regardless of methodological quality. Leadership problems were related to the implementation of knowledge into practice, the quality of nursing care and the resource availability. Organizational data was used in 27 studies to understand leadership problems, scientific evidence from literature was sought in 26 studies, and stakeholders’ views were explored in 24 studies. Perceived and measured effects of evidence-based leadership focused on nurses’ performance, organizational outcomes, and clinical outcomes. Economic data were not available.


This is the first systematic review to examine how evidence is used to solve leadership problems and to describe its measured and perceived effects from different sites. Although a variety of perceptions and effects were identified on nurses’ performance as well as on organizational and clinical outcomes, available knowledge concerning evidence-based leadership is currently insufficient. Therefore, more high-quality research and clinical trial designs are still needed.

Trail registration

The study was registered (PROSPERO CRD42021259624).

Peer Review reports

Global health demands have set new roles for nurse leaders [ 1 ].Nurse leaders are referred to as nurses, nurse managers, or other nursing staff working in a healthcare context who attempt to influence the behavior of individuals or a group based on goals that are congruent with organizational goals [ 2 ]. They are seen as professionals “armed with data and evidence, and a commitment to mentorship and education”, and as a group in which “leaders innovate, transform, and achieve quality outcomes for patients, health care professionals, organizations, and communities” [ 3 ]. Effective leadership occurs when team members critically follow leaders and are motivated by a leader’s decisions based on the organization’s requests and targets [ 4 ]. On the other hand, problems caused by poor leadership may also occur, regarding staff relations, stress, sickness, or retention [ 5 ]. Therefore, leadership requires an understanding of different problems to be solved using synthesizing evidence from research, clinical expertise, and stakeholders’ preferences [ 6 , 7 ]. If based on evidence, leadership decisions, also referred as leadership decision making [ 8 ], could ensure adequate staffing [ 7 , 9 ] and to produce sufficient and cost-effective care [ 10 ]. However, nurse leaders still rely on their decision making on their personal [ 11 ] and professional experience [ 10 ] over research evidence, which can lead to deficiencies in the quality and safety of care delivery [ 12 , 13 , 14 ]. As all nurses should demonstrate leadership in their profession, their leadership competencies should be strengthened [ 15 ].

Evidence-informed decision-making, referred to as evidence appraisal and application, and evaluation of decisions [ 16 ], has been recognized as one of the core competencies for leaders [ 17 , 18 ]. The role of evidence in nurse leaders’ managerial decision making has been promoted by public authorities [ 19 , 20 , 21 ]. Evidence-based management, another concept related to evidence-based leadership, has been used as the potential to improve healthcare services [ 22 ]. It can guide nursing leaders, in developing working conditions, staff retention, implementation practices, strategic planning, patient care, and success of leadership [ 13 ]. Collins and Holton [ 23 ] in their systematic review and meta-analysis examined 83 studies regarding leadership development interventions. They found that leadership training can result in significant improvement in participants’ skills, especially in knowledge level, although the training effects varied across studies. Cummings et al. [ 24 ] reviewed 100 papers (93 studies) and concluded that participation in leadership interventions had a positive impact on the development of a variety of leadership styles. Clavijo-Chamorro et al. [ 25 ] in their review of 11 studies focused on leadership-related factors that facilitate evidence implementation: teamwork, organizational structures, and transformational leadership. The role of nurse managers was to facilitate evidence-based practices by transforming contexts to motivate the staff and move toward a shared vision of change.

As far as we are aware, however, only a few systematic reviews have focused on evidence-based leadership or related concepts in the healthcare context aiming to analyse how nurse leaders themselves uses evidence in the decision-making process. Young [ 26 ] targeted definitions and acceptance of evidence-based management (EBMgt) in healthcare while Hasanpoor et al. [ 22 ] identified facilitators and barriers, sources of evidence used, and the role of evidence in the process of decision making. Both these reviews concluded that EBMgt was of great importance but used limitedly in healthcare settings due to a lack of time, a lack of research management activities, and policy constraints. A review by Williams [ 27 ] showed that the usage of evidence to support management in decision making is marginal due to a shortage of relevant evidence. Fraser [ 28 ] in their review further indicated that the potential evidence-based knowledge is not used in decision making by leaders as effectively as it could be. Non-use of evidence occurs and leaders base their decisions mainly on single studies, real-world evidence, and experts’ opinions [ 29 ]. Systematic reviews and meta-analyses rarely provide evidence of management-related interventions [ 30 ]. Tate et al. [ 31 ] concluded based on their systematic review and meta-analysis that the ability of nurse leaders to use and critically appraise research evidence may influence the way policy is enacted and how resources and staff are used to meet certain objectives set by policy. This can further influence staff and workforce outcomes. It is therefore important that nurse leaders have the capacity and motivation to use the strongest evidence available to effect change and guide their decision making [ 27 ].

Despite of a growing body of evidence, we found only one review focusing on the impact of evidence-based knowledge. Geert et al. [ 32 ] reviewed literature from 2007 to 2016 to understand the elements of design, delivery, and evaluation of leadership development interventions that are the most reliably linked to outcomes at the level of the individual and the organization, and that are of most benefit to patients. The authors concluded that it is possible to improve individual-level outcomes among leaders, such as knowledge, motivation, skills, and behavior change using evidence-based approaches. Some of the most effective interventions included, for example, interactive workshops, coaching, action learning, and mentoring. However, these authors found limited research evidence describing how nurse leaders themselves use evidence to support their managerial decisions in nursing and what the outcomes are.

To fill the knowledge gap and compliment to existing knowledgebase, in this mixed methods review we aimed to (1) examine what leadership problems nurse leaders solve using an evidence-based approach and (2) how they use evidence to solve these problems. We also explored (3) the measured and (4) perceived effects of the evidence-based leadership approach in healthcare settings. Both qualitative and quantitative components of the effects of evidence-based leadership were examined to provide greater insights into the available literature [ 33 ]. Together with the evidence-based leadership approach, and its impact on nursing [ 34 , 35 ], this knowledge gained in this review can be used to inform clinical policy or organizational decisions [ 33 ]. The study is registered (PROSPERO CRD42021259624). The methods used in this review were specified in advance and documented in a priori in a published protocol [ 36 ]. Key terms of the review and the search terms are defined in Table  1 (population, intervention, comparison, outcomes, context, other).

In this review, we used a mixed methods approach [ 37 ]. A mixed methods systematic review was selected as this approach has the potential to produce direct relevance to policy makers and practitioners [ 38 ]. Johnson and Onwuegbuzie [ 39 ] have defined mixed methods research as “the class of research in which the researcher mixes or combines quantitative and qualitative research techniques, methods, approaches, concepts or language into a single study.” Therefore, we combined quantitative and narrative analysis to appraise and synthesize empirical evidence, and we held them as equally important in informing clinical policy or organizational decisions [ 34 ]. In this review, a comprehensive synthesis of quantitative and qualitative data was performed first and then discussed in discussion part (parallel-results convergent design) [ 40 ]. We hoped that different type of analysis approaches could complement each other and deeper picture of the topic in line with our research questions could be gained [ 34 ].

Inclusion and exclusion criteria

Inclusion and exclusion criteria of the study are described in Table  1 .

Search strategy

A three-step search strategy was utilized. First, an initial limited search with #MEDLINE was undertaken, followed by analysis of the words used in the title, abstract, and the article’s key index terms. Second, the search strategy, including identified keywords and index terms, was adapted for each included data base and a second search was undertaken on 11 November 2021. The full search strategy for each database is described in Additional file 1 . Third, the reference list of all studies included in the review were screened for additional studies. No year limits or language restrictions were used.

Information sources

The database search included the following: CINAHL (EBSCO), Cochrane Library (academic database for medicine and health science and nursing), Embase (Elsevier), PsycINFO (EBSCO), PubMed (MEDLINE), Scopus (Elsevier) and Web of Science (academic database across all scientific and technical disciplines, ranging from medicine and social sciences to arts and humanities). These databases were selected as they represent typical databases in health care context. Subject headings from each of the databases were included in the search strategies. Boolean operators ‘AND’ and ‘OR’ were used to combine the search terms. An information specialist from the University of Turku Library was consulted in the formation of the search strategies.

Study selection

All identified citations were collated and uploaded into Covidence software (Covidence systematic review software, Veritas Health Innovation, Melbourne, Australia www.covidence.org ), and duplicates were removed by the software. Titles and abstracts were screened and assessed against the inclusion criteria independently by two reviewers out of four, and any discrepancies were resolved by the third reviewer (MV, KH, TL, WC). Studies meeting the inclusion criteria were retrieved in full and archived in Covidence. Access to one full-text article was lacking: the authors for one study were contacted about the missing full text, but no full text was received. All remaining hits of the included studies were retrieved and assessed independently against the inclusion criteria by two independent reviewers of four (MV, KH, TL, WC). Studies that did not meet the inclusion criteria were excluded, and the reasons for exclusion were recorded in Covidence. Any disagreements that arose between the reviewers were resolved through discussions with XL.

Assessment of methodological quality

Eligible studies were critically appraised by two independent reviewers (YT, SH). Standardized critical appraisal instruments based on the study design were used. First, quasi-experimental studies were assessed using the JBI Critical Appraisal Checklist for Quasi-experimental studies [ 44 ]. Second, case series were assessed using the JBI Critical Appraisal Checklist for Case Series [ 45 ]. Third, mixed methods studies were appraised using the Mixed Methods Appraisal Tool [ 46 ].

To increase inter-reviewer reliability, the review agreement was calculated (SH) [ 47 ]. A kappa greater than 0.8 was considered to represent a high level of agreement (0–0.1). In our data, the agreement was 0.75. Discrepancies raised between two reviewers were resolved through discussion and modifications and confirmed by XL. As an outcome, studies that met the inclusion criteria were proceeded to critical appraisal and assessed as suitable for inclusion in the review. The scores for each item and overall critical appraisal scores were presented.

Data extraction

For data extraction, specific tables were created. First, study characteristics (author(s), year, country, design, number of participants, setting) were extracted by two authors independently (JC, MV) and reviewed by TL. Second, descriptions of the interventions were extracted by two reviewers (JV, JC) using the structure of the TIDIeR (Template for Intervention Description and Replication) checklist (brief name, the goal of the intervention, material and procedure, models of delivery and location, dose, modification, adherence and fidelity) [ 48 ]. The extractions were confirmed (MV).

Third, due to a lack of effectiveness data and a wide heterogeneity between study designs and presentation of outcomes, no attempt was made to pool the quantitative data statistically; the findings of the quantitative data were presented in narrative form only [ 44 ]. The separate data extraction tables for each research question were designed specifically for this study. For both qualitative (and a qualitative component of mixed-method studies) and quantitative studies, the data were extracted and tabulated into text format according to preplanned research questions [ 36 ]. To test the quality of the tables and the data extraction process, three authors independently extracted the data from the first five studies (in alphabetical order). After that, the authors came together to share and determine whether their approaches of the data extraction were consistent with each other’s output and whether the content of each table was in line with research question. No reason was found to modify the data extraction tables or planned process. After a consensus of the data extraction process was reached, the data were extracted in pairs by independent reviewers (WC, TY, SH, GL). Any disagreements that arose between the reviewers were resolved through discussion and with a third reviewer (MV).

Data analysis

We were not able to conduct a meta-analysis due to a lack of effectiveness data based on clinical trials. Instead, we used inductive thematic analysis with constant comparison to answer the research question [ 46 , 49 ] using tabulated primary data from qualitative and quantitative studies as reported by the original authors in narrative form only [ 47 ]. In addition, the qualitizing process was used to transform quantitative data to qualitative data; this helped us to convert the whole data into themes and categories. After that we used the thematic analysis for the narrative data as follows. First, the text was carefully read, line by line, to reveal topics answering each specific review question (MV). Second, the data coding was conducted, and the themes in the data were formed by data categorization. The process of deriving the themes was inductive based on constant comparison [ 49 ]. The results of thematic analysis and data categorization was first described in narrative format and then the total number of studies was calculated where the specific category was identified (%).

Stakeholder involvement

The method of reporting stakeholders’ involvement follows the key components by [ 50 ]: (1) people involved, (2) geographical location, (3) how people were recruited, (4) format of involvement, (5) amount of involvement, (6) ethical approval, (7) financial compensation, and (8) methods for reporting involvement.

In our review, stakeholder involvement targeted nurses and nurse leader in China. Nurse Directors of two hospitals recommended potential participants who received a personal invitation letter from researchers to participate in a discussion meeting. Stakeholders’ participation was based on their own free will. Due to COVID-19, one online meeting (1 h) was organized (25 May 2022). Eleven participants joined the meeting. Ethical approval was not applied and no financial compensation was offered. At the end of the meeting, experiences of stakeholders’ involvement were explored.

The meeting started with an introductory presentation with power points. The rationale, methods, and preliminary review results were shared with the participants [ 51 ].The meeting continued with general questions for the participants: (1) Are you aware of the concepts of evidence-based practice or evidence-based leadership?; (2) How important is it to use evidence to support decisions among nurse leaders?; (3) How is the evidence-based approach used in hospital settings?; and (4) What type of evidence is currently used to support nurse leaders’ decision making (e.g. scientific literature, organizational data, stakeholder views)?

Two people took notes on the course and content of the conversation. The notes were later transcripted in verbatim, and the key points of the discussions were summarised. Although answers offered by the stakeholders were very short, the information was useful to validate the preliminary content of the results, add the rigorousness of the review, and obtain additional perspectives. A recommendation of the stakeholders was combined in the Discussion part of this review increasing the applicability of the review in the real world [ 50 ]. At the end of the discussion, the value of stakeholders’ involvement was asked. Participants shared that the experience of participating was unique and the topic of discussion was challenging. Two authors of the review group further represented stakeholders by working together with the research team throughout the review study.

Search results

From seven different electronic databases, 6053 citations were identified as being potentially relevant to the review. Then, 3133 duplicates were removed by an automation tool (Covidence: www.covidence.org ), and one was removed manually. The titles and abstracts of 3040 of citations were reviewed, and a total of 110 full texts were included (one extra citation was found on the reference list but later excluded). Based on the eligibility criteria, 31 studies (32 hits) were critically appraised and deemed suitable for inclusion in the review. The search results and selection process are presented in the PRISMA [ 52 ] flow diagram Fig.  1 . The full list of references for included studies can be find in Additional file 2 . To avoid confusion between articles of the reference list and studies included in the analysis, the studies included in the review are referred inside the article using the reference number of each study (e.g. ref 1, ref 2).

figure 1

Search results and study selection and inclusion process [ 52 ]

Characteristics of included studies

The studies had multiple purposes, aiming to develop practice, implement a new approach, improve quality, or to develop a model. The 31 studies (across 32 hits) were case series studies ( n  = 27), mixed methods studies ( n  = 3) and a quasi-experimental study ( n  = 1). All studies were published between the years 2004 and 2021. The highest number of papers was published in year 2020.

Table  2 describes the characteristics of included studies and Additional file 3 offers a narrative description of the studies.

Methodological quality assessment

Quasi-experimental studies.

We had one quasi-experimental study (ref 31). All questions in the critical appraisal tool were applicable. The total score of the study was 8 (out of a possible 9). Only one response of the tool was ‘no’ because no control group was used in the study (see Additional file 4 for the critical appraisal of included studies).

