how to critique a research article nursing

Reading and critiquing a research article

Nurses use research to answer questions about their practice, solve problems, improve the quality of patient care, generate new research questions, and shape health policy. Nurses who confront questions about practice and policy need strong, high-quality, evidence-based research. Research articles in peer-reviewed journals typically undergo a rigorous review process to ensure scholarly standards are met. Nonetheless, standards vary among reviewers and journals. This article presents a framework nurses can use to read and critique a research article.

When deciding to read an article, determine if it’s about a question you have an interest in or if it can be of use in your practice. You may want to have a research article available to read and critique as you consider the following questions.

Does the title accurately describe the article?

A good title will pique your interest but typically you will not know until you are done reading the article if the title is an accurate description. An informative title conveys the article’s key concepts, methods, and variables.

Is the abstract representative of the article?

The abstract provides a brief overview of the purpose of the study, research questions, methods, results, and conclusions. This helps you decide if it’s an article you want to read. Some people use the abstract to discuss a study and never read further. This is unwise because the abstract is just a preview of the article and may be misleading.

Does the introduction make the purpose of the article clear?

A good introduction provides the basis for the article. It includes a statement of the problem, a rationale for the study, and the research questions. When a hypothesis is being tested, it should be clearly stated and include the expected results.

Is a theoretical framework described?

When a theoretical framework is used, it should inform the study and provide a rationale. The concepts of the theoretical framework should relate to the topic and serve as a basis for interpreting the results. Some research doesn’t use a theoretical framework, such as health services research, which examines issues such as access to care, healthcare costs, and healthcare delivery. Clinical research such as comparing the effectiveness of two drugs won’t include a theoretical framework.

Is the literature review relevant to the study and comprehensive? Does it include recent research?

The literature review provides a context for the study. It establishes what is, and is not known about the research problem. Publication dates are important but there are caveats. Most literature reviews include articles published within the last 3 to 5 years. It can take more than a year for an article to be reviewed, revised, accepted, and published, causing some references to seem outdated.

Literature reviews may include older studies to demonstrate important changes in knowledge over time. In an area of study where little or no research has been conducted, there may be only a few relevant articles that are a decade or more old. In an emerging area of study there may be no published research, in which case related research should be referenced. If you are familiar with the area of research, review the references to determine if well-known and highly regarded studies are included.

Does the methods section explain how a research question was addressed?

The methods section provides enough information to allow the study to be replicated. Components of this section indicate if the design is appropriate to answer the research question(s).

• Did the researcher select the correct sample to answer the research questions and was the size sufficient to obtain valid results?
• If a data collection instrument was used, how was it created and validated?
• If any materials were used, such as written guides or equipment, were they described?
• How were data collected?
• Was reliability and validity accounted for?
• Were the procedures listed in a step-by-step manner?

Independent and dependent variables should be described and terms defined. For example, if patient falls in the hospital are considered the dependent variable, or outcome, what are the independent variables, or factors, being investigated that may influence the rate at which patient falls occur? In this example, independent variables might include nurse staffing, registered nurse composition (such as education and certification), and hospital Magnet &#174 status.

Is the analytical approach consistent with the study questions and research design?

The analytical approach relates to the study questions and research design. A quantitative study may use descriptive statistics to summarize the data and other tests, such as chi squares, t-tests, or regression analysis, to compare or evaluate the data. A qualitative study may use such approaches as coding, content analysis, or grounded theory analysis. A reader who is unfamiliar with the analytical approach may choose to rely on the expertise of the journal’s peer reviewers who assessed whether the analytical approach was correct.

Are the results presented clearly in the text and in tables and figures?

Results should be clearly summarized in the text, tables, and figures. Tables and figures are only a partial representation of the results and critical information may be only in the text. In a quantitative study, the significance of the statistical tests is important. The presentation of qualitative results should avoid interpretation, which is reserved for the discussion.

Are the limitations presented and their implications discussed?

It is essential that the limitations of the study be presented. These are the factors that explain why the results may need to be carefully interpreted, may only be generalized to certain situations, or may provide less robust results than anticipated. Examples of limitations include a low response rate to a survey, not being able to establish causality when a cross-sectional study design was used, and having key stakeholders refuse to be interviewed.

Does the discussion explain the results in relation to the theoretical framework, research questions, and significance of the study?

The discussion serves as an opportunity to explain the results in respect to the research questions and the theoretical framework. Authors use the discussion to interpret the results and explain the meaning and significance of the study. It’s also important to distinguish the study from others that preceded it and provide recommendations for future research.

Depending on the research, it may be equally important for the investigators to present the clinical and/or practical significance of the results. Relevant policy recommendations are also important. Evaluate if the recommendations are supported by the data or seem to be more of an opinion. A succinct conclusion typically completes the article.

Once you’re done reading the article, how do you decide if the research is something you want to use?

Determine the scientific merit of the study by evaluating the level and quality of the evidence. There are many scales to use, several of which can be found in the Research Toolkit on the American Nurses Association’s website http://www.nursingworld.org/research-toolkit.aspx . Consider what you learned and decide if the study is relevant to your practice or answered your question as well as whether you can implement the findings.

A new skill

A systematic approach to reading and critiquing a research article serves as a foundation for translating evidence into practice and policy. Every nurse can acquire this skill.

Louise Kaplan is director of the nursing program at Saint Martin’s University in Lacey, Washington. At the end of this article is a checklist for evaluating an article.

Selected references

Hudson-Barr D. How to read a research article. J Spec Pediatr Nurs . 2004;9(2):70-2.

King’s College D. Leonard Corgan Library. Reading a research article. http://www.lib.jmu.edu/ilworkshop08/materials/studyguide3.pdf . Accessed September 5, 2012.

Oliver D, Mahon SM. Reading a research article part I: Types of variables. Clin J Oncol Nurs . 2005;9(1):110-12.

Oliver D, Mahon SM. Reading a research article part II: Parametric and nonparametric statistics. Clin J Oncol Nurs . 2005;9(2):238-240.

Oliver D, Mahon SM. Reading a research article part III: The data collection instrument. Clin J Oncol Nurs . 2006;10(3):423-26.

Rumrill P, Fitzgerald S, Ware, M. Guidelines for evaluating research articles. Work . 2000;14(3):257-63.

15 Comments .

very helpful resource to critique any research article

I like it helped me a lot in my critical appraisal. thank you very much.

This article will help me with my understanding of how to read and critique a research article. This article was helpful in breaking down this information very basic to get a clear, concise understanding. Now I can take this information and go to the next level in my discussions

Great information and I will use this article for future reference.

This checklist and explanation for a literature review and/or reading and critiquing a research article was very helpful. As I only have 2 more classes to get my degree, I wish I knew this info 2 semesters ago! I will also pass this along to coworkers that will be going back to school in the near future.

Great article, I enjoyed the information. Thank You for this resource. Carolyn Martinez

Fantastic guide to the interpretation of clinical trials. Found this so helpful!

Great information and article. Thank you for the information.

well explained. its sometimes hard for P.G students to understand the concept but these guidelines are helpful to learn for novice.

This is great,am looking for guilgline on how to do research critique and this is just the solution.Thnks weldone

Unsure how to appropriately critique an article, thank you for your infomation

I am currently taking a Health Service Research course and was not sure how to sturcture my assignment. Thanks for posting this article!

very informative…very helpful to students doing research work.

Great timing; have just been asked to review and article and you provide the guide! Will share with colleagues.

I will be passing this article on to a friend who is taking a nursing research class. This article is a great reference for nursing students.

Comments are closed.

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Barker J, Linsley P, Kane R, 3rd edn. London: Sage; 2016

Ethical guidelines for educational research. 2018; https://tinyurl.com/c84jm5rt

Bowling A Research methods in health, 4th edn. Maidenhead: Open University Press/McGraw-Hill Education; 2014

Gliner JA, Morgan GAMahwah (NJ): Lawrence Erlbaum Associates; 2000

Critical Skills Appraisal Programme checklists. 2021; https://casp-uk.net/casp-tools-checklists

Cresswell J, 4th edn. London: Sage; 2013

Grainger A Principles of temperature monitoring. Nurs Stand. 2013; 27:(50)48-55 https://doi.org/10.7748/ns2013.08.27.50.48.e7242

Jupp VLondon: Sage; 2006

Continuing professional development (CPD). 2021; http://www.hcpc-uk.org/cpd

London: NHS England; 2017 http://www.hee.nhs.uk/our-work/advanced-clinical-practice

Kennedy M, Burnett E Hand hygiene knowledge and attitudes: comparisons between student nurses. Journal of Infection Prevention. 2011; 12:(6)246-250 https://doi.org/10.1177/1757177411411124

Lindsay-Smith G, O'Sullivan G, Eime R, Harvey J, van Ufflen JGZ A mixed methods case study exploring the impact of membership of a multi-activity, multi-centre community group on the social wellbeing of older adults. BMC Geriatrics. 2018; 18 https://bmcgeriatr.biomedcentral.com/track/pdf/10.1186/s12877-018-0913-1.pdf

Morse JM, Pooler C, Vann-Ward T Awaiting diagnosis of breast cancer: strategies of enduring for preserving self. Oncology Nursing Forum. 2014; 41:(4)350-359 https://doi.org/10.1188/14.ONF.350-359

Revalidation. 2019; http://revalidation.nmc.org.uk

Parahoo K Nursing research, principles, processes and issues, 3rd edn. Basingstoke: Palgrave Macmillan; 2014

Polit DF, Beck CT Nursing research, 10th edn. Philadelphia (PA): Wolters Kluwer; 2017

Critiquing a published healthcare research paper

Angela Grainger

Nurse Lecturer/Scholarship Lead, BPP University, and editorial board member

View articles · Email Angela

Research is defined as a ‘systematic inquiry using orderly disciplined methods to answer questions or to solve problems' ( Polit and Beck, 2017 :743). Research requires academic discipline coupled with specific research competencies so that an appropriate study is designed and conducted, leading to the drawing of relevant conclusions relating to the explicit aim/s of the study.

