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• Published: 06 August 2022

Undergraduate nursing students’ experiences of becoming a professional nurse: a longitudinal study

• Susanne Lundell Rudberg 1 , 2 ,
• Margareta Westerbotn 3 , 4 ,
• Taina Sormunen 2 ,
• Max Scheja 5 &
• Hanna Lachmann 1  

BMC Nursing volume  21 , Article number:  219 ( 2022 ) Cite this article

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During education it is essential for nursing students to develop professionalism in nursing. Nurses are placed in situations based on trust, and it is crucial that their patients have confidence in them to provide professional and safe care. A key period in nursing students’ development of a professionalism occurs during training when students gain knowledge and skills that separate nurses as professional healthcare workers from laypeople. The purpose of this study was to investigate nursing students’ experiences of professional competence development during education.

A longitudinal study was carried out using qualitative content analysis with a manifest inductive approach. Thirty-four students enrolled in a Swedish three-year nursing program, from August 2015 to January 2017 were interviewed on four occasions.

The results revealed that students’ professional role developed gradually. The students’ started their education with dreams and a naive understanding of the profession, but their understanding of the complexity of the nursing profession gradually evolved. Students became theoretically equipped at the university and developed clinical skills through practice. Students’ focus went from mastering medical technology to a more holistic approach. Before graduating, students felt ready but not fully trained.

Conclusions

Our findings indicate a discrepancy between the content of the theoretical education and the clinical settings since students identified a lack of evidence-based practice. A solid theoretical education before entering clinical training offered students possibilities for reflecting on evidence-based practice and the clinical settings. The realization that there is always potential for professional improvement can be interpreted as an emerging awareness, and development of professionalism. It is clear that students could benefit from increased collaborative work between clinical supervisors and faculty staff at the university.

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It is essential to maintain professionalism in the nursing profession [ 1 ]. Nurses are placed in situations based on trust, and it is crucial that the persons depending on these professionals have confidence in them to provide professional and safe care [ 1 ]. A key period in nursing students’ development of a professionalism occurs during training when they gain knowledge and skills that separate nurses as professional healthcare workers from laypeople [ 2 ]. However, there is limited theoretical knowledge of the aspects that constitute and drive the development of nursing students’ professional competence.

Professionalism and competence

The term ‘professionalism’ is used globally to describe professions with a nonspecific focus. There is no simple, generalizable definition of the multidimensional concept of professionalism, or a simple way of assessing it [ 3 ]. When applied to nursing, professionalism is associated with behaviors such as a belief in public service, autonomy and self-regulation, and a sense of vocation [ 1 ]. So the concept of professionalism is complex and maintaining professionalism is essential in the nursing profession [ 3 ]. Apart from being time specific and related to specific contexts, nursing students’ competencies, domains and levels vary by professional assignment, description, and country [ 4 ]. The governance of nursing education varies globally, and is controlled by national regulations [ 5 ]. It has become common to use a holistic view in defining nurse competencies, including behavior statements reflecting the skills, knowledge, attitudes, and judgments required for effective performance in the nursing profession [ 6 , 7 ]. Professionalism in healthcare is associated with a wide range of benefits, for example staff displaying higher levels of professional attitudes also seem to behave more professionally [ 8 ], and increased safety for patients [ 9 ]. To integrate quality into nursing education a framework has been developed comprising six nurse core competencies; person-centered care, evidence-based practice, teamwork and collaboration, safety, quality improvement and informatics [ 10 ].

Nursing students’ journey towards professionalism

Dr Benner describes the concept of professional development in the nursing profession as evolving from novice to expert in five stages: novice, advanced beginner, competent proficient and expert [ 11 ]. In health care, the learning process, and also the socialization to develop a professional identity, have often meant adopting standards and norms of the professional group [ 12 , 13 ]. Nursing students are socialized towards professionalism during training, being required to integrate the attributes of professionalism in their routine practice [ 1 ]. Students are motivated to learn when they feel included in the clinical environment, while experiences of exclusion and lack of belonging influences negatively on motivation to learn [ 14 ]. Deliktas et al. [ 15 ] found that undergraduate nursing students’ approach to the nursing profession is associated with humanism, also identified as conscience, coupled with an ambition to touch people’s lives. It requires great effort from the students together with substantial support from teachers and supervisors to develop a comfortable professional identity upon graduation [ 16 ]. Students’ journey to becoming an RN has been investigated previously [ 17 , 18 , 19 , 20 ]. However, longitudinal studies of students’ experiences of professional development throughout the whole education are scarce.