Case series studies . A case series study is typically defined as a collection of subjects with common characteristics. The studies do not include a comparison group and are often based on prevalent cases and on a sample of convenience [ 53 ]. Munn et al. [ 45 ] further claim that case series are best described as observational studies, lacking experimental and randomized characteristics, being descriptive studies, without a control or comparator group. Out of 27 case series studies included in our review, the critical appraisal scores varied from 1 to 9. Five references were conference abstracts with empirical study results, which were scored from 1 to 3. Full reports of these studies were searched in electronic databases but not found. Critical appraisal scores for the remaining 22 studies ranged from 1 to 9 out of a possible score of 10. One question (Q3) was not applicable to 13 studies: “Were valid methods used for identification of the condition for all participants included in the case series?” Only two studies had clearly reported the demographic of the participants in the study (Q6). Twenty studies met Criteria 8 (“Were the outcomes or follow-up results of cases clearly reported?”) and 18 studies met Criteria 7 (“Q7: Was there clear reporting of clinical information of the participants?”) (see Additional file 4 for the critical appraisal of included studies).

Mixed-methods studies

Mixed-methods studies involve a combination of qualitative and quantitative methods. This is a common design and includes convergent design, sequential explanatory design, and sequential exploratory design [ 46 ]. There were three mixed-methods studies. The critical appraisal scores for the three studies ranged from 60 to 100% out of a possible 100%. Two studies met all the criteria, while one study fulfilled 60% of the scored criteria due to a lack of information to understand the relevance of the sampling strategy well enough to address the research question (Q4.1) or to determine whether the risk of nonresponse bias was low (Q4.4) (see Additional file 4 for the critical appraisal of included studies).

Intervention or program components

The intervention of program components were categorized and described using the TiDier checklist: name and goal, theory or background, material, procedure, provider, models of delivery, location, dose, modification, and adherence and fidelity [ 48 ]. A description of intervention in each study is described in Additional file 5 and a narrative description in Additional file 6 .

Leadership problems

In line with the inclusion criteria, data for the leadership problems were categorized in all 31 included studies (see Additional file 7 for leadership problems). Three types of leadership problems were identified: implementation of knowledge into practice, the quality of clinical care, and resources in nursing care. A narrative summary of the results is reported below.

Implementing knowledge into practice

Eleven studies (35%) aimed to solve leadership problems related to implementation of knowledge into practice. Studies showed how to support nurses in evidence-based implementation (EBP) (ref 3, ref 5), how to engage nurses in using evidence in practice (ref 4), how to convey the importance of EBP (ref 22) or how to change practice (ref 4). Other problems were how to facilitate nurses to use guideline recommendations (ref 7) and how nurses can make evidence-informed decisions (ref 8). General concerns also included the linkage between theory and practice (ref 1) as well as how to implement the EBP model in practice (ref 6). In addition, studies were motivated by the need for revisions or updates of protocols to improve clinical practice (ref 10) as well as the need to standardize nursing activities (ref 11, ref 14).

The quality of the care

Thirteen (42%) focused on solving problems related to the quality of clinical care. In these studies, a high number of catheter infections led a lack of achievement of organizational goals (ref 2, ref 9). A need to reduce patient symptoms in stem cell transplant patients undergoing high-dose chemotherapy (ref 24) was also one of the problems to be solved. In addition, the projects focused on how to prevent pressure ulcers (ref 26, ref 29), how to enhance the quality of cancer treatment (ref 25) and how to reduce the need for invasive constipation treatment (ref 30). Concerns about patient safety (ref 15), high fall rates (ref 16, ref 19), dissatisfaction of patients (ref 16, ref 18) and nurses (ref 16, ref 30) were also problems that had initiated the projects. Studies addressed concerns about how to promote good contingency care in residential aged care homes (ref 20) and about how to increase recognition of human trafficking problems in healthcare (ref 21).

Resources in nursing care

Nurse leaders identified problems in their resources, especially in staffing problems. These problems were identified in seven studies (23%), which involved concerns about how to prevent nurses from leaving the job (ref 31), how to ensure appropriate recruitment, staffing and retaining of nurses (ref 13) and how to decrease nurses’ burden and time spent on nursing activities (ref 12). Leadership turnover was also reported as a source of dissatisfaction (ref 17); studies addressed a lack of structured transition and training programs, which led to turnover (ref 23), as well as how to improve intershift handoff among nurses (ref 28). Optimal design for new hospitals was also examined (ref 27).

Main features of evidence-based leadership

Out of 31 studies, 17 (55%) included all four domains of an evidence-based leadership approach, and four studies (13%) included evidence of critical appraisal of the results (see Additional file 8 for the main features of evidence-based Leadership) (ref 11, ref 14, ref 23, ref 27).

Organizational evidence

Twenty-seven studies (87%) reported how organizational evidence was collected and used to solve leadership problems (ref 2). Retrospective chart reviews (ref 5), a review of the extent of specific incidents (ref 19), and chart auditing (ref 7, ref 25) were conducted. A gap between guideline recommendations and actual care was identified using organizational data (ref 7) while the percentage of nurses’ working time spent on patient care was analyzed using an electronic charting system (ref 12). Internal data (ref 22), institutional data, and programming metrics were also analyzed to understand the development of the nurse workforce (ref 13).

Surveys (ref 3, ref 25), interviews (ref 3, ref 25) and group reviews (ref 18) were used to better understand the leadership problem to be solved. Employee opinion surveys on leadership (ref 17), a nurse satisfaction survey (ref 30) and a variety of reporting templates were used for the data collection (ref 28) reported. Sometimes, leadership problems were identified by evidence facilitators or a PI’s team who worked with staff members (ref 15, ref 17). Problems in clinical practice were also identified by the Nursing Professional Council (ref 14), managers (ref 26) or nurses themselves (ref 24). Current practices were reviewed (ref 29) and a gap analysis was conducted (ref 4, ref 16, ref 23) together with SWOT analysis (ref 16). In addition, hospital mission and vision statements, research culture established and the proportion of nursing alumni with formal EBP training were analyzed (ref 5). On the other hand, it was stated that no systematic hospital-specific sources of data regarding job satisfaction or organizational commitment were used (ref 31). In addition, statements of organizational analysis were used on a general level only (ref 1).

Scientific evidence identified

Twenty-six studies (84%) reported the use of scientific evidence in their evidence-based leadership processes. A literature search was conducted (ref 21) and questions, PICO, and keywords were identified (ref 4) in collaboration with a librarian. Electronic databases, including PubMed (ref 14, ref 31), Cochrane, and EMBASE (ref 31) were searched. Galiano (ref 6) used Wiley Online Library, Elsevier, CINAHL, Health Source: Nursing/Academic Edition, PubMed, and the Cochrane Library while Hoke (ref 11) conducted an electronic search using CINAHL and PubMed to retrieve articles.

Identified journals were reviewed manually (ref 31). The findings were summarized using ‘elevator speech’ (ref 4). In a study by Gifford et al. (ref 9) evidence facilitators worked with participants to access, appraise, and adapt the research evidence to the organizational context. Ostaszkiewicz (ref 20) conducted a scoping review of literature and identified and reviewed frameworks and policy documents about the topic and the quality standards. Further, a team of nursing administrators, directors, staff nurses, and a patient representative reviewed the literature and made recommendations for practice changes.

Clinical practice guidelines were also used to offer scientific evidence (ref 7, ref 19). Evidence was further retrieved from a combination of nursing policies, guidelines, journal articles, and textbooks (ref 12) as well as from published guidelines and literature (ref 13). Internal evidence, professional practice knowledge, relevant theories and models were synthesized (ref 24) while other study (ref 25) reviewed individual studies, synthesized with systematic reviews or clinical practice guidelines. The team reviewed the research evidence (ref 3, ref 15) or conducted a literature review (ref 22, ref 28, ref 29), a literature search (ref 27), a systematic review (ref 23), a review of the literature (ref 30) or ‘the scholarly literature was reviewed’ (ref 18). In addition, ‘an extensive literature review of evidence-based best practices was carried out’ (ref 10). However, detailed description how the review was conducted was lacking.

Views of stakeholders

A total of 24 studies (77%) reported methods for how the views of stakeholders, i.e., professionals or experts, were considered. Support to run this study was received from nursing leadership and multidisciplinary teams (ref 29). Experts and stakeholders joined the study team in some cases (ref 25, ref 30), and in other studies, their opinions were sought to facilitate project success (ref 3). Sometimes a steering committee was formed by a Chief Nursing Officer and Clinical Practice Specialists (ref 2). More specifically, stakeholders’ views were considered using interviews, workshops and follow-up teleconferences (ref 7). The literature review was discussed with colleagues (ref 11), and feedback and support from physicians as well as the consensus of staff were sought (ref 16).

A summary of the project findings and suggestions for the studies were discussed at 90-minute weekly meetings by 11 charge nurses. Nurse executive directors were consulted over a 10-week period (ref 31). An implementation team (nurse, dietician, physiotherapist, occupational therapist) was formed to support the implementation of evidence-based prevention measures (ref 26). Stakeholders volunteered to join in the pilot implementation (ref 28) or a stakeholder team met to determine the best strategy for change management, shortcomings in evidence-based criteria were discussed, and strategies to address those areas were planned (ref 5). Nursing leaders, staff members (ref 22), ‘process owners (ref 18) and program team members (ref 18, ref 19, ref 24) met regularly to discuss the problems. Critical input was sought from clinical educators, physicians, nutritionists, pharmacists, and nurse managers (ref 24). The unit director and senior nursing staff reviewed the contents of the product, and the final version of clinical pathways were reviewed and approved by the Quality Control Commission of the Nursing Department (ref 12). In addition, two co-design workshops with 18 residential aged care stakeholders were organized to explore their perspectives about factors to include in a model prototype (ref 20). Further, an agreement of stakeholders in implementing continuous quality services within an open relationship was conducted (ref 1).

Critical appraisal

In five studies (16%), a critical appraisal targeting the literature search was carried out. The appraisals were conducted by interns and teams who critiqued the evidence (ref 4). In Hoke’s study, four areas that had emerged in the literature were critically reviewed (ref 11). Other methods were to ‘critically appraise the search results’ (ref 14). Journal club team meetings (ref 23) were organized to grade the level and quality of evidence and the team ‘critically appraised relevant evidence’ (ref 27). On the other hand, the studies lacked details of how the appraisals were done in each study.

The perceived effects of evidence-based leadership

Perceived effects of evidence-based leadership on nurses’ performance.

Eleven studies (35%) described perceived effects of evidence-based leadership on nurses’ performance (see Additional file 9 for perceived effects of evidence-based leadership), which were categorized in four groups: awareness and knowledge, competence, ability to understand patients’ needs, and engagement. First, regarding ‘awareness and knowledge’, different projects provided nurses with new learning opportunities (ref 3). Staff’s knowledge (ref 20, ref 28), skills, and education levels improved (ref 20), as did nurses’ knowledge comprehension (ref 21). Second, interventions and approaches focusing on management and leadership positively influenced participants’ competence level to improve the quality of services. Their confidence level (ref 1) and motivation to change practice increased, self-esteem improved, and they were more positive and enthusiastic in their work (ref 22). Third, some nurses were relieved that they had learned to better handle patients’ needs (ref 25). For example, a systematic work approach increased nurses’ awareness of the patients who were at risk of developing health problems (ref 26). And last, nurse leaders were more engaged with staff, encouraging them to adopt the new practices and recognizing their efforts to change (ref 8).

Perceived effects on organizational outcomes

Nine studies (29%) described the perceived effects of evidence-based leadership on organizational outcomes (see Additional file 9 for perceived effects of evidence-based leadership). These were categorized into three groups: use of resources, staff commitment, and team effort. First, more appropriate use of resources was reported (ref 15, ref 20), and working time was more efficiently used (ref 16). In generally, a structured approach made implementing change more manageable (ref 1). On the other hand, in the beginning of the change process, the feedback from nurses was unfavorable, and they experienced discomfort in the new work style (ref 29). New approaches were also perceived as time consuming (ref 3). Second, nurse leaders believed that fewer nursing staff than expected left the organization over the course of the study (ref 31). Third, the project helped staff in their efforts to make changes, and it validated the importance of working as a team (ref 7). Collaboration and support between the nurses increased (ref 26). On the other hand, new work style caused challenges in teamwork (ref 3).

Perceived effects on clinical outcomes

Five studies (16%) reported the perceived effects of evidence-based leadership on clinical outcomes (see Additional file 9 for perceived effects of evidence-based leadership), which were categorized in two groups: general patient outcomes and specific clinical outcomes. First, in general, the project assisted in connecting the guideline recommendations and patient outcomes (ref 7). The project was good for the patients in general, and especially to improve patient safety (ref 16). On the other hand, some nurses thought that the new working style did not work at all for patients (ref 28). Second, the new approach used assisted in optimizing patients’ clinical problems and person-centered care (ref 20). Bowel management, for example, received very good feedback (ref 30).

The measured effects of evidence-based leadership

The measured effects on nurses’ performance.

Data were obtained from 20 studies (65%) (see Additional file 10 for measured effects of evidence-based leadership) and categorized nurse performance outcomes for three groups: awareness and knowledge, engagement, and satisfaction. First, six studies (19%) measured the awareness and knowledge levels of participants. Internship for staff nurses was beneficial to help participants to understand the process for using evidence-based practice and to grow professionally, to stimulate for innovative thinking, to give knowledge needed to use evidence-based practice to answer clinical questions, and to make possible to complete an evidence-based practice project (ref 3). Regarding implementation program of evidence-based practice, those with formal EBP training showed an improvement in knowledge, attitude, confidence, awareness and application after intervention (ref 3, ref 11, ref 20, ref 23, ref 25). On the contrary, in other study, attitude towards EBP remained stable ( p  = 0.543). and those who applied EBP decreased although no significant differences over the years ( p  = 0.879) (ref 6).

Second, 10 studies (35%) described nurses’ engagement to new practices (ref 5, ref 6, ref 7, ref 10, ref 16, ref 17, ref 18, ref 21, ref 25, ref 27). 9 studies (29%) studies reported that there was an improvement of compliance level of participants (ref 6, ref 7, ref 10, ref 16, ref 17, ref 18, ref 21, ref 25, ref 27). On the contrary, in DeLeskey’s (ref 5) study, although improvement was found in post-operative nausea and vomiting’s (PONV) risk factors documented’ (2.5–63%), and ’risk factors communicated among anaesthesia and surgical staff’ (0–62%), the improvement did not achieve the goal. The reason was a limited improvement was analysed. It was noted that only those patients who had been seen by the pre-admission testing nurse had risk assessments completed. Appropriate treatment/prophylaxis increased from 69 to 77%, and from 30 to 49%; routine assessment for PONV/rescue treatment 97% and 100% was both at 100% following the project. The results were discussed with staff but further reasons for a lack of engagement in nursing care was not reported.

And third, six studies (19%) reported nurses’ satisfaction with project outcomes. The study results showed that using evidence in managerial decisions improved nurses’ satisfaction and attitudes toward their organization ( P  < 0.05) (ref 31). Nurses’ overall job satisfaction improved as well (ref 17). Nurses’ satisfaction with usability of the electronic charting system significantly improved after introduction of the intervention (ref 12). In handoff project in seven hospitals, improvement was reported in all satisfaction indicators used in the study although improvement level varied in different units (ref 28). In addition, positive changes were reported in nurses’ ability to autonomously perform their job (“How satisfied are you with the tools and resources available for you treat and prevent patient constipation?” (54%, n  = 17 vs. 92%, n  = 35, p  < 0.001) (ref 30).

The measured effects on organizational outcomes

Thirteen studies (42%) described the effects of a project on organizational outcomes (see Additional file 10 for measured effects of evidence-based leadership), which were categorized in two groups: staff compliance, and changes in practices. First, studies reported improved organizational outcomes due to staff better compliance in care (ref 4, ref 13, ref 17, ref 23, ref 27, ref 31). Second, changes in organization practices were also described (ref 11) like changes in patient documentation (ref 12, ref 21). Van Orne (ref 30) found a statistically significant reduction in the average rate of invasive medication administration between pre-intervention and post-intervention ( p  = 0.01). Salvador (ref 24) also reported an improvement in a proactive approach to mucositis prevention with an evidence-based oral care guide. On the contrary, concerns were also raised such as not enough time for new bedside report (ref 16) or a lack of improvement of assessment of diabetic ulcer (ref 8).