Relevance of research to nursing and health care

For those embarking on a higher degree such as a master's, taught doctorate, or a doctor of philosophy, the relationship between research, knowledge production and knowledge utilisation becomes clear during their research tuition and guidance from their research supervisor. But why should other busy practitioners juggling a work/home life balance find time to be interested in healthcare research? The answer lies in the relationship between the outcomes of research and its relationship to the determination of evidence-based practice (EBP).

The Health and Care Professions Council (HCPC) and the Nursing and Midwifery Council (NMC) require registered practitioners to keep their knowledge and skills up to date. This requirement incorporates being aware of the current EBP relevant to the registrant's field of practice, and to consider its application in relation to the decisions made in the delivery of patient care.

Advanced clinical practitioners (ACPs) are required to be involved in aspects of research activities ( Health Education England, 2017 ). It is for this reason that practitioners need to know how EBP is influenced by research findings and, moreover, need to be able to read and interpret a research study that relates to a particular evidence base. Reading professional peer-reviewed journals that have an impact factor (the yearly average number of citations of papers published in a previous 2-year period in a given journal is calculated by a scientometric index giving an impact factor) is evidence of continuing professional development (CPD).

CPD fulfils part of the HCPC's and the NMC's required professional revalidation process ( HCPC, 2021 ; NMC, 2019 ). For CPD in relation to revalidation, practitioners can give the publication details of a research paper, along with a critique of that paper, highlighting the relevance of the paper's findings to the registrant's field of practice.

Defining evidence-based practice

According to Barker et al (2016:4.1) EBP is the integration of research evidence and knowledge to current clinical practice and is to be used at a local level to ensure that patients receive the best quality care available. Because patients are at the receiving end of EBP it is important that the research evidence is credible. This is why a research study has to be designed and undertaken rigorously in accordance with academic and scientific discipline.

The elements of EBP

EBP comprises three elements ( Figure 1 ). The key element is research evidence, followed by the expert knowledge and professional opinion of the practitioner, which is important especially when there is no research evidence—for example, the most appropriate way to assist a patient out of bed, or perform a bed bath. Last, but in no way of least importance, is the patient's preference for a particular procedure. An example of this is the continued use of thermal screening dots for measuring a child's temperature on the forehead, or in the armpit because children find these options more acceptable than other temperature measuring devices, which, it is argued, might give a more accurate reading ( Grainger, 2013 ).

Understanding key research principles

To interpret a published research study requires an understanding of key research principles. Research authors use specific research terms in their publications to describe and to explain what they have done and why. So without an awareness of the research principles underpinning the study, how can readers know if what they are reading is credible?

Validity and reliability have long been the two pillars on which the quality of a research study has been judged ( Gliner and Morgan, 2000 ). Validity refers to how accurately a method measures what it is intended to measure. If a research study has a high validity, it means that it produces results that correspond to real properties, characteristics, and variations in the part of the physical or social world that is being studied ( Jupp, 2006 ).

Reliability is the extent to which a measuring instrument, for example, a survey using closed questions, gives the same consistent results when that survey is repeated. The measurement is considered reliable if the same result can be consistently achieved by using the same methods under the same circumstances ( Parahoo, 2014 ).

The research topic is known as the phenomenon in a singular sense, or phenomena if what is to be researched is plural. It is a key principle of research that it is the nature of the phenomenon, in association with the study's explicit research aim/s, that determines the research design. The research design refers to the overall structure or plan of the research ( Bowling, 2014 :166).

Methodology means the philosophy underpinning how the research will be conducted. It is essential for the study's research design that an appropriate methodology for the conduct and execution of the study is selected, otherwise the research will not meet the requirements of being valid and reliable. The research methods will include the design for data sampling, how recruitment into the study will be undertaken, the method/s used for the actual data collection, and the subsequent data analysis from which conclusions will be drawn (see Figure 2 ).

Quantitative, qualitative, and mixed-methods studies

A quantitative methodology is where the phenomenon lends itself to an investigation of data that can be numerically analysed using an appropriate statistical test/s. Quantitative research rests on the philosophical view that science has to be neutral and value-free, which is why precise measurement instruments are required ( Box 1 ). Quantitative research is influenced by the physical sciences such as mathematics, physics, and chemistry. The purpose of quantitative studies is to identify whether there are any causal relationships between variables present in the phenomenon. In short, a variable is an attribute that can vary and take on different values, such as the body temperature or the heart rate ( Polit and Beck, 2017 :748).

Quantitative studies can sometimes have a hypothesis. A hypothesis is a prediction of the study's outcome, and the aim of the study is to show either that the hypothesis is demonstrated as proven, or that it is not proven. Often a hypothesis is about a predicted relationship between variables. There are two types of variables, independent and dependent. An independent variable causes a change in the specific phenomenon being studied, while a dependent variable is the change in that phenomenon. The first example in Box 1 might help to clarify the difference.

An example of a hypothesis would be that older people who have a history of falls have a reduction in the incidence of falls due to exercise therapy. The causal relationship is between the independent variable— the exercise therapy—and the dependent variable—a falls reduction.

A qualitative methodology aims to explore a phenomenon with the aim of understanding the experience of the phenomenon from the perspective of those affected by it. Qualitative research is influenced by the social and not the physical sciences. Concepts and themes arise from the researcher/s interpretation of the data gained from observations and interviews. The collected data are non-numerical and this is the distinction from a quantitative study. The data collected are coded in accordance with the type of method being used in the research study, for example, discourse analysis; phenomenology; grounded theory. The researcher identifies themes from the data descriptions, and from the data analysis a theoretical understanding is seen to emerge.

A qualitative methodology rests on the philosophical view that science cannot be neutral and value-free because the researcher and the participants are part of the world that the research study aims to explore.

Unlike quantitative studies, the results of which can often be generalised due to the preciseness of the measuring instruments, qualitative studies are not usually generalisable. However, knowledge comparisons can be made between studies that have some similarity of focus. For example, the uncovering of causative or aggravating factors leading to the experiences of pain management for oncology patients, and for patients who have rheumatoid arthritis, or another long-term health problem for which pain is a characteristic feature. The validity of a qualitative study relates to the accurate representation of the data collected and analysed, and which shows that data has been saturated, meaning no new data or analysed findings are forthcoming. This is demonstrated in a clear data audit trail, and the study's findings are therefore seen as credible (see the second example in Box 1 ).

Box 1.Research study examples

• An example of a quantitative research study Kennedy and Burnett (2011) conducted a survey to determine whether there were any discernible differences in knowledge and attitudes between second- and third-year pre-registration nursing students toward hand-hygiene practices. The collected data and its subsequent analysis is presented in numerical tables and graphs, but these are supported by text explaining the research findings and how these were ascertained. For full details, see 10.1177/1757177411411124
• 2. An example of a qualitative research study Morse et al (2014) undertook an exploratory study to see what coping strategies were used by women awaiting a possible diagnosis of breast cancer. Direct quotes from the study participants appeared in the writing up of the research because it is a requirement of qualitative research that there be a transparent data audit trail. The research showed two things, both essential requirements of qualitative research. First, how the collected data were saturated to ensure that no data had been left inadequately explored, or that the data coding had been prematurely closed and, second, having captured the breadth and depth of the data findings, the researchers showed how the direct quotes were thematically coded to reveal the women's coping strategies. For full details, see 10.1188/14.ONF.350-359
• 3. An example of a mixed-methods study Lindsay-Smith et al (2018) investigated and explored the impact on elderly people's social wellbeing when they were members of a community that provided multi-activities. The study combined a quantitative survey that recorded participants' sociodemographic characteristics and measured participation in activities with a focus group study to gauge participants' perceptions of the benefits of taking part in the activities. For full details, see https://bmcgeriatr.biomedcentral.com/track/pdf/10.1186/s12877-018-0913-1.pdf

Sometimes a study cannot meet its stated research aims by using solely a quantitative or a qualitative methodology, so a mixed-methods approach combining both quantitative and qualitative methods for the collection and analysis of data are used. Cresswell (2013) explains that, depending on the aim and purpose of the study, it is possible to collect either the quantitative data first and analyse these, followed by the qualitative data and their analysis. This is an explanatory/exploratory sequence. Or the qualitative data may be collected first and analysed, followed by the quantitative; an exploratory/explanatory process. Whichever approach is used, the cumulative data analyses have to be synthesised to give a clear picture of the overall findings ( Box 1 ).