The present study aimed at investigating nursing students’ experiences of professional competence development during education.

This study applied a descriptive longitudinal design involving qualitative content analysis with a manifest inductive approach.

Settings and participants

Thirty-four students enrolled in a Swedish three-year nursing program, starting from August 2015 to January 2017, were followed longitudinally. The group comprised 28 women and six men, a distribution coherent with national statistics of students in health care in HE [ 21 ]. In respect of age, students ranged from 20 to 51 on enrolment. Fourteen students had previously attended HE, and ten had completed a university degree in another subject. Twelve reported living in a single household and eight had children of their own, whilst ten students shared a household with up to three children.

Data collection

A purpose sampling technique was used. During the first week of education, all students enrolled were invited to participate. Information about the purpose of the study was given orally after an introductory lecture and in writing on the university’s learning platform. Students were also informed about whom to contact if they had questions prior to the interviews. Students who signed a written informed consent were invited on four occasions (Fig.  1 ) to individual, semi-structured interviews carried out in an undisturbed conference room at the university. A total of thirty-four students participated in all interviews. A semistructured interview guide was designed to capture students’ ongoing professional development, including questions about their views of nurse core competencies at interviews two, three and four, ( supplementary file ). All four interviews were carried out by the first author and lasted five to 40 min. The interviews were audio recorded and transcribed verbatim [ 22 , 23 ].

Overview of methods including generic categories, main categories, and overarching themes

The study was approved by the Regional Ethical Review Board, Stockholm (Registration no: 2015/894–31/5).

Data analysis

The interview transcripts were read several times making sense of the data as whole [ 24 ] and then analyzed using qualitative content analysis with a manifest inductive approach [ 25 , 26 ]. Data were divided into four chronological data sets, interviews 1–4. Each dataset was read again when conducting open coding, using NVivo software [ 27 ]. Identified codes were grouped into sub-categories labelled with a phrase that described the meaning content. Sub-categories were grouped by contextual meaning resulting in 19 generic categories. From this categorization, an abstraction was derived describing one main category of students’ experiences from each interview [ 28 ], Fig.  1 .

Individual patterns were analyzed to identify and validate shared patterns [ 29 ], Table 1 .

Finally, an overarching main theme of professional development was abstracted from the main categories and shared patterns, Table 2 . To ensure trustworthiness data was discussed among the authors in every step of the analysis until consensus was reached [ 22 ]

One main category was created from interviews performed at the same semester. Results are presented as four main categories: ‘Anticipation’; ‘Prepared for internship’; ‘Deepened understanding; ‘Insight’ with associated generic themes, summarized in the overarching theme: ‘Ready but not fully trained’, Fig.  1 .

Anticipation

In the first interview students expressed their conceptions, expectations and doubts regarding both education and the nursing profession.

Make a difference

Students voiced a desire to make a difference, to contribute to society, change structures, and help people. They also voiced expectations of receiving tools to deal with real-life problems and change the world for the better. For some students, this desire to make a difference had meant choosing to end a prosperous career in another field.

“I have expectations that you should be able to contribute something every day, to feel needed and important, an important cog in the wheel” (Student no 30).

Students also emphasized they were proud to become nurses and the profession was perceived depicted as incorporating aspects of emotionally rewarding personal development. Employment security was also underscored expressing beliefs that there will always be a need for RNs to help the sick and injured.

“I am going to have an occupation I’m proud of, when people ask what I do for a living I want to say that I am a nurse and it is the best job in the entire world, that is the strongest anticipation” (Student no 31).

Self-confidence

The students presented a picture of being aware of their own strengths and weaknesses, and expressed a belief in their personal capacity, looking forward to the challenges to come. Students explained the decision to become an RN saying that they had been told they had a suitable personality, but they underscored that the final decision had been their own. Some mentioned having a childhood dream of becoming an RN.

“Many have told me; you should become a nurse, but it was I who made this decision, because I did not want to become a nurse for a long time because I didn´t want to study” (Student no 1).

Doubts were identified in three areas: one´s true nature, life situation, and the nursing profession. Concerns of trying out if RN would be an appropriate occupation, being incapable, coming to dislike the profession or regretting having started the program were linked to ideas about self-awareness and personality. Responsibilities to significant others were mentioned as a potential obstacle in coping with the education. Doubts about the profession concerned poor working conditions including an overwhelming workload, becoming stuck in the middle and not being appreciated.

“That I shall never be able to relax but will always be sitting in the wrong chair all the time, and to have to struggle financially, no salary, will I be able to take extra shifts or not, yes worries, and if I should feel it isn´t my cup of tea too, it would be sad if I had put a lot of effort into the education” (Student no 31).