The measured effects on clinical outcomes

A variety of improvements in clinical outcomes were reported (see Additional file 10 for measured effects of evidence-based leadership): improvement in patient clinical status and satisfaction level. First, a variety of improvement in patient clinical status was reported. improvement in Incidence of CAUTI decreased 27.8% between 2015 and 2019 (ref 2) while a patient-centered quality improvement project reduced CAUTI rates to 0 (ref 10). A significant decrease in transmission rate of MRSA transmission was also reported (ref 27) and in other study incidences of CLABSIs dropped following of CHG bathing (ref 14). Further, it was possible to decrease patient nausea from 18 to 5% and vomiting to 0% (ref 5) while the percentage of patients who left the hospital without being seen was below 2% after the project (ref 17). In addition, a significant reduction in the prevalence of pressure ulcers was found (ref 26, ref 29) and a significant reduction of mucositis severity/distress was achieved (ref 24). Patient falls rate decreased (ref 15, ref 16, ref 19, ref 27).

Second, patient satisfaction level after project implementation improved (ref 28). The scale assessing healthcare providers by consumers showed improvement, but the changes were not statistically significant. Improvement in an emergency department leadership model and in methods of communication with patients improved patient satisfaction scores by 600% (ref 17). In addition, new evidence-based unit improved patient experiences about the unit although not all items improved significantly (ref 18).

Stakeholder involvement in the mixed-method review

To ensure stakeholders’ involvement in the review, the real-world relevance of our research [ 53 ], achieve a higher level of meaning in our review results, and gain new perspectives on our preliminary findings [ 50 ], a meeting with 11 stakeholders was organized. First, we asked if participants were aware of the concepts of evidence-based practice or evidence-based leadership. Responses revealed that participants were familiar with the concept of evidence-based practice, but the topic of evidence-based leadership was totally new. Examples of nurses and nurse leaders’ responses are as follows: “I have heard a concept of evidence-based practice but never a concept of evidence-based leadership.” Another participant described: “I have heard it [evidence-based leadership] but I do not understand what it means.”

Second, as stakeholder involvement is beneficial to the relevance and impact of health research [ 54 ], we asked how important evidence is to them in supporting decisions in health care services. One participant described as follows: “Using evidence in decisions is crucial to the wards and also to the entire hospital.” Third, we asked how the evidence-based approach is used in hospital settings. Participants expressed that literature is commonly used to solve clinical problems in patient care but not to solve leadership problems. “In [patient] medication and care, clinical guidelines are regularly used. However, I am aware only a few cases where evidence has been sought to solve leadership problems.”

And last, we asked what type of evidence is currently used to support nurse leaders’ decision making (e.g. scientific literature, organizational data, stakeholder views)? The participants were aware that different types of information were collected in their organization on a daily basis (e.g. patient satisfaction surveys). However, the information was seldom used to support decision making because nurse leaders did not know how to access this information. Even so, the participants agreed that the use of evidence from different sources was important in approaching any leadership or managerial problems in the organization. Participants also suggested that all nurse leaders should receive systematic training related to the topic; this could support the daily use of the evidence-based approach.

To our knowledge, this article represents the first mixed-methods systematic review to examine leadership problems, how evidence is used to solve these problems and what the perceived and measured effects of evidence-based leadership are on nurse leaders and their performance, organizational, and clinical outcomes. This review has two key findings. First, the available research data suggests that evidence-based leadership has potential in the healthcare context, not only to improve knowledge and skills among nurses, but also to improve organizational outcomes and the quality of patient care. Second, remarkably little published research was found to explore the effects of evidence-based leadership with an efficient trial design. We validated the preliminary results with nurse stakeholders, and confirmed that nursing staff, especially nurse leaders, were not familiar with the concept of evidence-based leadership, nor were they used to implementing evidence into their leadership decisions. Our data was based on many databases, and we screened a large number of studies. We also checked existing registers and databases and found no registered or ongoing similar reviews being conducted. Therefore, our results may not change in the near future.

We found that after identifying the leadership problems, 26 (84%) studies out of 31 used organizational data, 25 (81%) studies used scientific evidence from the literature, and 21 (68%) studies considered the views of stakeholders in attempting to understand specific leadership problems more deeply. However, only four studies critically appraised any of these findings. Considering previous critical statements of nurse leaders’ use of evidence in their decision making [ 14 , 30 , 31 , 34 , 55 ], our results are still quite promising.

Our results support a previous systematic review by Geert et al. [ 32 ], which concluded that it is possible to improve leaders’ individual-level outcomes, such as knowledge, motivation, skills, and behavior change using evidence-based approaches. Collins and Holton [ 23 ] particularly found that leadership training resulted in significant knowledge and skill improvements, although the effects varied widely across studies. In our study, evidence-based leadership was seen to enable changes in clinical practice, especially in patient care. On the other hand, we understand that not all efforts to changes were successful [ 56 , 57 , 58 ]. An evidence-based approach causes negative attitudes and feelings. Negative emotions in participants have also been reported due to changes, such as discomfort with a new working style [ 59 ]. Another study reported inconvenience in using a new intervention and its potential risks for patient confidentiality. Sometimes making changes is more time consuming than continuing with current practice [ 60 ]. These findings may partially explain why new interventions or program do not always fully achieve their goals. On the other hand, Dubose et al. [ 61 ] state that, if prepared with knowledge of resistance, nurse leaders could minimize the potential negative consequences and capitalize on a powerful impact of change adaptation.

We found that only six studies used a specific model or theory to understand the mechanism of change that could guide leadership practices. Participants’ reactions to new approaches may be an important factor in predicting how a new intervention will be implemented into clinical practice. Therefore, stronger effort should be put to better understanding the use of evidence, how participants’ reactions and emotions or practice changes could be predicted or supported using appropriate models or theories, and how using these models are linked with leadership outcomes. In this task, nurse leaders have an important role. At the same time, more responsibilities in developing health services have been put on the shoulders of nurse leaders who may already be suffering under pressure and increased burden at work. Working in a leadership position may also lead to role conflict. A study by Lalleman et al. [ 62 ] found that nurses were used to helping other people, often in ad hoc situations. The helping attitude of nurses combined with structured managerial role may cause dilemmas, which may lead to stress. Many nurse leaders opt to leave their positions less than 5 years [ 63 ].To better fulfill the requirements of health services in the future, the role of nurse leaders in evidence-based leadership needs to be developed further to avoid ethical and practical dilemmas in their leadership practices.

It is worth noting that the perceived and measured effects did not offer strong support to each other but rather opened a new venue to understand the evidence-based leadership. Specifically, the perceived effects did not support to measured effects (competence, ability to understand patients’ needs, use of resources, team effort, and specific clinical outcomes) while the measured effects could not support to perceived effects (nurse’s performance satisfaction, changes in practices, and clinical outcomes satisfaction). These findings may indicate that different outcomes appear if the effects of evidence-based leadership are looked at using different methodological approach. Future study is encouraged using well-designed study method including mixed-method study to examine the consistency between perceived and measured effects of evidence-based leadership in health care.

There is a potential in nursing to support change by demonstrating conceptual and operational commitment to research-based practices [ 64 ]. Nurse leaders are well positioned to influence and lead professional governance, quality improvement, service transformation, change and shared governance [ 65 ]. In this task, evidence-based leadership could be a key in solving deficiencies in the quality, safety of care [ 14 ] and inefficiencies in healthcare delivery [ 12 , 13 ]. As WHO has revealed, there are about 28 million nurses worldwide, and the demand of nurses will put nurse resources into the specific spotlight [ 1 ]. Indeed, evidence could be used to find solutions for how to solve economic deficits or other problems using leadership skills. This is important as, when nurses are able to show leadership and control in their own work, they are less likely to leave their jobs [ 66 ]. On the other hand, based on our discussions with stakeholders, nurse leaders are not used to using evidence in their own work. Further, evidence-based leadership is not possible if nurse leaders do not have access to a relevant, robust body of evidence, adequate funding, resources, and organizational support, and evidence-informed decision making may only offer short-term solutions [ 55 ]. We still believe that implementing evidence-based strategies into the work of nurse leaders may create opportunities to protect this critical workforce from burnout or leaving the field [ 67 ]. However, the role of the evidence-based approach for nurse leaders in solving these problems is still a key question.


This study aimed to use a broad search strategy to ensure a comprehensive review but, nevertheless, limitations exist: we may have missed studies not included in the major international databases. To keep search results manageable, we did not use specific databases to systematically search grey literature although it is a rich source of evidence used in systematic reviews and meta-analysis [ 68 ]. We still included published conference abstract/proceedings, which appeared in our scientific databases. It has been stated that conference abstracts and proceedings with empirical study results make up a great part of studies cited in systematic reviews [ 69 ]. At the same time, a limited space reserved for published conference publications can lead to methodological issues reducing the validity of the review results [ 68 ]. We also found that the great number of studies were carried out in western countries, restricting the generalizability of the results outside of English language countries. The study interventions and outcomes were too different across studies to be meaningfully pooled using statistical methods. Thus, our narrative synthesis could hypothetically be biased. To increase transparency of the data and all decisions made, the data, its categorization and conclusions are based on original studies and presented in separate tables and can be found in Additional files. Regarding a methodological approach [ 34 ], we used a mixed methods systematic review, with the core intention of combining quantitative and qualitative data from primary studies. The aim was to create a breadth and depth of understanding that could confirm to or dispute evidence and ultimately answer the review question posed [ 34 , 70 ]. Although the method is gaining traction due to its usefulness and practicality, guidance in combining quantitative and qualitative data in mixed methods systematic reviews is still limited at the theoretical stage [ 40 ]. As an outcome, it could be argued that other methodologies, for example, an integrative review, could have been used in our review to combine diverse methodologies [ 71 ]. We still believe that the results of this mixed method review may have an added value when compared with previous systematic reviews concerning leadership and an evidence-based approach.

Our mixed methods review fills the gap regarding how nurse leaders themselves use evidence to guide their leadership role and what the measured and perceived impact of evidence-based leadership is in nursing. Although the scarcity of controlled studies on this topic is concerning, the available research data suggest that evidence-based leadership intervention can improve nurse performance, organizational outcomes, and patient outcomes. Leadership problems are also well recognized in healthcare settings. More knowledge and a deeper understanding of the role of nurse leaders, and how they can use evidence in their own managerial leadership decisions, is still needed. Despite the limited number of studies, we assume that this narrative synthesis can provide a good foundation for how to develop evidence-based leadership in the future.


Based on our review results, several implications can be recommended. First, the future of nursing success depends on knowledgeable, capable, and strong leaders. Therefore, nurse leaders worldwide need to be educated about the best ways to manage challenging situations in healthcare contexts using an evidence-based approach in their decisions. This recommendation was also proposed by nurses and nurse leaders during our discussion meeting with stakeholders.

Second, curriculums in educational organizations and on-the-job training for nurse leaders should be updated to support general understanding how to use evidence in leadership decisions. And third, patients and family members should be more involved in the evidence-based approach. It is therefore important that nurse leaders learn how patients’ and family members’ views as stakeholders are better considered as part of the evidence-based leadership approach.

Future studies should be prioritized as follows: establishment of clear parameters for what constitutes and measures evidence-based leadership; use of theories or models in research to inform mechanisms how to effectively change the practice; conducting robust effectiveness studies using trial designs to evaluate the impact of evidence-based leadership; studying the role of patient and family members in improving the quality of clinical care; and investigating the financial impact of the use of evidence-based leadership approach within respective healthcare systems.

Data availability

The authors obtained all data for this review from published manuscripts.

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We want to thank the funding bodies, the Finnish National Agency of Education, Asia Programme, the Department of Nursing Science at the University of Turku, and Xiangya School of Nursing at the Central South University. We also would like to thank the nurses and nurse leaders for their valuable opinions on the topic.

The work was supported by the Finnish National Agency of Education, Asia Programme (grant number 26/270/2020) and the University of Turku (internal fund 26003424). The funders had no role in the study design and will not have any role during its execution, analysis, interpretation of the data, decision to publish, or preparation of the manuscript.

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Study design: MV, XL. Literature search and study selection: MV, KH, TL, WC, XL. Quality assessment: YT, SH, XL. Data extraction: JC, MV, JV, WC, YT, SH, GL. Analysis and interpretation: MV, SH. Manuscript writing: MV. Critical revisions for important intellectual content: MV, XL. All authors read and approved the final manuscript.

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Differences between the original protocol

We modified criteria for the included studies: we included published conference abstracts/proceedings, which form a relatively broad knowledge base in scientific knowledge. We originally planned to conduct a survey with open-ended questions followed by a face-to-face meeting to discuss the preliminary results of the review. However, to avoid extra burden in nurses due to COVID-19, we decided to limit the validation process to the online discussion only.

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Välimäki, M., Hu, S., Lantta, T. et al. The impact of evidence-based nursing leadership in healthcare settings: a mixed methods systematic review. BMC Nurs 23 , 452 (2024). https://doi.org/10.1186/s12912-024-02096-4

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     Omayal Achi College of Nursing was established in the year 1992 with the motto �Love to Serve�. The vision of the institution was to prepare student nurses at the undergraduate, postgraduate and doctoral level to provide quality focused, compassionate and evidenced informed nursing care services and to function in various capacities in the health care delivery system.

     Preparing nurses with the same vision requires capacity building in research among our students. Hence to explore, dream and discover, a Memorandum of Understanding was signed with the University of Saskatchewan, Canada and we got an opportunity to work with two very dynamic individuals from the university � Dr.David Popkin, the Dean and Dr.Vivian Ramsden. This association that developed into an intimate friendship helped us to make our dream come true. We started taking up collaborative Research projects, our faculty started presenting papers at international conferences and as years rolled by a firm relationship developed, which culminated in the signing of an MOU with the Research Department, University of Saskatchewan to institute the International Centre for Collaborative Research - ICCR for facilitating the research activities at Omayal Achi College of Nursing, by enhancing the research productivity and increasing the intensity of the research environment through collaboration with local, national and international research groups.

     In continuation to the signing of MOU, the first few months were spent in correspondence, formation of committees - Ethics committee, Governing committee, Research review committee etc. and the new centre started functioning in early 2009.

     During the first three years of our operations, we facilitated several research projects by researchers and Institutions from India and abroad - Asthma Foundation of India, University of Saskatchewan, Canada, Simon Fraser University, British Columbia, The T.N.Dr. M.G.R. Medical University, Chennai and Queen Margaret University, Edinburgh, Scotland, Singhvi Health Care Trust and AASAI foundation. The ICCR facilitates all the Research projects of the B.Sc. (N), MSc (N) students and PhD scholars of our college, every year.

     With growing research evidences in the nursing arena the ICCR wanted to provide a platform to communicate/ disseminate these evidences, hence the executive committee members have come up with the idea of instituting the Online Open Access Indexed Journal �ICCR�JNR (Journal of Nursing Research)� from January 2016. The Journal intends to publish quality research evidences for transforming nursing care services. The editorial for this journal comprises of national and international advisors and peer reviewers across the globe for all specialities in nursing.