The issue of bias

Bias is a negative feature of research because it relates to either an error in the conceptualisation of the study due to the researcher/s adopting a skewed or idiosyncratic perspective, or to errors in the data analysis. Bias will affect the validity and reliability of a study, so it is important that any bias is eliminated in quantitative studies, or minimised and accounted for in qualitative studies.

Scientific and ethical approval

It should be noted that, before any research study proceeds, the research proposal for that study must have been reviewed and agreed to by a scientific and ethics committee. The purpose of a scientific and ethics committee is to see that those recruited into a study are not harmed or damaged, and that the study will contribute to the advancement of knowledge. The committee pays particular attention to whether any bias might have been introduced to a study. The researchers will have detailed the reason why the study is required, the explicit aim/s and purpose of the study, the methodology of the study, and its subsequent design, including the chosen research methods for the collection of the data (sampling and study recruitment), and what method/s will be used for data analysis.

A literature review is undertaken and the established (published) international literature on the research topic is summarised to highlight what is already known on the topic and/or to show any topic gaps that have not yet been researched. The British Educational Research Association (BERA) (2018) also gives guidance for research proposals that are deemed to be educational evaluation studies, including ‘close-practice’ research studies. Any ethical issues such as how people will be recruited into the study, the gaining of informed voluntary consent, any conflict of interest between the researcher/s and the proposed research topic, and whether the research is being funded or financially supported by a particular source will also have been considered.

Critiquing a published research paper

It is important to remember that a published paper is not the research report. It is a sample of the research report. The research author/s are presenting their research findings as a succinct summary. Only a passing mention might be made that ethical approval and voluntary informed consent were obtained. However, readers can be assured that all publications in leading journals with a good reputation are subject to an external peer review process. Any concerns about a paper's content will have been ironed out prior to publication.

It will be apparent that there are several particular research designs. The Critical Skills Appraisal Programme (CASP) provides online information to help the interpretation of each type of study, and does this by providing questions to help the reader consider and critique the paper ( CASP, 2021 ).

General points for critiquing a paper include the following:

• The paper should be readable and have explicit statements on the purpose of the research, its chosen methodology and design
• Read the paper thoroughly to get a feel for what the paper is saying
• Consider what the researcher/s says about any ethical issues and how these have been handled
• Look at how the data were collected and analysed. Are the explanations for these aspects clear? In a quantitative study, are any graphs or charts easy to understand and is there supporting text to aid the interpretation of the data? In a qualitative study, are direct quotes from the research participants included, and do the researcher/s show how data collected from interviews and observations were coded into data categories and themes?
• In a mixed-method study, how are the quantitative and qualitative analyses synthesised?
• Do the conclusions seem to fit the handling of the data's analysis?
• An important test of validity is whether the study's title relates well to the content of the paper and, conversely, whether the content reflect a corresponding match to the study's title.

Finally, remember that the research study could have been conducted using a different methodological design provided the research aims would still have been met, but a critique of the paper relates to what has been published and not what otherwise might have been done.

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Writing, reading, and critiquing reviews

Écrire, lire et revue critique, douglas archibald.

1 University of Ottawa, Ontario, Canada;

Maria Athina Martimianakis

2 University of Toronto, Ontario, Canada

Why reviews matter

What do all authors of the CMEJ have in common? For that matter what do all health professions education scholars have in common? We all engage with literature. When you have an idea or question the first thing you do is find out what has been published on the topic of interest. Literature reviews are foundational to any study. They describe what is known about given topic and lead us to identify a knowledge gap to study. All reviews require authors to be able accurately summarize, synthesize, interpret and even critique the research literature. 1 , 2 In fact, for this editorial we have had to review the literature on reviews . Knowledge and evidence are expanding in our field of health professions education at an ever increasing rate and so to help keep pace, well written reviews are essential. Though reviews may be difficult to write, they will always be read. In this editorial we survey the various forms review articles can take. As well we want to provide authors and reviewers at CMEJ with some guidance and resources to be able write and/or review a review article.

What are the types of reviews conducted in Health Professions Education?

Health professions education attracts scholars from across disciplines and professions. For this reason, there are numerous ways to conduct reviews and it is important to familiarize oneself with these different forms to be able to effectively situate your work and write a compelling rationale for choosing your review methodology. 1 , 2 To do this, authors must contend with an ever-increasing lexicon of review type articles. In 2009 Grant and colleagues conducted a typology of reviews to aid readers makes sense of the different review types, listing fourteen different ways of conducting reviews, not all of which are mutually exclusive. 3 Interestingly, in their typology they did not include narrative reviews which are often used by authors in health professions education. In Table 1 , we offer a short description of three common types of review articles submitted to CMEJ.

Three common types of review articles submitted to CMEJ

More recently, authors such as Greenhalgh 4 have drawn attention to the perceived hierarchy of systematic reviews over scoping and narrative reviews. Like Greenhalgh, 4 we argue that systematic reviews are not to be seen as the gold standard of all reviews. Instead, it is important to align the method of review to what the authors hope to achieve, and pursue the review rigorously, according to the tenets of the chosen review type. Sometimes it is helpful to read part of the literature on your topic before deciding on a methodology for organizing and assessing its usefulness. Importantly, whether you are conducting a review or reading reviews, appreciating the differences between different types of reviews can also help you weigh the author’s interpretation of their findings.

In the next section we summarize some general tips for conducting successful reviews.

How to write and review a review article

In 2016 David Cook wrote an editorial for Medical Education on tips for a great review article. 13 These tips are excellent suggestions for all types of articles you are considering to submit to the CMEJ. First, start with a clear question: focused or more general depending on the type of review you are conducting. Systematic reviews tend to address very focused questions often summarizing the evidence of your topic. Other types of reviews tend to have broader questions and are more exploratory in nature.

Following your question, choose an approach and plan your methods to match your question…just like you would for a research study. Fortunately, there are guidelines for many types of reviews. As Cook points out the most important consideration is to be sure that the methods you follow lead to a defensible answer to your review question. To help you prepare for a defensible answer there are many guides available. For systematic reviews consult PRISMA guidelines ; 13 for scoping reviews PRISMA-ScR ; 14 and SANRA 15 for narrative reviews. It is also important to explain to readers why you have chosen to conduct a review. You may be introducing a new way for addressing an old problem, drawing links across literatures, filling in gaps in our knowledge about a phenomenon or educational practice. Cook refers to this as setting the stage. Linking back to the literature is important. In systematic reviews for example, you must be clear in explaining how your review builds on existing literature and previous reviews. This is your opportunity to be critical. What are the gaps and limitations of previous reviews? So, how will your systematic review resolve the shortcomings of previous work? In other types of reviews, such as narrative reviews, its less about filling a specific knowledge gap, and more about generating new research topic areas, exposing blind spots in our thinking, or making creative new links across issues. Whatever, type of review paper you are working on, the next steps are ones that can be applied to any scholarly writing. Be clear and offer insight. What is your main message? A review is more than just listing studies or referencing literature on your topic. Lead your readers to a convincing message. Provide commentary and interpretation for the studies in your review that will help you to inform your conclusions. For systematic reviews, Cook’s final tip is most likely the most important– report completely. You need to explain all your methods and report enough detail that readers can verify the main findings of each study you review. The most common reasons CMEJ reviewers recommend to decline a review article is because authors do not follow these last tips. In these instances authors do not provide the readers with enough detail to substantiate their interpretations or the message is not clear. Our recommendation for writing a great review is to ensure you have followed the previous tips and to have colleagues read over your paper to ensure you have provided a clear, detailed description and interpretation.

Finally, we leave you with some resources to guide your review writing. 3 , 7 , 8 , 10 , 11 , 16 , 17 We look forward to seeing your future work. One thing is certain, a better appreciation of what different reviews provide to the field will contribute to more purposeful exploration of the literature and better manuscript writing in general.

In this issue we present many interesting and worthwhile papers, two of which are, in fact, reviews.

Major Contributions

A chance for reform: the environmental impact of travel for general surgery residency interviews by Fung et al. 18 estimated the CO 2 emissions associated with traveling for residency position interviews. Due to the high emissions levels (mean 1.82 tonnes per applicant), they called for the consideration of alternative options such as videoconference interviews.