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Ghosh AK , Unruh MA , Yun H , Jung H. Clinicians Who Practice Primarily in Nursing Homes and the Quality of End-of-Life Care Among Residents. JAMA Netw Open. 2024;7(3):e242546. doi:10.1001/jamanetworkopen.2024.2546

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Clinicians Who Practice Primarily in Nursing Homes and the Quality of End-of-Life Care Among Residents

  • 1 Department of Medicine, Weill Cornell Medical College, Cornell University, New York, New York
  • 2 Department of Population Health Sciences, Weill Cornell Medical College, Cornell University, New York, New York
  • 3 Department of Health Services, Policy, and Practice, Brown School of Public Health, Providence, Rhode Island

Question   Do clinicians who practice primarily in skilled nursing facilities (SNFs) or nursing homes ( SNFists [ie, physicians, nurse practitioners, and physician assistants concentrating their practice in the SNF or nursing home setting]) provide higher-quality end-of-life care compared with other clinicians?

Findings   This cohort study comprised 2 091 954 nursing home decedents, including 953 722 residents who received care from SNFists and 1 138 323 decedents who received care from non-SNFists. Residents who received care from SNFists had a reduced risk of experiencing burdensome transitions at the end of life, such as hospital transfer in the last 3 days of life or lack of continuity in nursing homes after hospitalization.

Meaning   This study suggests that SNFists may be an important resource to improve the quality of end-of-life care for nursing home residents.

Importance   Clinician specialization in the care of nursing home (NH) residents or patients in skilled nursing facilities (SNFs) has become increasingly common. It is not known whether clinicians focused on NH care, often referred to as SNFists (ie, physicians, nurse practitioners, and physician assistants concentrating their practice in the NH or SNF setting), are associated with a reduced likelihood of burdensome transitions in the last 90 days of life for residents, which are a marker of poor-quality end-of-life (EOL) care.

Objective   To quantify the association between receipt of care from an SNFist and quality of EOL care for NH residents.

Design, Setting, and Participants   This cohort study analyzed Medicare fee-for-service claims for a nationally representative 20% sample of beneficiaries to examine burdensome transitions among NH decedents at the EOL from January 1, 2013, through December 31, 2019. Statistical analyses were conducted from December 2022 to June 2023.

Exposure   Receipt of care from an SNFist, defined as physicians and advanced practitioners who provided 80% or more of their evaluation and management visits in NHs annually.

Main Outcomes and Measures   This study used augmented inverse probability weighting in analyses of Medicare fee-for-service claims for a nationally representative 20% sample of beneficiaries. Main outcomes included 4 measures of burdensome transitions: (1) hospital transfer in the last 3 days of life; (2) lack of continuity in NHs after hospitalization in the last 90 days of life; (3) multiple hospitalizations in the last 90 days of life for any reason or any hospitalization for pneumonia, urinary tract infection, dehydration, or sepsis; and (4) any hospitalization in the last 90 days of life for an ambulatory care–sensitive condition.

Results   Of the 2 091 954 NH decedents studied (mean [SD] age, 85.4 [8.5] years; 1 470 724 women [70.3%]), 953 722 (45.6%) received care from SNFists and 1 138 232 (54.4%) received care from non-SNFists; 422 575 of all decedents (20.2%) experienced a burdensome transition at the EOL. Receipt of care by an SNFist was associated with a reduced risk of (1) hospital transfer in the last 3 days of life (−1.6% [95% CI, −2.5% to −0.8%]), (2) lack of continuity in NHs after hospitalization (−4.8% [95% CI, −6.7% to −3.0%]), and (3) decedents experiencing multiple hospitalizations for any reason or any hospitalization for pneumonia, urinary tract infection, dehydration, or sepsis (−5.8% [95% CI, −10.1% to −1.7%]). There was not a statistically significant association with the risk of hospitalization for an ambulatory care–sensitive condition in the last 90 days of life (0.0% [95% CI, −14.7% to 131.7%]).

Conclusions and Relevance   This study suggests that SNFists may be an important resource to improve the quality of EOL care for NH residents.

Nursing home (NH) residents at the end of life (EOL) frequently experience burdensome transitions, 1 reflecting poor quality of care. Burdensome transitions are disruptive to residents 2 and lower quality of life through increased risk of feeding tube use, 3 intensive care unit stays, 4 late enrollment in hospice, 5 and receipt of care that is not concordant with the resident’s wishes. 6

During the past 2 decades, the proportion of clinicians (ie, physicians, nurse practitioners, and physician assistants) who practice primarily in NHs or skilled nursing facilities (SNFs), frequently termed SNFists (ie, physicians, nurse practitioners, and physician assistants concentrating their practice in the NH or SNF]setting), has increased at a rapid pace. 7 , 8 Most NHs in the US now use SNFists. 9 However, it is unclear whether the use of SNFists improves the quality of EOL care for NH residents. Given the clinical complexity and frailty of NH residents, SNFists’ focus on the NH setting may provide them with stronger clinical, organizational, and regulatory knowledge for these patients and thus lower the risk of burdensome transitions at the EOL. 10 , 11 Alternatively, such specialization may increase fragmentation in care delivered to NH residents, leading to increased risk of EOL transfers. 12

Using a nationally representative sample of Medicare claims, we examined the association between receipt of care by SNFists and burdensome transitions of care in the last 90 days of life for NH residents. We hypothesized that NH residents who received care from SNFists had a lower risk of burdensome transitions at the EOL compared with residents who received care from other clinicians.

The cohort study population included decedents aged 65 years or older who were long-stay NH residents, defined as Medicare beneficiaries enrolled in Medicare Parts A and B with stays in the same facility for at least 100 days, with no more than 10 consecutive days outside the NH, prior to death. 13 This study was approved by the Weill Cornell Medicine institutional review board. The Centers for Medicare & Medicaid Services Privacy Board approved a waiver of informed consent because research using administrative datasets cannot practicably be carried out without such a waiver. This article followed the Strengthening the Reporting of Observational Studies in Epidemiology ( STROBE ) reporting guideline for observational studies.

We used Medicare fee-for-services claims for a 20% nationally representative sample of beneficiaries for January 1, 2013, through December 31, 2019. These included Medicare claims for inpatient and outpatient services, as well as the Master Beneficiary Summary File with the Chronic and Disabling Conditions Segments. These data were linked to Minimum Data Set assessments, NH-level data from the Long-Term Care: Facts on Care in the US (LTCFocus) database and Medicare’s Care Compare for NHs, and clinician-level data from the Medicare Accountable Care Organization (ACO) Provider file. In addition, county-level market information was merged from the Area Health Resources File.

The clinical characteristics of the NH residents, including activities of daily living score and Cognitive Function Scale, along with their marital status were derived from the Minimum Data Set. 14 Minimum Data Set assessments are federally mandated for all NH residents and include information on demographic characteristics, diagnoses, and measures of both physical and cognitive functional status. Resident characteristics; enrollment status for Medicare Parts A and B, including dual eligibility status for Medicare and Medicaid and reason for Medicare entitlement; and chronic conditions were obtained from the Master Beneficiary Summary File. These data were merged with NH characteristics from LTCFocus and Care Compare using facility identifers. 15 Clinicians’ ACO participation was derived from the ACO Provider File and aggregated to the NH level as a percentage of clinicians who were ACO participants. Nursing home Five Star ratings were derived from Care Compare. County-level clinician labor market characteristics were obtained from the Area Health Resources File (eFigure in Supplement 1 ).

Informed by the previous literature, 1 burdensome transitions in the last 90 days of life were defined as follows: (1) hospital transfer in the last 3 days of life; (2) lack of continuity in NHs after hospitalization (eg, transfer from one NH to the hospital and then to a different NH); (3) multiple hospitalizations for any reason or any hospitalization for pneumonia, urinary tract infection, dehydration, or sepsis (defined using International Classification of Diseases, Ninth Revision or International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes (eTable in Supplement 1 ); or (4) any hospitalization for an ambulatory care–sensitive condition as defined by the Agency for Healthcare Research and Quality. 16 Indicators for each of these 4 types of transitions were used as outcomes.

We defined SNFists as physicians and advanced practitioners (nurse practitioners and physician assistants) who provided 80% or more of their evaluation and management visits in the NH setting. 7 , 8 , 17 Physicians in the sample were limited to generalists (family practice, general practice, geriatric medicine, internal medicine, and physical medicine and rehabilitation). In addition, we required clinicians to have at least 100 service lines in claims annually and to have made 10 or more visits in NHs in a given year. Residents were attributed annually to the clinician with a plurality of their evaluation and management visits. 18

Resident demographic characteristics included age, sex, race and ethnicity, marital status, reason for Medicare entitlement, and dual eligibility for Medicare and Medicaid. Our analysis determined race and ethnicity using the race and ethnicity variable from the Medicare Beneficiary Summary File. We assessed race and ethnicity because of well-known racial and ethnic disparities in EOL care. 19 Residents’ clinical conditions included indicators for common chronic conditions, activities of daily living score (0- to 28-point physical function score, where higher scores indicate decreased independence), and Cognitive Function Scale (ranging from 1 to 4, where higher scores indicate worse cognitive impairment). Facility-level covariates included the total number of beds, proportion of White residents, indicators of for-profit status, being part of a multifacility chain, being associated with a hospital, presence of Alzheimer disease care unit, proportions of Medicare- and Medicaid-covered residents, percentage of clinicians who were ACO members, rural location, and overall Care Compare Five Star rating. The number of primary care clinicians per 100 000 population was used as a physician labor market characteristic.

Statistical analyses were conducted from December 2022 to June 2023. Unadjusted comparisons based on whether a resident received care from an SNFist or a non-SNFist were made using the 2-sample t test for continuous variables and the Pearson χ 2 test for categorical variables.

We performed a decedent-level, complete-case analysis to estimate the association between receipt of care from an SNFist compared with a non-SNFist and risk of burdensome transitions at the EOL. We used a hierarchical multivariable logistic regression model with augmented inverse probability weighting (AIPW), a causal inference technique that uses the Rubin causal effects framework to examine the probability of an outcome of interest when the counterfactual outcome is not always observed. 20 Augmented inverse probability weighting combines the properties of both a regression-based estimator of the outcome (ie, the probability of a burdensome transition) and the inverse probability–weighted (IPW) estimator that determines the probability of a resident receiving care from an SNFist. The AIPW is a doubly robust estimator, meaning that if either estimator is misspecified, the mean treatment effect converges to the true effect as the number of observations increases. 20

Both the regression model and the IPW model included the resident, NH, and market characteristics. To account for variation of practices within NHs and also for state-based variation in SNFist practice patterns over time, 8 individual intercepts were used in the regression models by including indicators for each NH and the state year. The AIPW model estimated the mean treatment effect, denoting the percentage difference of the average NH resident who received care from an SNFist experiencing a burdensome transition in the last 90 days of life compared with an equivalent NH resident who received care from a clinician who was not an SNFist.

For each model, balance of the covariates was assessed using the covariate balancing propensity score test derived by Imai and Ratkovic. 21 All P values were from 2-sided tests and, for each model, we considered results with P  < .05 to be statistically significant. All analyses were conducted using Stata, version 17 (StataCorp LLC).

Table 1 presents descriptive statistics for decedents, NHs, and markets. The study population included 2 091 954 decedents (mean [SD] age, 85.4 [8.5] years; 1 470 724 women [70.3%]). Compared with those who received care from non-SNFists, NH residents who received care from SNFists were somewhat younger (proportion aged ≥85 years: 543 711 [57.0%] vs 686 527 [60.3%]; P  < .001), less likely to be female (662 682 [69.5%] vs 808 042 [71.0%]; P  < .001), had higher rates of end-stage kidney disease (22 378 [2.4%] vs 21 963 [1.9%]; P  < .001), were more likely to be dually eligible for Medicare and Medicaid (770 217 [80.8%] vs 879 802 [77.3%]; P  < .001), and had higher rates of common chronic conditions, including Alzheimer disease and related dementias (811 615 [85.1%] vs 940 841 [82.7%]; P  < .001). Nursing home residents treated by SNFists were more likely to be in larger NHs (mean [SD] number of beds, 144.3 [84.7] vs 128.8 [74.5]; P  < .001), for-profit facilities (mean [SD], 70.8% [47.3%] vs 65.9% [45.4%]; P  < .001), and those with higher mean (SD) proportions of residents covered by Medicare (mean [SD], 14.7% [10.1%] vs 14.2% [10.0%]; P  < .001) and Medicaid (mean [SD], 62.0% [18.7%] vs 60.3% [19.9%]; P  < .001) and with lower percentages of clinicians participating in an ACO (181 888 [19.1%] vs 308 305 [27.1%]; P  < .001).

Overall, 422 575 of all decedents (20.2%) in our sample experienced at least 1 type of burdensome transition at the EOL. Those who received SNFist care had, on average, a lower unadjusted rate of each type of burdensome transition compared with those who received care from non-SNFists (hospital transfer in last 3 days of life: 145 474 [15.3%] vs 178 419 [15.7%]; lack of continuity in NHs after hospitalization: 35 732 [3.8%] vs 45 091 [4.0%]; multiple hospitalizations for any reason or any hospitalization for pneumonia, urinary tract infection, dehydration, or sepsis: 6689 [0.7%] vs 9351 [0.8%]; and hospitalization for an ambulatory care–sensitive condition: 414 [0.04%] vs 740 [0.07%]; all P  < .001) ( Table 1 ).

Adjusted estimates are reported in Table 2 . Compared with NH residents who received care from non-SNFist clinicians, residents who received care from an SNFist were 1.6% less likely to experience any hospital transfer in the last 3 days of life (95% CI, −2.5% to −0.8%; P  < .001). In the last 90 days of life, residents who received care from SNFists were 4.8% (95% CI, −6.7% to −3.0%) less likely to experience a lack of continuity in NHs and 5.8% (95% CI, −10.1% to −1.7%) less likely to have multiple hospitalizations or at least 1 hospitalization for pneumonia, urinary tract infections, dehydration, or sepsis. There was not a statistically significant difference (0.0% [95% CI, −14.7% to 131.7%]) in the risk of a hospital admission for an ambulatory care–sensitive condition in the last 90 days of life.

In this national cohort study of NH decedents, we found that receipt of care from SNFists was associated with a reduced likelihood of experiencing 3 of 4 types of burdensome transitions, suggesting that these clinicians may play an important role in improving the EOL care for this population. To our knowledge, this is the first study to examine the association between care provided by SNFists and the quality of EOL care.

Previous studies examining NH residents receiving postacute and long-term care have described associations of receipt of SNFist care with reduced rehospitalization rates, 18 long-term use of antipsychotics, and indwelling bladder catheter use. 22 Our findings extend the literature by suggesting that SNFists’ strengths may facilitate better EOL care. 12 , 23 These strengths include familiarity with the common clinical conditions faced by NH residents, 22 the unique regulatory environment of NHs, and the likelihood of better communication between residents, families, and NH staff. 12 , 23 Moreover, our findings are of a similar magnitude and direction as those from a post hoc analysis, the Pragmatic Trial of Video Education in Nursing Homes (PROVEN) published by Moyo et al, 24 that demonstrated a 1.7% (95% CI, −3.2% to −0.1%) reduction in burdensome transitions in the last 90 days of life with the use of video-assisted advance care planning. However, our results are lower in magnitude than those reported by Miller et al. 25 In their propensity score–matched retrospective cohort study that examined the role of palliative care consultations in the last 6 months of life, there was an estimated reduction in burdensome transitions at the EOL (16.2% [95% CI, 12.7%-18.6%]) compared with matched controls (28.2% [95% CI, 25.8%-30.6%]).

Although further research is required to better characterize the mechanisms and the degree to which SNFists provide holistic care across various domains, including multimorbidity, functional and cognitive impairment, and frailty of NH residents, there are several policy implications that can be drawn from these findings. First, as the proportion of clinicians providing care in NHs who are SNFists continues to increase 8 and active recruitment of them by NHs nationwide continues, 9 our findings underscore the growing importance of SNFists in the delivery of EOL care to frail US individuals with advanced age and associated comorbidities, particularly those with dementia, as two-thirds of all deaths related to Alzheimer disease occur in NHs. 26

Second, the increase in SNFists reflects not only a growing need but a pattern of site-specific specialization similar to the practice of hospital medicine, and it is being increasingly recognized as such. 11 Several institutions, including the American Medical Directors Association–The Society for Post-Acute and Long-Term Care Medicine, provide structured training through certification in recognition of the unique skills required to expertly care for NH residents. However, most of the growth among clinicians focusing on NH care stems from advanced practitioners, which may reflect an unmet need in the supply of physician SNFists. 8 This differential growth among clinicians may reflect a lack of exposure to the NH environment during medical training, poorer financial incentives to practice in this setting, and a lack of a clear pathway to specializing in NH care. Medical schools and residency training programs led by the Accreditation Council for Graduate Medical Education may consider ways of providing these experiences for all primary care adult specialties to potentially increase the number of physicians focusing on NH care. Furthermore, such training, and specifically EOL care training, should be provided to other health care professionals, particularly nurse practitioners and physician assistants, who practice in the NH setting.

Third, historically, the quality of EOL care in NHs has focused on the use of in-hospital care and advance care planning. However, our findings indicate that 1 in 5 NH decedents experiences a burdensome transition at the EOL that, compared with earlier estimates, indicates little to no reduction in the rates of these events during the previous decade or more. 1 This finding suggests that greater emphasis on reducing their frequency is needed by NHs, payers, and policymakers.

Our results should be considered in light of the following limitations. First, although we used a rigorous AIPW approach for estimation of the association between receipt of care from an SNFist and the likelihood of a burdensome transition at the EOL, we cannot rule out the possibility of unobserved confounding. For example, decisions about EOL care may be informed by teams of health professionals and not just the SNFists, whose knowledge and experience may vary across NHs. Therefore, estimates should be viewed as associations and not causal effects. Second, we did not have information on the presence of advance directives or resident preferences for care at the EOL. Third, our estimates indicate modestly lower rates of burdensome transitions at the EOL associated with care provided by SNFists vs non-SNFists. However, the estimated differences translate to approximately 120 000 avoided hospitalizations in the last 90 days of life among the 2 million decedents in our sample.

This cohort study suggests that burdensome transitions at the EOL among NH residents are frequent and may be reduced through care provided by SNFists. These findings highlight the potential of SNFists to improve the quality of EOL care for this vulnerable and medically complex population.

Accepted for Publication: January 24, 2024.

Published: March 15, 2024. doi:10.1001/jamanetworkopen.2024.2546

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

Corresponding Author: Arnab K. Ghosh, MD, MSc, MA, Department of Medicine, Weill Cornell Medical College, Cornell University, 525 E 68th St, New York, NY10065 ( [email protected] ).

Author Contributions: Drs Ghosh and Jung had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Ghosh, Unruh, Jung.

Acquisition, analysis, or interpretation of data: Unruh, Yun, Jung.

Drafting of the manuscript: Ghosh, Unruh, Jung.

Critical review of the manuscript for important intellectual content: All authors.

Statistical analysis: Ghosh, Jung.

Obtained funding: Jung.

Administrative, technical, or material support: Yun, Jung.

Supervision: Unruh, Jung.

Conflict of Interest Disclosures: Dr Unruh reported receiving grants from Arnold Ventures, the National Institute on Aging, and the New York eHealth Collaborative; receiving personal fees from the American College of Physicians, the Agency for Healthcare Research and Quality, Brown University, and Chung-Ang University; and serving as an unpaid member of the Moving Forward Nursing Home Quality Coalition during the conduct of the study. Dr Jung reported receiving personal fees from Chung-Ang University during the conduct of the study. No other disclosures were reported.

Funding/Support: This work was supported by grant K08HL163329 from the National Heart, Lung, and Blood Institute (Dr Ghosh) and grant K01AG 057824 from the National Institute on Aging (Dr Jung).

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

Data Sharing Statement: See Supplement 2 .

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This paper is in the following e-collection/theme issue:

Published on 8.7.2024 in Vol 12 (2024)

Use and Design of Virtual Reality–Supported Learning Scenarios in the Vocational Qualification of Nursing Professionals: Scoping Review

Authors of this article:

Author Orcid Image

  • Jenny-Victoria Steindorff 1 * , BSc, MSc   ; 
  • Lisa-Marie Redlich 2 * , BSc   ; 
  • Denny Paulicke 1, 3 * , Prof Dr   ; 
  • Patrick Jahn 1 * , Prof Dr  

1 Health Service Research Working Group, Acute Care, Department of Internal Medicine, Faculty of Medicine, University Medicine Halle (Saale), Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany

2 Interdisciplinary Center for Health Sciences, Institute of Health and Nursing Science, Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany

3 Department of Medical Pedagogy, Akkon University of Human Sciences, Berlin, Germany

*all authors contributed equally

Corresponding Author:

Jenny-Victoria Steindorff, BSc, MSc

Health Service Research Working Group, Acute Care, Department of Internal Medicine

Faculty of Medicine, University Medicine Halle (Saale)

Martin-Luther-University Halle-Wittenberg

Magdeburger Straße 12

Halle (Saale), 06112

Phone: 49 345 557 4164

Email: [email protected]

Background: Numerous reviews advocate using virtual reality (VR) in educational contexts. This medium allows learners to test experiences in realistic environments. Virtually supported scenarios offer a safe and motivating way to explore, practice, and consolidate nursing skills in rare and critical nursing tasks. This is also cited as one of the reasons why VR can significantly increase the knowledge acquisition of nursing students. Nevertheless, studies are limited in their significance owing to the chosen design. Despite great interest, this results in a low level of confidence in VR as a curricular teaching method for nursing education. Therefore, defining concrete design and didactic-methodological parameters that support teachers in the use and implementation of VR is more relevant.

Objective: This scoping review aims to provide an overview of significant design aspects for VR scenario conception and its transfer to generalist nursing education to generate value for the development of teaching scenarios and their sustainable implementation in teaching.

Methods: A comprehensive literature search was performed using the MEDLINE (via PubMed) and CINAHL databases, and the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews) checklist was applied. The search was conducted from May to July 2022, using a specific search principle corresponding to the focus and the growing study corpus. A previously defined “population, concept, and context” scheme was employed as the basis for the double-blind review of all relevant international German and English publications released up to May 1, 2022.

Results: In accordance with the predefined selection procedure, 22 publications were identified. The identified aspects aided in the development of design, didactic, and research recommendations. The intuitive operation of realistically designed VR scenarios, which are standardized, reliable, and modifiable, as well as clear instructions and specific multimodal feedback functions were described positively. The same applied to the linear structure of the sequences with graduated demands and high image quality for increased immersion with low sensory overload. Changes in perspectives, multiuser options, dialogs, and recording functions can contribute to an interactive care practice. On the research side, it is advisable to define VR terminologies. In addition to considering larger samples, varying settings, and financial issues, it is recommended to conduct long-term studies on knowledge acquisition or improved patient outcomes.

Conclusions: VR scenarios offer high potential in the context of nursing education if teachers and learners develop them co-creatively according to design features and implement them by means of a well-conceived concept. VR enables trainees to develop practical skills continuously in a standardized way. In addition, its deployment supports the sensitization of trainees to digital nursing technologies and the expansion of their digital skills in a practical setting. Furthermore, it allows sustainability issues to be addressed.


Germany and the German health care system are facing enormous challenges. In addition to an increase in the need for care, demographic change is also leading to a blatant and increasing shortage of skilled nursing staff. Thus, the care gap in Germany is growing in all areas of care, and the need for nursing staff will rise alarmingly to 500,000 by 2035 [ 1 ]. However, in addition to the quantitative needs, the complexity of care is also increasing. A multimodal approach that considers other solutions in addition to human resources is required to counter the care crisis effectively [ 2 ]. Increasing technologization and digitalization in the health care sector can not only provide relief and additional security, but also strengthen the availability of current and person-centered (specialist) knowledge and skills in training and further education [ 3 ]. Accordingly, the educational pathways for the health care system in Germany are also changing. On the one hand, the academization of nursing education is being discussed and implemented in model study programs, while on the other hand, the new curricular orientation provides for generalist nursing education [ 4 ].

One recommendation therefore advocates transformative learning approaches that enable trainees and existing nurses to deal constructively and reflectively with the changing processes of an increasingly complex care reality.

Virtual Reality as a Transformative Learning Approach in Nursing Education

Gradually, more educational institutions of health care are making use of virtually supported teaching-learning scenarios [ 4 ], as they represent a suitable medium to train or support the skills of health care professionals.

One of the potentials is attributed to the immersive effect [ 5 ]. With the help of virtual reality (VR), users immerse themselves in a computer-generated synthetic environment [ 6 ] and perceive it via the senses of sight and hearing and increasingly via movement and touch as well. Therefore, immersion refers to the objective degree of sensory reality fidelity. According to Milgram et al [ 7 ], the degree of reality representation, which originally referred primarily to visual representation and has since been extended to haptic or acoustic experiences, can be classified on a “virtuality continuum” between the extremes of reality and VR.

As there is no standardized usage of the term VR yet, we applied the description of immersive virtual reality simulation (iVRS) according to Shorey et al [ 8 ] as a working definition, which was decisive for determining the study inclusion and exclusion criteria as follows: “The virtual world [also “virtual reality,” authors’ note] is a 3D computer environment that provides users with interactive experiences of an alternate reality in which they are avatars who can move, sense, touch, and act upon simulated objects that appear real [ 9 ]. There are 2 variations of virtual worlds, namely, desktop virtual reality simulation (dVRS) and iVRS [ 10 ]. dVRS, also known as non-iVRS, is where users interact with an environment displayed on a computer monitor using a mouse, keyboard, touchscreen, or joystick [ 11 ]. In contrast, iVRS provides a complete simulated environment where the user is equipped with several sensory output devices such as a head-mounted device, stereoscopic unit, audio device, and haptic device [ 10 ]. It involves a higher degree of interactivity compared to dVRS — by blocking out many visual elements of the real-world environment and inducing sensory stimuli that correspond with the virtual environment, it enables the user to immerse in the virtual environment [ 12 ].”

Nevertheless, both these varieties use the principles of interaction and user participation in addition to the characteristic of graduated immersion [ 13 ]. This characteristic enables nursing trainees to experience both routines and the complexity of rare or dangerous care tasks in an activating but safe and motivating environment [ 14 ].

In the last decade, various international studies have investigated the application of VR for educational purposes in nursing. As an interesting complement to traditional teaching methods, the use of VR to improve the teaching of basic nursing skills, communication, or teamwork [ 15 ] has increased. Here, above all, the possibility of conveying abstract and complicated content is used, as one’s actions and their effects are brought into focus and the learning content is perceived as more attractive [ 13 ] and is addressed via several sensory channels in parallel [ 16 ]. Beyond this, the procedure for learning and acquiring skills and competencies, which trainees can repeat as often as needed, promotes neuronal linkage [ 17 , 18 ] and the resulting confidence in action. In following this approach, ways of translating theoretical knowledge into practical skills and abilities emerge [ 19 ]. However, learners and teachers have described this theory-practice transfer as critical and inadequate if only conventional teaching methods are used [ 13 ]. This can lead to not only inadequate care but also dropouts from training as trainees demonstrate an excessive demand for the learning content and its transfer to concrete practical requirements [ 20 ], especially since the number and regularity of patient contacts during training are often insufficient.

Accordingly, technology-supported teaching-learning arrangements can provide multiple services as follows:

  • They can take up the changing range of professional tasks in nursing, depict them, and teach the competencies required for this in a situational and interactive way in a safe learning setting or support the acquisition by opening up opportunities for self-observation and self-reflection [ 5 ], particularly for complex action situations that occur rather rarely in care practice and cannot be guaranteed or practiced in the training phases.
  • They can increase the intrinsic motivation to learn and the attractiveness of training [ 18 ] and can make it more effective [ 21 ].
  • They can indirectly fulfill the demand for the inclusion of digital-related competence requirements in curricula [ 22 ].

In order to establish a connection between educational and care contexts and thus provide educational value, digital technologies should be used as a learning medium in a reflected and justified manner. This makes it more relevant to define concrete design and didactic-methodological parameters that support teachers in the use and implementation of VR in their teaching.

Despite the increasing number of publications on VR as a learning medium in the educational context of health care, there is still a lack of a merger between best practice experiences and recommendations for targeted use and specific design in generalist nursing education. To our knowledge, this didactic-methodological approach to VR-supported nursing education has not been applied yet. Based on this, our scoping review is intended to contribute to showing the potentials and indications of VR as a specifically selected and supplementary teaching-learning medium and to reveal the needs of this distinctive target group for an efficient design.

Study Objectives

The aim of this comprehensive literature review is to compile the findings and best practice examples of projects on VR-supported educational processes in nursing that have already been completed or are still in progress. With the help of this exploratory overview of the currently available evidence, it should be possible to make statements and recommendations as to which design aspects are relevant for the conception and use of didactically and methodologically significant virtually supported teaching-learning scenarios in the professional qualification of nursing specialists and to what extent these can be transferred to basic nursing training.

This scoping review, based on the JBI methodology [ 23 ], has obtained and mapped an overview of previous and current international research projects [ 24 ], and it is as broad and in-depth as possible [ 23 ]. With the help of the procedure described by Arksey and O'Malley [ 25 ], which comprises the steps of searching for and identifying relevant studies; selecting them; presenting the data; and compiling, summarizing, and reporting the results, it is possible to both make use of the research results already generated and identify the research gaps that still exist [ 25 ].

Search Strategy

From May to July 2022, a comprehensive search was conducted in 2 specialist databases (MEDLINE via PubMed and CINAHL via EBSCO) according to predefined inclusion and exclusion criteria, which are presented in Textbox 1 . The search strings for the literature search in the databases are presented in Multimedia Appendix 1 . In addition to publications identified in the reference lists that appeared to be suitable according to the keywords and were available as full texts, grey literature from other databases and websites available online was also taken into account and included in the screening of abstracts and full texts.

Inclusion criteria


  • All publication types.
  • Publications until May 5, 2022.
  • Available full text (author request if applicable).
  • German or English publications.
  • International studies.
  • Trainees, students, and teachers in nursing care.
  • Working nursing professionals participating in continuing education programs.
  • Immersive applications
  • Use of a head-mounted display
  • Effectiveness
  • Design features
  • Basic training as a nursing professional.
  • Basic studies to become a nursing professional.
  • Continuing education and training for nursing professionals.
  • Interprofessional teaching-learning settings in which future nursing professionals also participate.

Exclusion criteria

  • Publications after May 5, 2022.
  • Full text subject to a fee.
  • Non-German or non-English publications.
  • Exclusively students of human, dental, or veterinary medicine.
  • Exclusively practitioners of human, dental, or veterinary medicine.
  • Exclusively trainees of other health professions.
  • Exclusively practitioners of other health professions.
  • Other simulation-based teaching-learning forms without VR or immersive approaches.
  • Programming aspects of VR applications only.
  • VR applications in medical-therapeutic settings without an educational purpose.
  • VR applications in other educational or recreational contexts.