Understanding community family medicine preceptors’ involvement in educational scholarship: perceptions, influencing factors and promising areas for action by Ward and team 19 identified barriers, enablers, and opportunities to grow educational scholarship at community-based teaching sites. They discovered a growing interest in educational scholarship among community-based family medicine preceptors and hope the identification of successful processes will be beneficial for other community-based Family Medicine preceptors.

Exploring the global impact of the COVID-19 pandemic on medical education: an international cross-sectional study of medical learners by Allison Brown and team 20 studied the impact of COVID-19 on medical learners around the world. There were different concerns depending on the levels of training, such as residents’ concerns with career timeline compared to trainees’ concerns with the quality of learning. Overall, the learners negatively perceived the disruption at all levels and geographic regions.

The impact of local health professions education grants: is it worth the investment? by Susan Humphrey-Murto and co-authors 21 considered factors that lead to the publication of studies supported by local medical education grants. They identified several factors associated with publication success, including previous oral or poster presentations. They hope their results will be valuable for Canadian centres with local grant programs.

Exploring the impact of the COVID-19 pandemic on medical learner wellness: a needs assessment for the development of learner wellness interventions by Stephana Cherak and team 22 studied learner-wellness in various training environments disrupted by the pandemic. They reported a negative impact on learner wellness at all stages of training. Their results can benefit the development of future wellness interventions.

Program directors’ reflections on national policy change in medical education: insights on decision-making, accreditation, and the CanMEDS framework by Dore, Bogie, et al. 23 invited program directors to reflect on the introduction of the CanMEDS framework into Canadian postgraduate medical education programs. Their survey revealed that while program directors (PDs) recognized the necessity of the accreditation process, they did not feel they had a voice when the change occurred. The authors concluded that collaborations with PDs would lead to more successful outcomes.

Experiential learning, collaboration and reflection: key ingredients in longitudinal faculty development by Laura Farrell and team 24 stressed several elements for effective longitudinal faculty development (LFD) initiatives. They found that participants benefited from a supportive and collaborative environment while trying to learn a new skill or concept.

Brief Reports

The effect of COVID-19 on medical students’ education and wellbeing: a cross-sectional survey by Stephanie Thibaudeau and team 25 assessed the impact of COVID-19 on medical students. They reported an overall perceived negative impact, including increased depressive symptoms, increased anxiety, and reduced quality of education.

In Do PGY-1 residents in Emergency Medicine have enough experiences in resuscitations and other clinical procedures to meet the requirements of a Competence by Design curriculum? Meshkat and co-authors 26 recorded the number of adult medical resuscitations and clinical procedures completed by PGY1 Fellow of the Royal College of Physicians in Emergency Medicine residents to compare them to the Competence by Design requirements. Their study underscored the importance of monitoring collection against pre-set targets. They concluded that residency program curricula should be regularly reviewed to allow for adequate clinical experiences.

Rehearsal simulation for antenatal consults by Anita Cheng and team 27 studied whether rehearsal simulation for antenatal consults helped residents prepare for difficult conversations with parents expecting complications with their baby before birth. They found that while rehearsal simulation improved residents’ confidence and communication techniques, it did not prepare them for unexpected parent responses.

Review Papers and Meta-Analyses

Peer support programs in the fields of medicine and nursing: a systematic search and narrative review by Haykal and co-authors 28 described and evaluated peer support programs in the medical field published in the literature. They found numerous diverse programs and concluded that including a variety of delivery methods to meet the needs of all participants is a key aspect for future peer-support initiatives.

Towards competency-based medical education in addictions psychiatry: a systematic review by Bahji et al. 6 identified addiction interventions to build competency for psychiatry residents and fellows. They found that current psychiatry entrustable professional activities need to be better identified and evaluated to ensure sustained competence in addictions.

Six ways to get a grip on leveraging the expertise of Instructional Design and Technology professionals by Chen and Kleinheksel 29 provided ways to improve technology implementation by clarifying the role that Instructional Design and Technology professionals can play in technology initiatives and technology-enhanced learning. They concluded that a strong collaboration is to the benefit of both the learners and their future patients.

In his article, Seven ways to get a grip on running a successful promotions process, 30 Simon Field provided guidelines for maximizing opportunities for successful promotion experiences. His seven tips included creating a rubric for both self-assessment of likeliness of success and adjudication by the committee.

Six ways to get a grip on your first health education leadership role by Stasiuk and Scott 31 provided tips for considering a health education leadership position. They advised readers to be intentional and methodical in accepting or rejecting positions.

Re-examining the value proposition for Competency-Based Medical Education by Dagnone and team 32 described the excitement and controversy surrounding the implementation of competency-based medical education (CBME) by Canadian postgraduate training programs. They proposed observing which elements of CBME had a positive impact on various outcomes.

You Should Try This

In their work, Interprofessional culinary education workshops at the University of Saskatchewan, Lieffers et al. 33 described the implementation of interprofessional culinary education workshops that were designed to provide health professions students with an experiential and cooperative learning experience while learning about important topics in nutrition. They reported an enthusiastic response and cooperation among students from different health professional programs.

In their article, Physiotherapist-led musculoskeletal education: an innovative approach to teach medical students musculoskeletal assessment techniques, Boulila and team 34 described the implementation of physiotherapist-led workshops, whether the workshops increased medical students’ musculoskeletal knowledge, and if they increased confidence in assessment techniques.

Instagram as a virtual art display for medical students by Karly Pippitt and team 35 used social media as a platform for showcasing artwork done by first-year medical students. They described this shift to online learning due to COVID-19. Using Instagram was cost-saving and widely accessible. They intend to continue with both online and in-person displays in the future.

Adapting clinical skills volunteer patient recruitment and retention during COVID-19 by Nazerali-Maitland et al. 36 proposed a SLIM-COVID framework as a solution to the problem of dwindling volunteer patients due to COVID-19. Their framework is intended to provide actionable solutions to recruit and engage volunteers in a challenging environment.

In Quick Response codes for virtual learner evaluation of teaching and attendance monitoring, Roxana Mo and co-authors 37 used Quick Response (QR) codes to monitor attendance and obtain evaluations for virtual teaching sessions. They found QR codes valuable for quick and simple feedback that could be used for many educational applications.

In Creation and implementation of the Ottawa Handbook of Emergency Medicine Kaitlin Endres and team 38 described the creation of a handbook they made as an academic resource for medical students as they shift to clerkship. It includes relevant content encountered in Emergency Medicine. While they intended it for medical students, they also see its value for nurses, paramedics, and other medical professionals.

Commentary and Opinions

The alarming situation of medical student mental health by D’Eon and team 39 appealed to medical education leaders to respond to the high numbers of mental health concerns among medical students. They urged leaders to address the underlying problems, such as the excessive demands of the curriculum.

In the shadows: medical student clinical observerships and career exploration in the face of COVID-19 by Law and co-authors 40 offered potential solutions to replace in-person shadowing that has been disrupted due to the COVID-19 pandemic. They hope the alternatives such as virtual shadowing will close the gap in learning caused by the pandemic.

Letters to the Editor

Canadian Federation of Medical Students' response to “ The alarming situation of medical student mental health” King et al. 41 on behalf of the Canadian Federation of Medical Students (CFMS) responded to the commentary by D’Eon and team 39 on medical students' mental health. King called upon the medical education community to join the CFMS in its commitment to improving medical student wellbeing.

Re: “Development of a medical education podcast in obstetrics and gynecology” 42 was written by Kirubarajan in response to the article by Development of a medical education podcast in obstetrics and gynecology by Black and team. 43 Kirubarajan applauded the development of the podcast to meet a need in medical education, and suggested potential future topics such as interventions to prevent learner burnout.

Response to “First year medical student experiences with a clinical skills seminar emphasizing sexual and gender minority population complexity” by Kumar and Hassan 44 acknowledged the previously published article by Biro et al. 45 that explored limitations in medical training for the LGBTQ2S community. However, Kumar and Hassen advocated for further progress and reform for medical training to address the health requirements for sexual and gender minorities.

In her letter, Journey to the unknown: road closed!, 46 Rosemary Pawliuk responded to the article, Journey into the unknown: considering the international medical graduate perspective on the road to Canadian residency during the COVID-19 pandemic, by Gutman et al. 47 Pawliuk agreed that international medical students (IMGs) do not have adequate formal representation when it comes to residency training decisions. Therefore, Pawliuk challenged health organizations to make changes to give a voice in decision-making to the organizations representing IMGs.

In Connections, 48 Sara Guzman created a digital painting to portray her approach to learning. Her image of a hand touching a neuron showed her desire to physically see and touch an active neuron in order to further understand the brain and its connections.

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How to Read and Critique Research A Guide for Nursing and Healthcare Students

• Helen Aveyard - Oxford Brookes University, UK
• Nancy Preston - Lancaster University
• Morag Farquhar - University of East Anglia, UK
• Description

Do you find research challenging to read? Do you struggle to get to grips with a research paper?