Study Selection

The online tool “Rayyan” [ 26 ] was used for the consolidation and further processing of internationally published German or English articles, which were initially selected on the basis of the title and abstract. With the help of this tool, the research team was able to process the data set independently and in a blinded manner on the one hand but still cooperatively on the other. In this way, articles published up to May 1, 2022, were checked for their suitability with regard to the research question, and relevant hits were identified and extracted in a structured manner. No selection was made with regard to the study design, but both the population involved and the technologies used were taken into consideration. Therefore, we included studies in which nursing trainees, students, and teachers or nursing professionals in further education or training tested the use of VR in the form of head-mounted displays as a medium in targeted teaching-learning arrangements or helped to shape the development process. Of relevance here were, above all, statements on questions of effectiveness; information on increases in knowledge, technology acceptance, and usability; and concrete information on the didactic design of scenarios.

For this reason, publications that focused on other forms of VR representation (eg, nonimmersive 2D representation on a screen or Cardboard app–based models) or use as an assistive technology in nursing or medicine, or focused exclusively on other health professions were not considered. Furthermore, studies that focused on technological details and programming issues, but did not address the educational context, were also excluded.

Data Extraction and Synthesis

To systematically extract, summarize, and present the information on the current state of science that is relevant to answering the research question, the included studies were first processed narratively in a data table. The analysis and structuring of the data were carried out in terms of the study characteristics and the categories deduced in advance. Accordingly, the upper categories “creative design aspects,” “methodological-didactic indications for use,” and “research recommendations” served as a tabular and thematic structural basis for the present evidence synthesis ( Multimedia Appendix 2 [ 8 , 27 - 47 ]). The category “general conclusions” included further relevant statements that did not fit into these categories.

Research and Selection of Studies

Through a comprehensive database search, 774 potentially relevant studies were initially found. These were supplemented by 172 publications from a hand search. Studies automatically identified as duplicates by the program were only excluded after an additional manual cross-check, and 562 studies initially remained for the review process. The preselection of 45 articles, which was carried out by a double-blinded examination of the titles and abstracts according to previously defined criteria, led to the evaluation of the full text according to the inclusion criteria. Eventually, the data synthesis included 22 articles. There were no conflicts between the independent reviewers during this process. Figure 1 depicts this procedure graphically in the form of a PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flowchart [ 48 ].

research journal of nursing

Characteristics of the Studies Included in the Assessment

The 22 studies included in the assessment were from 14 different countries. Of the 22 studies, 8 were from the United States [ 31 , 33 , 35 , 36 , 40 , 42 , 46 ], with 1 co-authored by researchers from Australia [ 39 ]; 2 from Ireland [ 27 , 47 ]; 2 from Germany [ 29 , 45 ]; and 1 each from Switzerland [ 37 ], Belgium [ 43 ], Scotland [ 28 ], Norway [ 8 ], Canada [ 43 ], Brazil [ 30 ], South Africa [ 34 ], Singapore [ 8 ], South Korea [ 38 ], and Taiwan [ 32 ]. The publication language was mainly English, apart from 1 study, which was published in German. The date of release of more than 77% of the studies was between 2020 and 2022, and only 5 had been published between 2014 and 2019. This is probably due to the fact that VR technologies have become significantly more affordable in recent years through several manufacturers and have thus found their way into private households as well as practical application contexts, with accompanying research. With regard to the study design, the publications were very heterogeneous as is to be expected in a scoping review. Most of the articles involved mixed methods studies [ 28 , 30 , 34 - 38 , 40 , 41 , 43 , 45 - 47 ]. Moreover, there were 2 qualitative studies [ 27 , 32 ], 2 experimental studies [ 33 , 41 ], and 3 theoretical papers [ 31 , 39 , 42 ]. Some of these studies were also partially cited in 3 included systematic reviews [ 8 , 29 , 44 ]. Therefore, this review attempted to reveal aspects that provided hints and recommendations to the chosen categories for the development of virtually supported teaching-learning scenarios for nursing trainees from among different types of publications with regard to their divergent study objectives, settings, and populations. On the basis of this, the research team scanned and divided the publications into groups according to their contribution to one or more of the 3 predefined categories. However, this scoping review aimed to provide a summary of the results of interest and not an all-encompassing presentation of the results. Table 1 illustrates the contribution of the included studies to the deductive categories.

Study (author, year)Creative design aspectsMethodological-didactic indications for useResearch recommendations
Weiß et al [ ], 2018YesYesYes
Hara et al [ ], 2021YesYesYes
Wells-Beede et al [ ], 2022YesYesNo
Chang et al [ ], 2020YesYesYes
Adhikari et al [ ], 2021YesYesNo
Ma et al [ ], 2021YesYesNo
Botha et al [ ], 2021YesYesNo
Butt et al [ ], 2018YesYesYes
Shah et al [ ], 2021NoYesYes
Saab et al [ ], 2021YesYesYes
Schlegel et al [ ], 2019YesYesYes
Lee et al [ ], 2020YesYesNo
Dean et al [ ], 2020YesYesNo
Dorozhkin et al [ ], 2017YesYesNo
Paquay et al [ ], 2022YesYesYes
INACSL Standards Committee [ ], 2021YesYesYes
Thompson et al [ ], 2020NoYesNo
Plotzky et al [ ], 2021YesYesYes
Kleven et al [ ], 2014YesYesYes
Breitkreutz et al [ ], 2021YesYesNo
Shorey et al [ ], 2021YesYesNo
Hardie et al [ ], 2020YesYesYes

a INACSL: International Nursing Association of Clinical and Simulation Learning.

Characteristics of the Study Participants

Of the 22 studies, 19 described the methodical approach in the empirical surveys (for the cumulative data from the 3 theoretical papers [ 31 , 39 , 42 ], reference is made here to the respective publication). Accordingly, these included a total of 1193 participants, consisting of 14 teachers, 1018 nursing students or trainees at different stages of their studies or training, and 112 learners from other study programs. The students were studying midwifery (52 participants) [ 47 ], emergency medical services (24 participants) [ 41 ], and medicine (24 participants) [ 41 ], and were participating in interprofessional courses with nursing students in which VR was used for study purposes. A total of 12 students from other nonmedical programs completed the virtual learning program as a control group [ 45 ]. One study included 49 participants from a conference, but their professions and levels of education were not explicitly stated [ 40 ]. Nevertheless, the study was included because it tested an application that is also explicitly aimed at nurses in training and practice. The sociodemographic data, which were not given in detail in all publications, showed that the participants in the learner group were predominantly female and in an age range of 18 to 36 years but were mostly younger than 25 years. Most of the studies were conducted at a single institution, while only 4 publications presented their results from multicenter studies [ 30 , 33 , 41 , 46 ]. Nevertheless, almost all researchers reported that the participants had heterogeneous experiences with VR at the time of the first surveys.

Potential of Implementing VR Into Nursing Education

The included studies depicted a variety of potentials and didactic contexts in which virtually supported teaching-learning scenarios can efficiently supplement conventional teaching methods.

Due to the almost unlimited scope for design, virtually supported teaching-learning scenarios offer a wide range of content-related practice areas for future nursing professionals. This can range from free practice and reflection of communication occasions to technology-assisted patient assessments and nursing actions [ 36 ].

The acquisition of knowledge with VR scenarios is based, on the one hand, on the theory of situated learning [ 8 ] in order to promote an active connection of didactic principles with clinical competencies [ 27 , 28 , 30 , 35 , 36 , 43 , 46 ]. The learning process in VR takes place in the context of specific action goals, competencies, structures, and rules of the simulated nursing action [ 49 ]. It also offers a way in which interactions can be experienced and practiced in the social context of a “Community of Practice (CoP)” [ 50 ]. On the other hand, VR offers a way for experiential and constructivist learning [ 8 , 27 , 33 , 37 , 43 , 47 ] by allowing learners to gain meaningful and realistic experiences, even in stressful, rare, and dangerous situations [ 28 , 30 , 37 , 38 , 40 , 41 , 47 ]. This comes into play especially when conventional teaching methods can only deficiently depict those situations or if it is important to control them more intensively than in the reality of care [ 39 ]. In this way, safe; low-risk; contactless; and shame-, stress-, and fear-free learning is possible [ 8 , 27 , 28 , 30 , 32 , 36 , 44 ] when the paradigm of experimental knowledge acquisition and the associated trial-and-error strategy [ 27 , 28 , 32 ] can be considered its basis. Learners thus perceive less direct pressure that can be exerted by teachers during exercise [ 32 ] and can acquire a better understanding of the relevance and effects of individual action steps through directly experienced and concrete consequences [ 38 , 46 , 47 ]. Combined with gamification elements, trainees enter into a playful learning experience with a positive culture of error [ 30 , 37 ], which, when used sensibly, is able to increase interest and engagement in learning as well as motivation and willingness to actively acquire and discuss the learning content [ 8 , 28 , 30 , 34 , 35 , 37 , 43 , 45 - 47 ]. While this indicates a positive added value for a better and more satisfying learning experience [ 27 , 34 , 38 ], the use of VR-supported scenarios can emphasize increased self-confidence and self-awareness from a didactic perspective [ 27 , 28 , 32 , 43 ]. The pride and perception of the enhanced competence of learners as well as the playfully conveyed pleasure in a challenge or a competition with fellow students can promote the attention and memorability of the content [ 27 , 28 , 47 ].

While traditional teaching methods (eg, teaching in the skills lab) require observation and subsequent assessment of performance by a teacher, VR allows learners to gather experiences and impressions unobserved but still in a kind of safe space [ 46 ] and to discuss and analyze them later with teachers. As an assistive teaching-learning tool that usefully expands and supplements existing methods [ 27 , 28 , 32 , 44 ], VR could replace up to 50% of the clinical hours in the conventional teaching of nursing students [ 36 ]. Thus, both novices and experts [ 30 , 44 ] can benefit from it during training (eg, improvement of soft skills such as empathy, interprofessional communication, and collaboration) [ 29 , 36 , 44 , 45 ]. Here, the function of the change of perspective or the location-independent multiplayer game option is suitable, which places learners in a realistically depicted setting of care in a targeted situation (eg, communicatively challenging situation of case discussion or family counseling) and thus extends conventional role play [ 44 , 45 ]. Similarly, in this environment, it is possible to expand competencies, such as observation and reflection, on a case- and action-related basis or to look at doubtful situations from different perspectives and then discuss them together with the teacher or in a class group [ 30 , 47 ]. Accordingly, the deliberate use of virtual scenarios in generalist nursing education is well suited to acquiring new knowledge for the first time in a multisensory way, consolidating it through repetition or different action requirements, and forming abstract concepts in an experience-based and feedback-supported way [ 27 , 28 , 32 , 46 , 47 ].

Above all, the option of applying theoretically taught content with the accompanying required practical skills and abilities of nursing in a situation-oriented manner and connected with virtual persons who require care enables learners to gather and reflect on practical experiences even before their first clinical assignments. This, in turn, can result in them being more courageous, motivated, and committed in their active engagement with real patients. On the other hand, they might also experience a feeling of greater competence and self-efficacy, which can reduce the theory-practice transfer that is often perceived as difficult [ 27 , 30 , 36 , 38 , 42 - 47 ]. Although the respective studies had some limitations with regard to design and generalizability, some research teams reported objectively ascertainable cognitive, procedural, and psychomotor gains, in addition to the rather subjectively assessed personal and affective added values.

However, VR is not suitable as a stand-alone teaching approach that can or should replace teaching without specific instructions and guidance [ 27 ]. Rather, it is a matter of meaningfully integrating the possibilities offered by immersive virtual simulations into the teaching of prospective nurses or into the continuing education and training of nurses who are already working.

Didactic-Methodological Recommendations for the Use of Virtually Supported Scenarios in Nursing Education

The possible values of virtually supported teaching-learning scenarios in generalist nursing education are numerous. Nevertheless, there is a need for some didactic-methodological considerations and measures to be able to use them.

The prerequisite for this, however, is the economic, intentional, systematic, flexible, and learner-centered concept that facilitates the use of this medium, which has been adapted to the respective groups of learners, their levels of skills and knowledge, their learning experiences, and previous methods [ 30 , 32 , 35 , 37 , 42 ]. According to the deliberate practice theory, exercises should be selected on the basis of clearly defined, specific, appropriate, and measurable learning objectives that correspond to the real requirements of nursing practice [ 29 , 30 , 35 , 37 , 38 , 42 ]. Thus, teachers face the task of didactically reducing the available virtual possibilities by focusing on single aspects and significant content [ 44 , 47 ]. Due to this and several other factors, VR is not an adequate substitute for experienced instructors to teach professional nursing [ 27 ].

Saab et al [ 27 ] emphasized that the core of the nursing values of care and compassion is still human interaction. Trainees cannot acquire these exclusively through simulations. Rather, the personal and professional experience of teachers should convey these values. Additionally, they have to stimulate an empathic curiosity to generate a greater willingness to put oneself in the situation of the person receiving care and to support an accompanying in-depth understanding of the respective situation [ 39 ]. Moreover, VR cannot replace the deepening practice with the person receiving care or those involved in care for the hermeneutic case understanding of learners, in which individualized or at least partially individualized decisions about interventions in particular cases should be made with direct communicative reflection on needs and requirements. Furthermore, the abovementioned group of authors stated that there is no adequate substitute for personal and continuous feedback from the teacher for the preparation, support, and reflection of the learning situation [ 27 ]. In addition to this reflected use in general, it requires a well thought-out concept to leverage the potential of virtually supported scenarios in nursing education.

Considerations on Implementing VR Into Teaching

The naive use of VR for self-purposes or entertainment should only be found in the leisure sector. However, in order to make a purposeful and targeted contribution to the acquisition of skills and abilities by nursing trainees, it is important to proceed in a planned and systematic manner. Thus, Dean et al [ 39 ] called for users to not become passive VR consumers but to continue to maintain a critical, analytical, and thoughtful attitude for transferability to the reality of care. This also reflects the basic attitude of caregivers. Since future nursing professionals should always adopt a critical and reflexive attitude in the course of the increasing use of technologies in nursing practice and should also be sensitized to this in their training, this applies equally to not only teachers but also learners with regard to the use of virtual scenarios.

This also presupposes that teachers organize optimal framework conditions. The International Nursing Association of Clinical and Simulation Learning (INACSL) Standards Committee [ 42 ] and Hardie et al [ 47 ] therefore recommended a detailed prebriefing for preparation and introduction to the handling of the technology. This includes concrete preinstructions [ 32 , 38 , 41 , 44 ], which involve the correct use of technical devices, such as the controller [ 30 , 37 ], and getting used to the glasses and the changing perception [ 30 , 32 ]. Instructions on the associated teaching material and learning content and the requirements of the scenario should also be part of the introduction. This can be done either face-to-face with tutors or instructors or via a video [ 28 ] or interactive tutorial. Good instructions and ease of use open up the potential for learners to use VR independently of teachers and thus of location [ 44 , 46 ], and possibly even use a multiplayer version [ 35 , 40 , 44 ]. A final debriefing in the form of feedback sessions or accompanying reflection tasks supplements meaningful usage. This can support teachers and trainees to identify learners’ current strengths and weaknesses or to analyze and discuss discrepancies between the learning experience provided and the understanding of the nursing concepts presented or even the reality of care.

Accordingly, the use of virtual scenarios is recommended especially for smaller classes [ 27 ], so that trainers can handle the organization of the set-up of the simulations as well as the assignment and creation of rotation plans [ 36 ] in a manageable and efficient way. Under certain circumstances, the information or involvement of additional teachers should be considered [ 36 ]. Moreover, it should be considered whether specifically trained instructors or fellow students should provide support for the learners, for example, to secure the environment [ 43 ]. This also becomes relevant if trainees are given the opportunity to use or borrow VR headsets for voluntary practice in their free time in a separate room [ 27 ].

This, in turn, would not only enable the self-organized learning demanded by learners and the curricula [ 38 ] but also invalidate the argument that VR isolates users and show that it promotes social interaction [ 44 ], which is a highly relevant component in nursing.

In addition to the meaningful intention to implement VR in educational contexts, design aspects are crucial elements for using the various potentials of VR.

Overview of the Design Considerations of Virtually Supported Scenarios

With the exception of 2 studies [ 36 , 43 ], all included publications contained mostly experience-based hints and recommendations regarding the design of virtually supported teaching-learning scenarios for generalist nursing education.

To empower trainees to handle care situations, specific circumstances, and various settings, virtually supported scenarios should provide a realistic, plausible, and immersive learning environment [ 28 , 38 , 41 , 45 , 47 ], which should have consistent [ 31 ], clinically correct [ 34 ], and narrative story structures [ 47 ]. Due to this, multiprofessionally composed development and research groups [ 32 , 42 ] have to predefine concrete learning objectives [ 42 ] adapted to the current ability and knowledge level of learners [ 30 ], whereby learners come across the subjective relevance of the scenario they have experienced [ 51 ]. This forms the basis for the deduction of the most profitable specific means, details, and features. Authentic, motivating, and moderately challenging experiences should always be the goal. Thus, focusing on typical visual and auditory details relevant to the nursing process [ 44 , 46 ] is a major aspect. A basic prerequisite is high image and sound quality [ 27 , 34 , 38 , 41 ]. By observing the correct lens focus [ 28 ] and a high refresh rate, users can read text insertions [ 31 ] or recognize facial expressions and gestures [ 30 ] more easily. Moreover, this can increase the sense of immersion and perceived spatial presence within the chosen scenario [ 33 , 38 , 45 ] and prevent motion sickness [ 30 ]. Considering the cognitive load, the INACSL Standards Committee [ 42 ] recommends the selection of the type and degree of fidelity (eg, with regard to physical, conceptual, or psychological parameters). Therefore, trainees are able to draw their attention to the respective action demands [ 27 ] and challenges of different stress levels [ 29 , 37 , 38 ]. This could be supported by the targeted use of visual cues, including color markings, highlights, or animations [ 30 , 31 ]. The function of pausing during an exercise [ 31 ] in order to reflect on the next steps or to record the entire exercise [ 8 ] for later discussion can help to create a critical reflective attitude toward one’s performance. In addition to realistic visual and auditory details, the integration of tactile stimuli in the sense of a mixed reality experience [ 46 ] and 360° views, which enable observation of one’s performance from different angles [ 31 ], could be useful. The change of perspective [ 51 ] or modality of experience provides a basis for the reflection and discussion of actions and reactions demanded in specific situations. Since VR allows for slipping into other roles, it can promote essential nursing skills, such as empathy [ 52 - 54 ], which is particularly important for recreating other life perspectives and situations. The understanding of the needs and requirements of virtual people who require care on a physiological level can be supported by interactive models visualizing anatomical structures as well as regular or pathological processes [ 27 , 45 , 47 ].

Another essential recommendation for VR learning scenarios is the use of gamification elements [ 55 ]. The implementation of game-based details in the applications enables the strengthening of memory pathways [ 46 , 47 ], which in turn can positively influence learning outcomes [ 28 ]. This includes, for example, scores or rewards in the form of medals, congratulatory banners, or colored lights [ 30 ]. The given feedback can additionally motivate learners to perform practical nursing activities in VR [ 28 ] and support them in the development of problem-solving [ 27 ] and procedural skills [ 30 ]. Likewise, this can be supported by time limits for the execution of individual nursing actions.

Furthermore, if the application enables the collection of game-played data [ 41 ] and, for example, allows their visualization to both learners and teachers in the form of error rates [ 40 ], it can not only document but also promote intended learning outcomes, particularly when learners use this feature to analyze the learning gains according to performance [ 8 ]. Consequently, the scenarios, which rise in complexity in more challenging difficulty levels [ 35 ], should offer the possibility of the repetition of exercises [ 35 , 44 ] in order to achieve an increase in competence individually and in terms of one’s responsibility. If a trial-and-error strategy [ 27 ] forms the basis for this procedure, the learning process can be positively reinforced.

However, virtually supported scenarios can only unfold their potential if the handling scenarios allow. On the one hand, uncomplicated and trouble-free handling and experience of technical possibilities can increase the learners’ sense of presence in the situation [ 41 ]. On the other hand, it is an essential factor in the prevention of motion sickness [ 30 ]. Therefore, designers should pay attention to a high degree of correspondence between the image and the respective head movement, and the use of high-resolution graphics and the mitigation of technical overreactions, for example, can be useful when reaching for objects in virtual space [ 8 , 46 ].

Thus, design aspects should address the questions of handling and acceptance and the associated benefits for learning.

Research Recommendations

Owing to the greater availability of and interest in the use of VR as a teaching-learning medium, the corpus of studies in the field of nursing education has grown immensely in recent years. Nevertheless, the studies included in this review have stated the inconsistent use of VR terminology, indicating the need for an unambiguous definition in publications [ 29 , 44 ], and have mentioned the requirement for further research with larger samples and associated statistical analysis [ 27 , 29 ] with regard to various aspects.

On the one hand, this involves the investigation of technical parameters and interactive possibilities, such as stereognosis [ 32 ], motion tracking, and the integration of haptic devices, enhancing VR interface elements or social media and other mobile technologies to enable collaborative learning and effective distribution of educational content [ 45 ]. On the other hand, there is a demand for further investigation of the learning process itself by means of virtual simulations and the transferability of learned nursing-relevant content to real clinical practice [ 30 ]. Shah et al [ 36 ] recommended quantitative ethnography as a possible research method to take a closer look at associated emotions; ways of thinking and acting during immersion; and how, why, or when learning groups differ in this respect. If researchers use such comparative studies, for example, to analyze several sessions with the same and different instructors and assess learners’ perceptions during the instructions in prebriefings and debriefings or with regard to different content [ 36 ], they should take care to pilot the study [ 42 ] and to provide comparable test conditions for participants in the control group so that they can, for example, walk through a real patient room in search of faulty aspects of patient and workplace safety [ 37 ]. They should ensure almost the same conditions when surveying individual learning experiences [ 42 ], learning gains [ 36 ], and long-term knowledge retention or improved patient outcomes [ 35 ]. Studies for examining and evaluating the use of VR scenarios in education in more detail should also survey possible previous VR experiences of users [ 41 ] to be able to consider possible influencing factors or risks of bias.

For the use and design of virtually supported teaching-learning scenarios for generalist nursing education, the integration of a best-practice simulation framework [ 47 ] (eg, INACSL criteria [ 42 ] and Jeffries’ Simulation Theory [ 32 ]) for the consideration of not only microdidactic but also meso- and macrodidactic influencing factors is recommended. Thus, in addition to design and application aspects, questions about financial effects or the return on investment [ 35 ] also come into focus, and interprofessional cooperation [ 32 ] should take these into account, especially for continuous modification and optimization of scenarios. Targeted needs assessment [ 42 ] and continuous learner and teacher involvement in development [ 30 ] are critical factors for the appropriate and economic development of an effective teaching-learning medium.

Implications and Aspects of the Use of VR Teaching-Learning Scenarios

Within the framework of the literature research and the results presented, it must be stated that there are various ways to define VR, and it can encompass different devices, degrees of immersion, and interactions. Uniform definitions of the terms used would therefore be desirable [ 35 , 50 ]. Nevertheless, this medium in its various manifestations is generating successively more interest not only within the private leisure sector but also as a supplementary teaching-learning instrument in both general education and medical and nursing education contexts, as VR can meaningfully expand the number of methods with regard to various teaching-learning outcomes [ 36 , 38 ].

On the one hand, a virtual change of perspectives, role plays, or teamwork tasks in authentically depicted nursing scenarios could support the learning, practice, and repetition of personal and social competencies, such as empathy, heuristic case understanding, and targeted observation, which are relevant in the relational profession of nursing [ 2 , 39 ]. On the other hand, learners can consolidate procedural skills and abilities in virtually supported care situations by means of demonstrations, step-by-step instructions, and various feedback mechanisms [ 8 ]. In this way, they can safely apply theoretical content before, during, or even after a practical assignment in a concrete action situation and thus consolidate or assess their knowledge. This has the potential to soften limiting framework conditions and facilitate theory-practice transfer [ 2 , 36 ]. Teachers can benefit from the targeted use of VR in that they can give trainees learning tasks that are not bound to time and place, and these trainees are in turn more motivated and committed to partly self-directed teaching [ 41 , 50 ]. In addition, teachers and trainees command content illustrated more practically for appropriate discussion and reflection together [ 48 , 53 ].

Beyond the possibility of enhancing practical skills continuously in a standardized way, the use of VR supports trainees’ sensitization to digital nursing technologies and helps expand their digital skills in a practical setting. Even sustainability issues can be addressed in this way [ 38 ].

Nevertheless, it is important to note that almost all studies unanimously emphasized that virtually supported teaching-learning scenarios are still not an omnipotent substitute in teaching and that their use is rather critically reflected and well-considered at those points where conventional teaching methods reach their limits [ 40 , 46 ] to comprehensively prepare learners for the future role of a professionally acting nurse [ 38 ]. This scoping review offers an overview of the implications, considerations, and recommendations to develop and implement virtually supported scenarios reasonably and purposefully for educational demands in nursing education. An excerpt of the results is shown in Textbox 2 .

This includes not handing out VR glasses to learners in an uncontrolled manner, but rather embedding the application methodically and didactically in the lessons in a meaningful way to ensure pre- and postdiscussions as well as parallel professional and technical support. Only then can the presented content effectively support individual learning [ 2 , 42 , 48 ].

VR is consequently highly recommended to complement the third location of learning, that is, the skills lab [ 50 ]. The complexity of the practice is only approximately representable owing to current restrictions, such as limitations in haptics or olfaction, which are of great relevance in the care sector, and the combination of these can lead to the high resemblance of daily nursing practice and the broad preparation of trainees [ 16 , 38 ]. In addition, technology in the field of VR will continue to develop in the future, and possibilities for realization may arise for those constraints. In the best case, this will happen based on the needs and requirements of respective target groups in multiprofessional teams and with co-creative participatory procedures [ 38 ]. Thus, further prospective research fields are emerging in addition to the current cost-benefit analyses, large randomized controlled studies in various teaching-learning settings, and surveys on improved patient outcomes [ 35 , 36 , 38 , 41 ], and these will offer further potential and provide focal points for investigation that need to be critically considered.

Design recommendations

  • Realism and plausibility
  • Attractive playful design with high image and sound quality
  • Dialog-based narration
  • Adoption of perspective
  • Direct feedback and tangible consequences of action
  • Hierarchical structure
  • Data collection and reproduction
  • Clear handling, navigation, and instructions
  • Pause, repeat, and record functions
  • Location-independent multiplayer option

Didactic considerations

  • Assistive, activating, and motivating
  • Multimodal, learner-centered, and experience-based teaching concept
  • Specifically formulated learning goals
  • Secure standardized environment
  • Consolidation of theoretical, procedural, and application knowledge
  • One-to-one support including feedback
  • Situational testing
  • Independent and flexible in terms of time, and repeatable as often as required
  • Heuristically reflexive decision-making and problem-solving processes
  • Self-confidence in processes, expertise, and communication skills

Research recommendations

  • Clear definition of terminology
  • Cooperative and co-creative development processes
  • Larger samples and statistical analysis
  • Varying settings and conditions
  • Evaluation of improved patient outcomes
  • Longitudinal studies on knowledge
  • Cost-benefit analyses
  • Inclusion of additional interactive functions
  • Consideration of theoretical frameworks
  • Integration of best-practice simulation frameworks (eg, International Nursing Association of Clinical and Simulation Learning criteria)


A methodological strength of this scoping review is the comprehensive and supplementary hand search conducted in parallel with the database search and the citation tracking to counteract the risk of excluding relevant hits. Furthermore, the research team used a tool for blinded analysis to avoid selection bias in the selection of studies as far as possible. Nevertheless, the initial decision for a sensitive search principle was changed in favor of a specific procedure, as there has been an enormous growth of extended reality (XR) applications in educational and medical contexts in recent years. Accordingly, there is a growing amount of research papers on a wide variety of focal points. However, these often only correspond to the previously defined inclusion criteria in individual points, and thus, they do not answer or inadequately answer the concrete underlying research questions for the selected target group or the corresponding application. This is also the reason for another limitation of the study. As nursing education in its generalist application in Germany is unique in a worldwide comparison, the largely international research results are only partly transferable to local framework conditions, teaching methods, and content, as well as the requirements in the initial training of future nursing professionals. Furthermore, the data protection regulations applicable in Germany should be taken into account. These can influence not only the choice of devices but also the processing and use of the generated data. Therefore, critical considerations are relevant in the reception and the attempt to generalize the results in other contexts, especially since the focus was on a selective collection of data and not on a dedicated analysis or detailed comparison of the studies with each other.

Comparison With Prior Work

This scoping review reveals the results of selected publications according to a specific search principle. Although the aim was not to compare the studies with regard to the respective design or the reported results, the latter could be summarized under the deductively created paragraphs that address recommendations and considerations.

Compared with previous studies, which were partly considered in this study, it was possible to generate a general overview of relevant aspects that fundamentally characterize virtually supported teaching-learning scenarios in initial nursing education. On the other hand, the basis for the identification was the very specific context of nursing education in Germany. However, a large number of studies published thus far have focused on other study populations from the medical and general education sectors or other definitions of VR in their surveys and explanations.

The inclusion and exclusion criteria used served primarily to provide those actors involved in German nursing education and training with information on the use and development of virtually supported teaching-learning scenarios, which corresponded to the international consensus and met the needs of the German context. Consequently, this publication can serve as a point of reference for both national and international recipients, provided that they critically evaluate it and, if necessary, supplement relevant aspects, which are related to the respective country, action, teaching, or study population background.


Flexible use, a positive error culture, and learning that can be individually controlled and adapted to the knowledge levels of trainees by means of virtually supported teaching-learning scenarios can increase learning motivation and satisfaction. Simultaneously and compared to other common teaching methods, VR can reduce time, personnel, and material resources, and future nursing professionals can specifically train, deepen, and consolidate the procedural, personal, and social competencies of professional nursing knowledge and actions in both theoretical and practical teaching sessions.

Nevertheless, VR cannot and should not replace experienced nursing teachers, especially to convey elementary nursing values such as care and compassion. Therefore, learners and teachers should be actively involved in the co-creative design and evaluation process of virtually supported teaching-learning scenarios for the acquisition of skills and competencies in a practical yet safe setting. This will help to reveal the needs of the target group from the beginning and to incorporate them directly into the development on an iterative basis. In addition, future users can identify weak points or errors in content or applications more quickly than nonspecialist developers who may focus on different aspects. This could also launch the systematic implementation of this medium in the curriculum. Moreover, trainees and teachers will be sensitized to apply it critically and reflectively owing to the deeper insights that accompany the process.


The study conducted as part of the DigiCare project was financed from funds of the Federal Ministry of Education and Research and within the implementation phase of the WIR! Programme – Change through innovation in the region (project duration: August 01, 2021, to July 31, 2024; funding code: 03WIR3106B).

Authors' Contributions

All involved authors equally contributed to all manuscript components.

Conflicts of Interest

None declared.

Search strings for the literature search in 2 separate databases.

Overview of the essential characteristics of the studies included in this scoping review.

PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews) checklist.

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desktop virtual reality simulation
International Nursing Association of Clinical and Simulation Learning
immersive virtual reality simulation
virtual reality

Edited by N Ahmadpour; submitted 04.10.23; peer-reviewed by X Yi, W Li, S Matsuda; comments to author 25.02.24; revised version received 16.03.24; accepted 16.04.24; published 08.07.24.