Understanding, critiquing and using research is a key requirement of students studying nursing and healthcare. This bookwill equip you with the skills you need to understand research and use it in your practice and academic assignments. The approach used in this book is unique: each chapter focuses on a published research paper – one you might be asked to read for a seminar or include in your academic work. In clear, straightforward language, the authors take you through each paper step by step, using it as a basis for exploring the underpinning research method or design, and how it has been reported.

Key features:

·       Each chapter focuses on a different research method by working through a relevant research paper

·       Identifies the main skills you need for your course: understanding research methods and critiquing articles

·       Written specifically for nursing and healthcare students by experienced nursing and health care lecturers

·       Develops your confidence in understanding research by helping you to apply your knowledge to real research papers.

This is an ideal text for undergraduate nursing and paramedic students reading and learning to appraise research. This is pitched at the right level and students will find this extremely helpful as they develop these appraisal skills. 

This is a practical textbook for students which does exactly what it says in the title -demonstrates how to read and critique research. Using examples, it leads the student through the process and is an essential textbook for any research module. 

I am excited for this book release, as I find the work by Helen Aveyard incredibly helpful and aligned to teachers/students' requirements. The chapter 3 is very well written, it provides an excellent overview on generic qualitative research. It provides key words, examples and a contemporary approach which will certainly benefit both undergraduate and postgraduate students and lecturers alike. 

This book is an ideal introduction to research and methodologies used for undergraduate healthcare students as it provides clear, systematic discussions throughout, building knowledge and understanding. It is also well placed further develop healthcare professionals understanding of research.

It is really helpful to have this set out by research type, and to be able to direct learners to it when they come across one of these documents.

Relevance to the module descriptor

Adopted for the academic literacy project to develop midwifery students academic skills

Excellent book to accompany our research methods module.

Highly recommended resource for students who are looking to develop their research literacy and critique skills. It a provides step by step guide to critically evaluating research studies, focusing on a different research method in each chapter.

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Sample materials & chapters.

Chapter 1: Getting started with reading research

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Nursing: How to Read a Research Article

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Evaluating the Evidence

Guidelines for reading and critiquing a research article  from my american nurse.

1. Critiquing the research article

a. Title describes the article b. Abstract summarizes the article c. Introduction makes the purpose clear d. Problem is properly introduced e. Purpose of the study is explained f. Research question(s) are clearly presented g. Theoretical framework informs the research h. Literature review is relevant, comprehensive, and includes recent research i. Methods section details how the research questions were addressed or hypotheses were tested j. Analysis is consistent with the study questions and research design k. Results are clearly presented and statistics clearly explained l. Discussion explains the results in relation to the theoretical framework, research questions, and significance to nursing m. Limitations are presented and their implications discussed n. Conclusion includes recommendations for nursing practice, future research, and policymakers

2. Is it an appropriate level of evidence?  (See the visual examples below)

3. Decide if the study is applicable to your practice.

How to Critically Evaluate a Research Article

Reading and Critiquing a Research Article--from the American Nurse Website

Is it a Research Article?

Primary research examples.

Primary sources are original materials.  It is authored by researchers, contains original research data, and is usually published in a peer-reviewed journal. Different methodologies can be used but the distinguishing characteristic is that the authors of the study designed and conducted the study first hand.  Examples include case studies and randomized control trials. 

Secondary Research Examples

Literature reviews are summaries of the literature on a particular topic. Reviews are generally considered "research", especially systematic and integrative reviews, but are not experimental in nature. There are several kinds of reviews: plain  literature reviews ,  systematic reviews , and  integrative reviews  are the most common.  Chapter 5 of  Introduction to Nursing Research: Incorporating Evidence-based Practice  (Cannon & Boswell, 2011, 2nd ed. Sudbury, Mass: Jones & Bartlett Learning) covers the purpose and process of a literature review in the context of writing a research article, thesis, or dissertation.  How to undertake a literature search: a step-by-step guide  (Watson, 2020, BJN, 29(7): 431-435) is a good overall guide.

Types of literature reviews:

• summaries of relevant literature
• generally descriptive
• not necessarily any analysis of the literature
• methodology of the literature search is not always given
• good for gaining background knowledge of a subject without having to do all the searches and reading yourself.
• good source for starting reading lists and literature searches.
• not generally considered a good source for clinical decision making
• Note: In the past, reviews were not differentiated by type, so older reviews may use systematic or integrative methodology but not be specified as such.
• Reading:  Ten simple rules for writing a literature review  (Pautasso, M. (2013).  PLoS Comput Biol ,  9 (7), e1003149.)
• Reading:  Conducting Your Literature Review  (Hempel, S. (2020). Washington, DC : American Psychological Association.)
• specifically includes experimental research studies
• search and selection methodology is very precise and should be explicitly described well enough for another researcher to duplicate the searches and the study selection. See  Table 1 of this article  (Hoojimans et al. (2012).  PLoS One,  7 (11): e48811) for a good example of describing the search methods.
• the purpose of a systematic review is to reach some conclusion regarding the topic: for example, the selection of high quality studies to be used in a meta-analysis*, the gaps in current research, or the best clinical evidence for determining evidence based practice.
• the first stage of meta-analysis studies--all meta-analyses should include a systematic review, but all systematic reviews do not lead to a meta-analysis
• usually done in a group to reduce researcher bias in the selection and evaluation of individual studies
• Reading:  A practical guide to conducting a systematic review  (Forward & Hobby, 2002,  Nursing Times,  98 (2), 36) provides some basic advice for conducting a systematic review. Reading:   PRISMA-S: an extension to the PRISMA Statement for Reporting Literature Searches in Systematic Reviews . (Rethlefsen, M.L., et al. (2021).  Syst Rev   10 ,  39. https://doi.org/10.1186/s13643-020-01542-z)
• commonly include non-experimental research, such as case studies, observational studies, and meta-analyses, but may also include practice applications, theory, and guidelines
• should have clear and precise search and selection criteria
• search and selection methodology should be described well enough for another researcher to duplicate the process
• selected literature should be analyzed, not just summarized--articles and groups of articles compared, themes identified, gaps noted, etc.
• Reading:  The integrative review: updated methodology  (Whittemore & Knaf, 2005, Journal of Advanced Nursing, 52(5), 546–553) provides an overview of the purpose and practice of integrative reviews.  
• aims at determining the scope or extent of the research on a topic.

*A meta-analysis study is one where carefully selected data from previous studies is combined to bring more rigor to a statistical or other analysis. No additional experimental work is done (usually). A systematic review is necessary to be sure that the data from the selected studies is comparable and combinable

Levels of Evidence

In some journals, you will see a 'level of evidence' assigned to a research article. Levels of evidence are assigned to studies based on the methodological quality of their design, validity, and applicability to patient care. The combination of these attributes gives the level of evidence for a study.  Many systems for assigning levels of evidence exist.  A frequently used system in medicine is from the  Oxford Center for Evidence-Based Medicine .  In nursing, the system for assigning levels of evidence is often from Melnyk & Fineout-Overholt's 2011 book,  Evidence-based Practice in Nursing and Healthcare: A Guide to Best Practice .  The Levels of Evidence below are adapted from Melnyk & Fineout-Overholt's (2011) model. 

Uses of Levels of Evidence : Levels of evidence from one or more studies provide the "grade (or strength) of recommendation" for a particular treatment, test, or practice. Levels of evidence are reported for studies published in some medical and nursing journals. Levels of Evidence are most visible in Practice Guidelines, where the level of evidence is used to indicate how strong a recommendation for a particular practice is. This allows health care professionals to quickly ascertain the weight or importance of the recommendation in any given guideline. In some cases, levels of evidence in guidelines are accompanied by a Strength of Recommendation.

About Levels of Evidence and the Hierarchy of Evidence : While Levels of Evidence correlate roughly with the hierarchy of evidence (discussed elsewhere on this page), levels of evidence don't always match the categories from the Hierarchy of Evidence, reflecting the fact that study design alone doesn't guarantee good evidence. For example, the systematic review or meta-analysis of randomized controlled trials (RCTs) are at the top of the evidence pyramid and are typically assigned the highest level of evidence, due to the fact that the study design reduces the probability of bias (Melnyk, 2011), whereas the weakest level of evidence is the opinion from authorities and/or reports of expert committees. However, a systematic review may report very weak evidence for a particular practice and therefore the level of evidence behind a recommendation may be lower than the position of the study type on the Pyramid/Hierarchy of Evidence.

About Levels of Evidence and Strength of Recommendation : The fact that a study is located lower on the Hierarchy of Evidence does not necessarily mean that the strength of recommendation made from that and other studies is low--if evidence is consistent across studies on a topic and/or very compelling, strong recommendations can be made from evidence found in studies with lower levels of evidence, and study types located at the bottom of the Hierarchy of Evidence. In other words, strong recommendations can be made from lower levels of evidence.