©Jenny-Victoria Steindorff, Lisa-Marie Redlich, Denny Paulicke, Patrick Jahn. Originally published in JMIR Serious Games (https://games.jmir.org), 08.07.2024.

This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Serious Games, is properly cited. The complete bibliographic information, a link to the original publication on https://games.jmir.org, as well as this copyright and license information must be included.

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Thanks to a $1 billion gift, most Johns Hopkins medical students will no longer pay tuition


A sign stands in front of part of the Johns Hopkins Hospital complex, July 8, 2014, in Baltimore. Most medical students at Johns Hopkins University will no longer pay tuition thanks to a $1 billion gift from Bloomberg Philanthropies. Starting in the fall, the gift announced Monday, July 8, 2024 will cover full tuition for medical students from families earning less than $300,000. (AP Photo/Patrick Semansky, file)

FILE - Former mayor of New York Michael Bloomberg speaks during the Earthshot Prize Innovation Summit in New York, Sept. 19, 2023. Most medical students at Johns Hopkins University will no longer pay tuition thanks to a $1 billion gift from Bloomberg Philanthropies. Starting in the fall, the gift announced Monday, July 8, 2024 will cover full tuition for medical students from families earning less than $300,000. (Shannon Stapleton via AP, Pool, File)

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Most medical students at Johns Hopkins University will no longer pay tuition thanks to a $1 billion gift from Bloomberg Philanthropies announced Monday.

Starting in the fall, the donation will cover full tuition for medical students from families earning less than $300,000. Living expenses and fees will be covered for students from families who earn up to $175,000.

Bloomberg Philanthropies said that currently almost two-thirds of all students seeking a doctor of medicine degree from Johns Hopkins qualify for financial aid, and 45% of the current class will also receive living expenses. The school estimates that graduates’ average total loans will decrease from $104,000 currently to $60,279 by 2029.

The gift will also increase financial aid for students at the university’s schools of nursing, public health, and other graduate schools.

“By reducing the financial barriers to these essential fields, we can free more students to pursue careers they’re passionate about – and enable them to serve more of the families and communities who need them the most,” Michael Bloomberg, founder of Bloomberg Philanthropies and Bloomberg LP, said in a statement on Monday. Bloomberg received a bachelor’s degree in electrical engineering from Johns Hopkins University in 1964.


The gift will go to John Hopkins’ endowment and every penny will go directly to students, said Ron Daniels, president of Johns Hopkins University.

“Mike has really been moved by the challenges that the professions confronted during the course of the pandemic and the heroic efforts they’ve made to protecting and providing care to American citizens during the pandemic,” Daniels said in an interview. “I think he simply wanted to recognize the importance of these fields and provide this support to ensure that the best and brightest could attend medical school and the school of nursing and public health.”

Bloomberg Philanthropies previously gifted $1.8 billion to Johns Hopkins in 2018 to ensure that undergraduate students are accepted regardless of their family’s income.

Johns Hopkins will be the latest medical school to offer free tuition to most or all of their medical students.

In February Ruth Gottesman , a former professor at the Albert Einstein College of Medicine and the widow of a Wall Street investor, announced that she was donating $1 billion to the school. The gift meant that four-year students immediately received free tuition and all other students will be offered free tuition in the fall.

In 2018, Kenneth and Elaine Langone gave $100 million to the NYU Grossman School of Medicine to make tuition free for all current and future medical students through an endowment fund. The couple gave a second gift of $200 million in 2023 to the NYU Grossman Long Island School of Medicine to guarantee free tuition for all medical students. Kenneth Langone is a co-founder of Home Depot.

Other medical schools, like UCLA’s David Geffen School of Medicine, offer merit-based scholarships thanks to some $146 million in donations from the recording industry mogul, David Geffen. The Cleveland Clinic Lerner College of Medicine has also offered tuition-free education for medical students since 2008.

Candice Chen, associate professor, Milken Institute School of Public Health at The George Washington University, has researched the social missions of medical schools and had a strong reaction to the recent major gifts to John Hopkins, NYU and Albert Einstein.

“Collectively the medical schools right now, I hate to say this, but they’re failing in terms of producing primary care, mental health specialists as well as the doctors who will work in and serve in rural and underserved communities,” Chen said. She would have loved to see this gift go to Meharry Medical College in Tennessee, for example, which is a historically Black school that has produced many primary care doctors who work in communities that have shortages.

Bloomberg granted Meharry Medical College $34 million in 2020 as part of a $100 million gift he made to four Black medical schools to help reduce the debt of their medical students for four years.

There have been only a handful of previous $1 billion donations to universities in the U.S., most coming in the past several years.

In 2022, the venture capitalist John Doerr and his wife, Ann, gave $1.1 billion to Stanford University for a new school focusing on climate change.

The small liberal arts school McPherson College has received two matching pledges since 2022 from an anonymous donor totaling $1 billion. The school, which has around 800 enrolled students, has a program for automotive restoration and is located 57 miles north of Wichita, Kansas.

Bloomberg, the former New York mayor, gave $3 billion to charities in 2023 , making him one of the largest donors, according to research by the Chronicle of Philanthropy.

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How Does Research Start?

Capili, Bernadette PhD, NP-C

Bernadette Capili is director of the Heilbrunn Family Center for Research Nursing, Rockefeller University, New York City. This manuscript was supported in part by grant No. UL1TR001866 from the National Institutes of Health's National Center for Advancing Translational Sciences Clinical and Translational Science Awards Program. Contact author: [email protected] . The author has disclosed no potential conflicts of interest, financial or otherwise. A podcast with the author is available at www.ajnonline.com .

research journal of nursing

Editor's note: This is the first article in a new series on clinical research by nurses. The series is designed to give nurses the knowledge and skills they need to participate in research, step by step. Each column will present the concepts that underpin evidence-based practice—from research design to data interpretation. The articles will also be accompanied by a podcast offering more insight and context from the author.

This article—the first in a new series on clinical research by nurses—focuses on how to start the research process by identifying a topic of interest and developing a well-defined research question.

Clinical research aims to deliver health care advancements that are “safe, beneficial, and cost-effective.” 1 It applies a methodical approach to developing studies that generate high-quality evidence to support changes in clinical practice. This is a stepwise process that attempts to limit the chances of errors, random or systematic, that can compromise conclusions and invalidate findings. 2 Nurses need to be well versed in the research in their field in order to find the best evidence to guide their clinical practice and to develop their own research. To effectively use the literature for these purposes, it is imperative to understand the principles of critical appraisal and basic study design.

There are many roles for nurses in research. Nurses can be consumers who stay abreast of current issues and trends in their specialty area, nurse champions who initiate quality improvement projects guided by the best clinical evidence, members of an interprofessional research team helping to address a complex health problem, or independent nurse scientists developing a line of scientific inquiry. Regardless of the nurse's role, a common goal of clinical research is to understand health and illness and to discover novel methods to detect, diagnose, treat, and prevent disease.

This column is the first in a series on the concepts of clinical research using a step-by-step approach. Each column will build on earlier columns to provide an overview of the essential components of clinical research. The focus of this inaugural column is how to start the research process, which involves the identification of the topic of interest and the development of a well-defined research question. This article also discusses how to formulate quantitative and qualitative research questions.


The motivation to explore an area of inquiry often starts with an observation that leads to questioning why something occurs or what would happen if we tried a different approach. Speaking to patients and hearing their concerns about how to manage specific conditions or symptoms is another way to be inspired. Exploring new technologies, examining successful techniques, and adapting the procedures of other fields or disciplines can be other sources for new insights and discoveries. 2 Nurses working in a cardiac setting, for example, may take an interest in using fitness watches to monitor adherence to a walking program to reduce blood pressure and body weight. Their ease of use, cost, and availability may be what draws nurses to exploring the potential uses of this technology. Since the goal of research is to improve patients' lives, it's vital that anyone engaging in clinical research be curious and willing to understand clinical issues and explore the problems that need solving.

Reviewing the literature . Developing a research project requires in-depth knowledge of the chosen area of inquiry (for example, the etiology and treatment of hypertension, which is the hypothetical area of inquiry in this article). Ways to become immersed in the topic include speaking to experts in the field and conducting a comprehensive literature review. Two main types of review found in the literature are narrative and systematic.

Narrative reviews present an overview of current issues and trends in the area of interest and can address clinical, background, or theoretical questions. They can summarize current findings, identify gaps in research, and provide suggestions for next steps. 3 On the downside, narrative reviews can be biased because they are based on the author's experience and interpretation of findings and lack systematic and objective selection criteria. 4

Systematic reviews differ from narrative reviews in that they use a systematic approach to select, appraise, and evaluate the literature. Systematic reviews start with a clinical question to be answered by the review. They use clearly defined criteria to determine which articles to include and which to exclude. Systematic reviews can help nurses understand what works and what doesn't in terms of intervention-based research, and they are excellent resources if an area of inquiry is an intervention-based project. (For the categories of interventional studies, see Table 1 .)


Reviewing citations from published papers is another way to find relevant publications. A frequently cited publication in a particular area may indicate a landmark paper in which the authors present an important discovery or identify a critical issue. An essential goal of the literature review is to ensure that previous studies in the area of interest are located and understood. Previous studies provide insight into recent discoveries in the field, as well as into the dilemmas and challenges others encountered in conducting the research.


The two main branches of research methods are experimental and observational. Randomized controlled trials and non–randomized controlled trials belong in the experimental category, while analytical studies with control groups and descriptive studies without control groups belong in the observational category. Types of analytical studies include cohort and case–control studies; types of descriptive studies include ecological and cross-sectional studies, and case reports.

Despite their differences, the common thread among these research methods is the research question. This question helps guide the study design and is the foundation for developing the study. In the health sciences, the question needs to pass the “So what?” test. That is, is the issue relevant, is studying it feasible, and will it advance the field?

Cummings and colleagues use the mnemonic FINER ( F easible, I nteresting, N ovel, E thical, R elevant) to define the characteristics of a good research question. 2

Feasible . Feasibility is a critical element of research. Research questions must be answerable and focus on clear approaches to measuring or quantifying change or outcome. For example, assessing blood pressure for a study on the benefits of reducing hypertension is feasible because methods to measure blood pressure, the stages of hypertension, and the positive results associated with achieving normal blood pressure are established. For research requiring human participants, approaches to recruiting and enrolling them in the study require careful planning. Strategies must consider where and how to recruit the best participants to fit the study population under investigation. In addition, an adequate number of study participants is necessary in order to conduct the study. The allotted time frame to complete the study, the workforce to perform the study, and the budget to conduct the study must also be realistic. Research studies funded by private or public sponsors usually have defined time frames to completion, such as two or three years. Funders may also request a timeline showing when various aspects of the research will be achieved (institutional review board [IRB] approval, recruitment of participants, data analysis, and so on).

Interesting . Several factors may drive a researcher's interest in an area of inquiry. Cummings and colleagues use the term interesting to describe an area the investigator believes is important to examine. 2 For some investigators, an experience or an observation is the motivation for evaluating the underpinnings of a situation or condition. For some, the possibility of obtaining financial support, either through private or public funding, is an important consideration in choosing a research question or study subject. For others, pursuing a particular research question is the logical next step in their program of research.

Novel . Novel research implies that the study provides new information that contributes to or advances a field of inquiry. This may include research that confirms or refutes earlier study results or that replicates past research to validate scientific findings. When replicating studies, improving previously used research methods (for example, increasing sample size, outcome measures, or the follow-up period) can strengthen the project. A study replicating an earlier hypertension study may add a way to assess dietary sodium intake physiologically instead of only by collecting food records.

Ethical . It is mandatory that research proceed in an ethical manner, from the protection of human and animal subjects to data collection, data storage, and the reporting of research results. Research studies must obtain IRB approval before they can proceed. The IRB is an ethics committee that reviews the proposed research plan to ensure it has adequate safeguards for the well-being of the study participants. It also evaluates the potential risk versus benefit of the proposed study. If the level of risk posed by the study outweighs the benefits of the potential outcome, the IRB may require changes to the research plan to improve the safety profile, or it may reject the study. For example, an IRB may not approve a study proposing to use a placebo for comparison when well-established and effective treatments are available. The National Institutes of Health offers an excellent educational resource, Clinical Research Training ( https://ocr.od.nih.gov/clinical_research_training.html ), a free online tutorial on ethics, patient safety, protocol implementation, and regulatory research. Registration is required and each module takes 15 to 90 minutes to complete.

Relevant . Relevant research questions address critical issues. A relevant question will add to the current knowledge in the field. It may also change clinical practice or influence policy. The question must be timely and appropriate for the study population under investigation. For instance, to continue our hypothetical hypertension study example, for individuals diagnosed with hypertension, it is recognized that reducing the dietary intake of sodium and increasing potassium can lower blood pressure and reduce the risk of heart disease and stroke. Therefore, in conducting a dietary study to reduce blood pressure, an investigator might target the intakes of both sodium and potassium. Focusing solely on one and not the other ignores the best available evidence in the field.


Guidelines are available to help frame the research question, and PICO and PEO are among the most common. PICO is best suited for quantitative studies, while PEO is appropriate for qualitative studies. Quantitative and qualitative methodologies approach research using different lenses. In quantitative research, numerical data is produced, necessitating statistical analysis. Qualitative research generates themes, and the outcome of interest is the understanding of phenomena and experiences. It's important to note that some topics may not fit the PICO or PEO frameworks. In those cases, novice researchers may want to consult with a mentor or academic research adviser for help in formulating the research question.

PICO questions incorporate the following components: P opulation, I ntervention, C omparison, and O utcome.

  • Population is the people or community affected by a specific health condition or problem (for instance, middle-age adults ages 45 to 65 with stage 1 hypertension, or older adults ages 65 and older with stage 1 hypertension living in nursing homes).
  • Intervention is the process or action under investigation. Interventions can be pharmaceutical agents, devices, or procedures; changes in a process; or patient education on diet and exercise. They can be either investigational or already available to consumers or health care professionals.
  • Comparison means the group or intervention being compared with the intervention under investigation (for instance, those eating a vegan diet compared with those eating a Mediterranean-style diet).
  • Outcome is the planned measure to determine the effect of an intervention on the population under study. For example, in the study comparing a vegan diet with a Mediterranean-style diet, the outcomes of interest could be the percent reductions in body weight and blood pressure.
  • PEO questions incorporate the following components: P opulation, E xposure, and O utcome.
  • Population centers on those affected and their problems (for example, middle-age adults who have hypertension and smoke).
  • Exposure focuses on the area of interest (for example, experience with smoking cessation programs or triggers of smoking). Since qualitative studies can denote a broad area of research or specific subcategories of topics, the exposure viewpoint depends on the framing or wording of the research question and the goals of the project. 5
  • Outcome might encompass a person's experience with smoking cessation and the themes associated with quitting and relapsing. Since the PEO model is best suited for qualitative studies, the outcome tends to include the definition of a person's experiences in certain areas or discover processes that happen in specific locations or contexts. 6

How to formulate a research question using the PICO and PEO frameworks is reviewed in Table 2 .



This has been a brief review of how to find an area of interest for your research and how to form an effective research question. For some, the inspiration for research will come from observations and experiences in the work setting, colleagues, investigations in other fields, and past research. As has been noted, before delving into developing a research protocol it's important to master the subject of interest by speaking with experts and gaining a firm understanding of the literature in the field. Then, consider using the FINER mnemonic as a guide to determine if your research question can pass the “So what?” test and the PICO or PEO model to structure the question. Formulating the appropriate research question is vital to conducting your research because the question is the starting point to selecting the study design, population of interest, interventions or exposure, and outcomes. The next column will discuss the process for selecting the study participants.

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