For example: a case series observed in 1961 in which two physicians who noted a high incidence (approximately 20%) of children born with birth defects to mothers taking thalidomide resulted in very strong recommendations against the prescription and eventually, manufacture and marketing of thalidomide. In other words, as a result of the case series, a strong recommendation was made from a study that was in one of the lowest positions on the hierarchy of evidence.

How to Read a Research Paper

Evaluating the evidence from medical studies can be a complex process, involving an understanding of study methodologies, reliability and validity, as well as how these apply to specific study types. While this can seem daunting, in a series of articles by Trisha Greenhalgh from BMJ, the author introduces the methods of evaluating the evidence from medical studies, in language that is understandable even for non-experts. Although these articles date from 1997, the methods the author describes remain relevant. Use the links below to access the articles.

Not all published research is worth considering. This provides an outline of how to decide whether or not you should consider a research paper.

This article discusses how to assess the methodological validity of recent research, using five questions that should be addressed before applying recent research findings to your practice.

This article and the next present the basics for assessing the statistical validity of medical research. The two articles are intended for readers who struggle with statistics

The second article on evaluating the statistical validity of a research article.

A set of questions that could be used to analyze the validity of qualitative research

Daly, J., Willis, K., Small, R., Green, J., Welch, N., Kealy, M., & Hughes, E. (2007). A hierarchy of evidence for assessing qualitative health research.  Journal of Clinical Epidemiology ,  60 (1), 43–49. doi:10.1016/j.jclinepi.2006.03.014

McBride, W. G. ‘‘Thalidomide and Congenital Abnormalities.’’ Letter to the Editor. The Lancet 2 (December 16, 1961): 1358.

Melnyk, B. M. (2011).  Evidence-based practice in nursing & healthcare: a guide to best practice  (2nd ed.). Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins.

Slawson, D. C., & Shaughnessy, A. F. (1997). Obtaining useful information from expert based sources.  BMJ (Clinical Research Ed.) ,  314 (7085), 947–949.

Hierarchy of Evidence for Quantitative Studies

The pyramid below represents the hierarchy of evidence, which illustrates the strength of study types; the higher the study type on the pyramid, the more likely it is that the research is valid. The pyramid is meant to assist researchers in prioritizing studies they have located to answer a clinical or practice question. 

For clinical questions, you should try to find articles with the highest quality of evidence. Systematic Reviews and Meta-Analyses are considered the highest quality of evidence for clinical decision-making and should be used above other study types, whenever available, provided the Systematic Review or Meta-Analysis is fairly recent. 

As you move up the pyramid, fewer studies are available, because the study designs become increasingly more expensive for researchers to perform. It is important to recognize that high levels of evidence may not exist for your clinical question, due to both costs of the research and the type of question you have.  If the highest levels of study design from the evidence pyramid are unavailable for your question, you'll need to move down the pyramid.

While the pyramid of evidence can be helpful, individual studies--no matter the study type--must be assessed to determine the validity.

Hierarch of Evidence for Qualitative Studies

Qualitative studies are not included in the Hierarchy of Evidence above. Since qualitative studies provide valuable evidence about patients' experiences and values, qualitative studies are important--even critically necessary--for Evidence-Based Nursing. Just like quantitative studies, qualitative studies are not all created equal. The pyramid below  shows a hierarchy of evidence for qualitative studies.

Adapted from Daly et al. (2007)

Primary/Secondary/Tertiary Sources

Types of sources - primary, secondary and tertiary.

Types of Medical Literature

Medical literature is often classified based on how far removed the information is from the original source.

Primary Literature/Source Primary sources are original materials.  It is authored by researchers, contains original research data, and is usually published in a peer-reviewed journal. Primary literature may also include conference papers, pre-prints, or preliminary reports.

Secondary Literature/Source  Secondary literature consists of interpretations and evaluations that are derived from or refer to the primary source literature. Examples include review articles (e.g., meta-analysis and systematic reviews) and reference works. Professionals within each discipline take the primary literature and synthesize, generalize, and integrate new research.

Tertiary  Literature/Source Tertiary literature consists of a distillation and collection of primary and secondary sources such as textbooks, encyclopedia articles, and guidebooks or handbooks. The purpose of tertiary literature is to provide an overview of key research findings and an introduction to principles and practices within the discipline.

Adapted from the Information Services Department of the Library of the Health Sciences-Chicago, University of Illinois at Chicago.

One more way to look at it:   Six Degrees of Separation (or Six Degrees of Kevin Bacon)

• Primary Literature/Source:   someone talked to Kevin Bacon and wrote about it
• Secondary Literature/Source:   someone else read the above article and summarized it for a radio show
• Tertiary Literature/Source:   a magazine included a mention of the article in a summary of Kevin Bacon interviews
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• Volume 24, Issue 2
• Five tips for developing useful literature summary tables for writing review articles
• Article Text
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• http://orcid.org/0000-0003-0157-5319 Ahtisham Younas 1 , 2 ,
• http://orcid.org/0000-0002-7839-8130 Parveen Ali 3 , 4
• 1 Memorial University of Newfoundland , St John's , Newfoundland , Canada
• 2 Swat College of Nursing , Pakistan
• 3 School of Nursing and Midwifery , University of Sheffield , Sheffield , South Yorkshire , UK
• 4 Sheffield University Interpersonal Violence Research Group , Sheffield University , Sheffield , UK
• Correspondence to Ahtisham Younas, Memorial University of Newfoundland, St John's, NL A1C 5C4, Canada; ay6133{at}mun.ca

https://doi.org/10.1136/ebnurs-2021-103417

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Introduction

Literature reviews offer a critical synthesis of empirical and theoretical literature to assess the strength of evidence, develop guidelines for practice and policymaking, and identify areas for future research. 1 It is often essential and usually the first task in any research endeavour, particularly in masters or doctoral level education. For effective data extraction and rigorous synthesis in reviews, the use of literature summary tables is of utmost importance. A literature summary table provides a synopsis of an included article. It succinctly presents its purpose, methods, findings and other relevant information pertinent to the review. The aim of developing these literature summary tables is to provide the reader with the information at one glance. Since there are multiple types of reviews (eg, systematic, integrative, scoping, critical and mixed methods) with distinct purposes and techniques, 2 there could be various approaches for developing literature summary tables making it a complex task specialty for the novice researchers or reviewers. Here, we offer five tips for authors of the review articles, relevant to all types of reviews, for creating useful and relevant literature summary tables. We also provide examples from our published reviews to illustrate how useful literature summary tables can be developed and what sort of information should be provided.

Tip 1: provide detailed information about frameworks and methods

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Tabular literature summaries from a scoping review. Source: Rasheed et al . 3

The provision of information about conceptual and theoretical frameworks and methods is useful for several reasons. First, in quantitative (reviews synthesising the results of quantitative studies) and mixed reviews (reviews synthesising the results of both qualitative and quantitative studies to address a mixed review question), it allows the readers to assess the congruence of the core findings and methods with the adapted framework and tested assumptions. In qualitative reviews (reviews synthesising results of qualitative studies), this information is beneficial for readers to recognise the underlying philosophical and paradigmatic stance of the authors of the included articles. For example, imagine the authors of an article, included in a review, used phenomenological inquiry for their research. In that case, the review authors and the readers of the review need to know what kind of (transcendental or hermeneutic) philosophical stance guided the inquiry. Review authors should, therefore, include the philosophical stance in their literature summary for the particular article. Second, information about frameworks and methods enables review authors and readers to judge the quality of the research, which allows for discerning the strengths and limitations of the article. For example, if authors of an included article intended to develop a new scale and test its psychometric properties. To achieve this aim, they used a convenience sample of 150 participants and performed exploratory (EFA) and confirmatory factor analysis (CFA) on the same sample. Such an approach would indicate a flawed methodology because EFA and CFA should not be conducted on the same sample. The review authors must include this information in their summary table. Omitting this information from a summary could lead to the inclusion of a flawed article in the review, thereby jeopardising the review’s rigour.

Tip 2: include strengths and limitations for each article

Critical appraisal of individual articles included in a review is crucial for increasing the rigour of the review. Despite using various templates for critical appraisal, authors often do not provide detailed information about each reviewed article’s strengths and limitations. Merely noting the quality score based on standardised critical appraisal templates is not adequate because the readers should be able to identify the reasons for assigning a weak or moderate rating. Many recent critical appraisal checklists (eg, Mixed Methods Appraisal Tool) discourage review authors from assigning a quality score and recommend noting the main strengths and limitations of included studies. It is also vital that methodological and conceptual limitations and strengths of the articles included in the review are provided because not all review articles include empirical research papers. Rather some review synthesises the theoretical aspects of articles. Providing information about conceptual limitations is also important for readers to judge the quality of foundations of the research. For example, if you included a mixed-methods study in the review, reporting the methodological and conceptual limitations about ‘integration’ is critical for evaluating the study’s strength. Suppose the authors only collected qualitative and quantitative data and did not state the intent and timing of integration. In that case, the strength of the study is weak. Integration only occurred at the levels of data collection. However, integration may not have occurred at the analysis, interpretation and reporting levels.

Tip 3: write conceptual contribution of each reviewed article

While reading and evaluating review papers, we have observed that many review authors only provide core results of the article included in a review and do not explain the conceptual contribution offered by the included article. We refer to conceptual contribution as a description of how the article’s key results contribute towards the development of potential codes, themes or subthemes, or emerging patterns that are reported as the review findings. For example, the authors of a review article noted that one of the research articles included in their review demonstrated the usefulness of case studies and reflective logs as strategies for fostering compassion in nursing students. The conceptual contribution of this research article could be that experiential learning is one way to teach compassion to nursing students, as supported by case studies and reflective logs. This conceptual contribution of the article should be mentioned in the literature summary table. Delineating each reviewed article’s conceptual contribution is particularly beneficial in qualitative reviews, mixed-methods reviews, and critical reviews that often focus on developing models and describing or explaining various phenomena. Figure 2 offers an example of a literature summary table. 4

Tabular literature summaries from a critical review. Source: Younas and Maddigan. 4

Tip 4: compose potential themes from each article during summary writing

While developing literature summary tables, many authors use themes or subthemes reported in the given articles as the key results of their own review. Such an approach prevents the review authors from understanding the article’s conceptual contribution, developing rigorous synthesis and drawing reasonable interpretations of results from an individual article. Ultimately, it affects the generation of novel review findings. For example, one of the articles about women’s healthcare-seeking behaviours in developing countries reported a theme ‘social-cultural determinants of health as precursors of delays’. Instead of using this theme as one of the review findings, the reviewers should read and interpret beyond the given description in an article, compare and contrast themes, findings from one article with findings and themes from another article to find similarities and differences and to understand and explain bigger picture for their readers. Therefore, while developing literature summary tables, think twice before using the predeveloped themes. Including your themes in the summary tables (see figure 1 ) demonstrates to the readers that a robust method of data extraction and synthesis has been followed.

Tip 5: create your personalised template for literature summaries

Often templates are available for data extraction and development of literature summary tables. The available templates may be in the form of a table, chart or a structured framework that extracts some essential information about every article. The commonly used information may include authors, purpose, methods, key results and quality scores. While extracting all relevant information is important, such templates should be tailored to meet the needs of the individuals’ review. For example, for a review about the effectiveness of healthcare interventions, a literature summary table must include information about the intervention, its type, content timing, duration, setting, effectiveness, negative consequences, and receivers and implementers’ experiences of its usage. Similarly, literature summary tables for articles included in a meta-synthesis must include information about the participants’ characteristics, research context and conceptual contribution of each reviewed article so as to help the reader make an informed decision about the usefulness or lack of usefulness of the individual article in the review and the whole review.

In conclusion, narrative or systematic reviews are almost always conducted as a part of any educational project (thesis or dissertation) or academic or clinical research. Literature reviews are the foundation of research on a given topic. Robust and high-quality reviews play an instrumental role in guiding research, practice and policymaking. However, the quality of reviews is also contingent on rigorous data extraction and synthesis, which require developing literature summaries. We have outlined five tips that could enhance the quality of the data extraction and synthesis process by developing useful literature summaries.

• Aromataris E ,
• Rasheed SP ,

Twitter @Ahtisham04, @parveenazamali

Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Competing interests None declared.

Patient consent for publication Not required.

Provenance and peer review Not commissioned; externally peer reviewed.

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UB nurses disseminate award-winning research at the 36th ENRS Scientific Sessions

Nursing students, faculty and staff at the 2024 ENRS conference in Boston.

Published April 5, 2024

Several students and faculty from the University at Buffalo’s School of Nursing presented research during the Eastern Nursing Research Society’s annual conference, held in Boston on April 3-5. UB representatives disseminated a range of research topics that include care access, health disparities, mental health, palliative care, oncology, and health technologies, among others.

Two UB nursing students earned awards for their research:

• Kathryn Ledwin received the 2 nd place award for PhD student posters for “Heart Failure Trends After COVID-19: A Significant Shift in Healthcare Utilization Pattern” (co-author: Sharon Hewner).
• Skylar Bard received the 3 rd place award for undergraduate student posters for "Impact of a Mobile App Mindfulness Based Stress Reduction Program on Stress and Anxiety in Underserved Communities” (co-author: Yu-Ping Chang).

Undergraduate nursing student Skylar Bard won third place for her research poster.

Poster Session Participants

• Stakeholder Perceptions of Rural Access to Prenatal Care: An Integrative Review (Stephanie Durfee; Danielle Nazarenko; Kafuli Agbemenu)
• The Association Between Mindfulness, Symptom Severity, and Depression in Adults with Pulmonary Hypertension (Cristina de Rosa; Tania Von Visger)
• Exploring Pressure Injury Risk Factors in Adult Patients with Cancer: an Integrative Review (Melissa Hiscock; Darryl Somayaji)
• The Effect of Integrating Palliative Medicine in the Intensive Care Unit on Moral Distress among Critical Care Nurses (Vidya Chan)
• Virtual, Nurse-Led, Group Brief Behavioral Therapy for Insomnia in Cancer Survivors (Kelly Foltz-Ramos)
• Development of a Family Planning Video Intervention for African Refugee Women with Low-Literacy Living in the United States (Kafuli Agbemenu; Danielle Nazarenko; Stephanie Durfee; Gloria Aidoo-Frimpong; Ariel Daniel; Gretchen Ely)
• Heart Failure Trends After COVID-19: A Significant Shift in Healthcare Utilization Patterns (Kathryn Ledwin; Sharon Hewner)
• How Disparate Organizations Adapt to Complexity While Implementing an Innovative Cross-Sector Transitional Care Intervention for Post-Acute High-Need Individuals (Jarod Gabello; Sharon Hewner)
• Impact of a Mobile App Mindfulness Based Stress Reduction Program on Stress and Anxiety in Underserved Communities (Skylar Bard; Yu-Ping Chang)
• The Relationship Between Mindfulness and Mental Health Outcomes among Adults in Low-Income and Underserved Communities During the COVID-19 Pandemic (Leann Balcerzak; Yu-Ping Chang)

Scientific Series Presentations

Older Adults

• The Moderating Effect of Dementia on Mental Health and Perceived General Health in Dyads of Older Adults and Their Family Caregivers (Cristina de Rosa; Weijun Wang, University at Buffalo, The State University of New York School of Nursing; Yu-Ping Chang, University at Buffalo School of Nursing)

Social Determinants of Health

• Predictors of Low-Value Utilization in Heart Failure Using Machine Learning: The Impact of Area Deprivation and Patient Complexity (Kathryn Ledwin, University at Buffalo & St. John Fisher University; Sabrina Casucci, University at Buffalo School of Nursing; Suzanne Sullivan, State University of New York Upstate Medical University; Sharon Hewner, University at Buffalo School of Nursing
• Factors Associated with Help-seeking among Chinese Americans Who Reported Elder Mistreatment (Ying-Yu Chao, Rutgers University; Jin Young Seo, Hunter College; Yu-Ping Chang, University at Buffalo School of Nursing)

Mobile App-Based Interventions for Mental Health and Substance Use

• Development and Evaluation of an Mindfulness-based Stress Reduction Mobile App Intervention for Underserved Communities during COVID-19 (Yu-Ping Chang, University at Buffalo School of Nursing; Cristina de Rosa; Courtney Hanny, University at Buffalo School of Nursing; Leann Balcerzak, University at Buffalo; Ashleigh Holmes, University at Buffalo School of Nursing; Tania Von Visger, State University of New York at Buffalo School of Nursing; Loralee Sessanna, University at Buffalo, School of Nursing; Christopher Barrick, University at Buffalo)
• Development of A Mobile App to Address E-Cigarette Use among Adolescents (Eunhee Park, University at Buffalo; Sushanth Grandhi, State University of New York at Buffalo; Youngran Cha, School of Nursing, University at Buffalo, SUNY; Victoria Finamore, SUNY Buffalo; Zhanpeng Jin, State University of New York at Buffalo; Yu-Ping Chang, University at Buffalo School of Nursing)
• Incorporating mindfulness-based interventions (MBIs) for symptom management using mobile-health approaches in pulmonary hypertension (Tania Von Visger, State University of New York at Buffalo School of Nursing; Bhargav Vasist, The State University of New York At Buffalo; Yanjun Zhou, University of Buffalo School of Nursing; Harman Singh, The State University of New York At Buffalo; Anant Patni, The State University of New York At Buffalo; Yu-Ping Chang, University at Buffalo School of Nursing)

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• Open access
• Published: 03 April 2024

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

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

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

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

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

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

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

Conclusions

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

Graphical Abstract

Peer Review reports

Introduction

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

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

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

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

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

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

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

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

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

Study design

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

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

Participants

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

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

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

Data collection

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

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

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

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

Data analysis

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

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

Nurses’ awareness, knowledge, attitudes and skills.

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

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

Representation of the frequency of nursing environmental behavior

Difficulty of engaging in adequate environmental behaviors

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

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

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

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

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

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

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

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

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

Sustainable environmental behaviors were emerged by Green Teams.

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

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

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

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

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

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

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

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

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

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

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

Barriers and limitations, were drawn from nurses’ responsibilities.

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

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

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

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

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

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

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

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

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

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

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

Limitations

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

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

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

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

Data availability

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

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

Article   PubMed   Google Scholar  

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

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

Article   PubMed   PubMed Central   Google Scholar  

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

Article   Google Scholar  

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

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

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

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

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

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

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

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

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

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

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

PubMed   Google Scholar  

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

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

Article   CAS   PubMed   PubMed Central   Google Scholar  

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

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

Article   CAS   PubMed   Google Scholar  

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

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

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

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

Google Scholar  

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Acknowledgements

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

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

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

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• 29 March 2024

The great rewiring: is social media really behind an epidemic of teenage mental illness?

• Candice L. Odgers 0

Candice L. Odgers is the associate dean for research and a professor of psychological science and informatics at the University of California, Irvine. She also co-leads international networks on child development for both the Canadian Institute for Advanced Research in Toronto and the Jacobs Foundation based in Zurich, Switzerland.

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Social-media platforms aren’t always social. Credit: Getty

The Anxious Generation: How the Great Rewiring of Childhood is Causing an Epidemic of Mental Illness Jonathan Haidt Allen Lane (2024)

Two things need to be said after reading The Anxious Generation . First, this book is going to sell a lot of copies, because Jonathan Haidt is telling a scary story about children’s development that many parents are primed to believe. Second, the book’s repeated suggestion that digital technologies are rewiring our children’s brains and causing an epidemic of mental illness is not supported by science. Worse, the bold proposal that social media is to blame might distract us from effectively responding to the real causes of the current mental-health crisis in young people.

Haidt asserts that the great rewiring of children’s brains has taken place by “designing a firehose of addictive content that entered through kids’ eyes and ears”. And that “by displacing physical play and in-person socializing, these companies have rewired childhood and changed human development on an almost unimaginable scale”. Such serious claims require serious evidence.

Collection: Promoting youth mental health

Haidt supplies graphs throughout the book showing that digital-technology use and adolescent mental-health problems are rising together. On the first day of the graduate statistics class I teach, I draw similar lines on a board that seem to connect two disparate phenomena, and ask the students what they think is happening. Within minutes, the students usually begin telling elaborate stories about how the two phenomena are related, even describing how one could cause the other. The plots presented throughout this book will be useful in teaching my students the fundamentals of causal inference, and how to avoid making up stories by simply looking at trend lines.

Hundreds of researchers, myself included, have searched for the kind of large effects suggested by Haidt. Our efforts have produced a mix of no, small and mixed associations. Most data are correlative. When associations over time are found, they suggest not that social-media use predicts or causes depression, but that young people who already have mental-health problems use such platforms more often or in different ways from their healthy peers 1 .

These are not just our data or my opinion. Several meta-analyses and systematic reviews converge on the same message 2 – 5 . An analysis done in 72 countries shows no consistent or measurable associations between well-being and the roll-out of social media globally 6 . Moreover, findings from the Adolescent Brain Cognitive Development study, the largest long-term study of adolescent brain development in the United States, has found no evidence of drastic changes associated with digital-technology use 7 . Haidt, a social psychologist at New York University, is a gifted storyteller, but his tale is currently one searching for evidence.

Of course, our current understanding is incomplete, and more research is always needed. As a psychologist who has studied children’s and adolescents’ mental health for the past 20 years and tracked their well-being and digital-technology use, I appreciate the frustration and desire for simple answers. As a parent of adolescents, I would also like to identify a simple source for the sadness and pain that this generation is reporting.

A complex problem

There are, unfortunately, no simple answers. The onset and development of mental disorders, such as anxiety and depression, are driven by a complex set of genetic and environmental factors. Suicide rates among people in most age groups have been increasing steadily for the past 20 years in the United States. Researchers cite access to guns, exposure to violence, structural discrimination and racism, sexism and sexual abuse, the opioid epidemic, economic hardship and social isolation as leading contributors 8 .

How social media affects teen mental health: a missing link

The current generation of adolescents was raised in the aftermath of the great recession of 2008. Haidt suggests that the resulting deprivation cannot be a factor, because unemployment has gone down. But analyses of the differential impacts of economic shocks have shown that families in the bottom 20% of the income distribution continue to experience harm 9 . In the United States, close to one in six children live below the poverty line while also growing up at the time of an opioid crisis, school shootings and increasing unrest because of racial and sexual discrimination and violence.

The good news is that more young people are talking openly about their symptoms and mental-health struggles than ever before. The bad news is that insufficient services are available to address their needs. In the United States, there is, on average, one school psychologist for every 1,119 students 10 .

Haidt’s work on emotion, culture and morality has been influential; and, in fairness, he admits that he is no specialist in clinical psychology, child development or media studies. In previous books, he has used the analogy of an elephant and its rider to argue how our gut reactions (the elephant) can drag along our rational minds (the rider). Subsequent research has shown how easy it is to pick out evidence to support our initial gut reactions to an issue. That we should question assumptions that we think are true carefully is a lesson from Haidt’s own work. Everyone used to ‘know’ that the world was flat. The falsification of previous assumptions by testing them against data can prevent us from being the rider dragged along by the elephant.

A generation in crisis

Two things can be independently true about social media. First, that there is no evidence that using these platforms is rewiring children’s brains or driving an epidemic of mental illness. Second, that considerable reforms to these platforms are required, given how much time young people spend on them. Many of Haidt’s solutions for parents, adolescents, educators and big technology firms are reasonable, including stricter content-moderation policies and requiring companies to take user age into account when designing platforms and algorithms. Others, such as age-based restrictions and bans on mobile devices, are unlikely to be effective in practice — or worse, could backfire given what we know about adolescent behaviour.

A third truth is that we have a generation in crisis and in desperate need of the best of what science and evidence-based solutions can offer. Unfortunately, our time is being spent telling stories that are unsupported by research and that do little to support young people who need, and deserve, more.

Nature 628 , 29-30 (2024)

doi: https://doi.org/10.1038/d41586-024-00902-2

Heffer, T., Good, M., Daly, O., MacDonell, E. & Willoughby, T. Clin. Psychol. Sci. 7 , 462–470 (2019).

Article   Google Scholar  

Hancock, J., Liu, S. X., Luo, M. & Mieczkowski, H. Preprint at SSRN https://doi.org/10.2139/ssrn.4053961 (2022).

Odgers, C. L. & Jensen, M. R. J. Child Psychol. Psychiatry 61 , 336–348 (2020).

Article   PubMed   Google Scholar  

Orben, A. Soc . Psychiatry Psychiatr. Epidemiol. 55 , 407–414 (2020).

Valkenburg, P. M., Meier, A. & Beyens, I. Curr. Opin. Psychol. 44 , 58–68 (2022).

Vuorre, M. & Przybylski, A. K. R. Sci. Open Sci. 10 , 221451 (2023).

Miller, J., Mills, K. L., Vuorre, M., Orben, A. & Przybylski, A. K. Cortex 169 , 290–308 (2023).

Martínez-Alés, G., Jiang, T., Keyes, K. M. & Gradus, J. L. Annu. Rev. Publ. Health 43 , 99–116 (2022).

Danziger, S. Ann. Am. Acad. Pol. Soc. Sci. 650 , 6–24 (2013).

US Department of Education. State Nonfiscal Public Elementary/Secondary Education Survey 2022–2023 (National Center for Education Statistics, 2024).

Google Scholar  

Download references

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• PMID: 30871968
• DOI: 10.1016/j.pedhc.2019.01.005

Nurse practitioners need to critically appraise the abundance of research evidence and clinical practice guidelines to make astute decisions about the implementation of the best available evidence to clinical practice. There are numerous ways to appraise research and practice guidelines that are designed to inform clinical practice with the overall goals of improving patient outcomes. This article presents existing tools to appraise the research evidence in addition to a guide for providers on critical appraisal of a research study.

Keywords: Clinical decision-making; evidence-based practice; nurse practitioners; nursing research.

Copyright © 2019 National Association of Pediatric Nurse Practitioners. Published by Elsevier Inc. All rights reserved.

• Data Interpretation, Statistical
• Decision Making
• Evidence-Based Practice
• Nurse Practitioners* / education
• Nursing Research*