Prepared for internship

In the second interview after two semesters in theoretical education students were about to put their theoretical knowledge into practical skills.

Theoretically equipped

Students expressed a belief in their own progress and having learned a lot, feeling theoretically prepared for internship. However, this experience of being successful in their studies was not particularly influenced by failing exams or not passing a course.

“A lot of theoretical knowledge that I think is still present even if you forget a little here and there, I think it is in the back of your head somewhere, and anyway, still you don’t feel that you’re thrown in at the deep end, now you get to learn to swim, but you still have some knowledge, that you hopefully will be able to try” (Student no 11).

Need experience

The transition of knowledge from abstract to concrete was expressed as a longing to develop clinical skills. Consequently, the desire for internship was regarded as a long-awaited opportunity to develop practical experience.

“I’m just looking forward more and more to internship and to see how it is for real and so on, because sometimes you want to be able to see if it is as good as you read in the books” (Student no 20).

Professional approach

Students testified to the experience of having changed their outlook on their personal life and of being able to act professionally when needed. They felt more competent having acquired more knowledge. Students talked about an increased interest in searching for evidence-based practice in daily life and compared this with how they used to do things because they had heard or read about it somewhere. They described this in terms of a change in mindset, being more thorough when it came to searching for information.

“I have learned the difference between just being nice and being too much sugar and spice with the risk of being condescending, just think of small things such as saying that, like not to say, come on, let’s go and shower, because it may not actually be the way to talk to someone, it becomes a little statement of stupidity, sweetie or love or whatever, so I think my communication has probably improved, and I think I have a slightly more humble attitude than before” (Student no 3).

Trust in educators

A trust in educators emerged in this interview, expressed by expectations about being taught what they need to become an RN. Additionally, sometimes the understanding and relevance of topics brought to the fore in the teaching did not occur until after having completed a course; during the course the aims and structure sometimes came across as unclear and ambiguous. Students expressed taking for granted that all the topics taught built on evidence-based practice.

“It’s hard to say because I have not practiced it, I feel that we get the tools at university that equip us to think safely” (Student no 8).

Insecurity was brought up by students in terms of lacking knowledge, competence, or ability. The fear of making mistakes and harming a patient was one of the students’ worst fears. Feelings of underperforming were mentioned and often related to personal issues. When talking about pressures felt in relation to studying, students mentioned that they had themselves to blame, for example because of poor planning or prioritizing other things besides studying.

“The thought of internship makes me incredibly nervous, but also very excited so there are conflicting emotions… it is nerve-racking in both directions, but I hope that you feel safe then with all the theory that we have received, we have gained a very solid knowledge so that’s not what I’m unsure of, it’s rather my own competence to take in everything I’m a little unsure of” (Student no 23).

Fairy-tale world

Since students were about to embark on their clinical practice, issues about this reality were highlighted. There was a preconception of what to expect, combined with thoughts of being taught about a fairy tale world. Even so, the pre-understanding of how things worked was considered valuable. Additionally, an awareness of being underpaid as an RN was raised, but this was overruled by the prospect of receiving emotional rewards in the profession.

“These things are repeated all the time, but you never get the chance to discuss what reality looks like, and what do I do if it doesn´t look like this, because it doesn´t, so it becomes very much like what the fairy tale world looks like, and we hope reality looks like that too “ (Student no 5).

Deepened understanding

The third interview took place halfway through the program when all students had attended internship. The internship was described as an opportunity to transfer theoretical knowledge to practical skills. Students particularly testified to experiences involving broadened knowledge of the nursing profession, nurse core competencies and the health-care organization.

Constant process

Development at this stage was experienced as challenging. Learning was described as a personal responsibility, although students also stressed the importance of being able to observe supervisors as good role models.

“It is a constant learning process, searching for knowledge, you should always question why do we do this, there should be evidence… we develop all the time” (Student no 26).

Contrariwise learning

Students described examples of supervision settings in which the tutor did not follow guidelines or failed to uphold patient safety. Students dealt with such ‘negative learning experiences’ by setting personal objectives not to act as these tutors. Students underscored that those experiences of negative examples could potentially be more beneficial given opportunities to reflect on these together with a peer.

“It is very educational to be out and see both good and bad examples because then you see how you absolutely don´t want to work and how you don´t want to become and what you don´t think is okay” (Student no 16).

Want to influence

When talking about negative matters in health care, students highlighted their visions of making influence. Students talked about the ability to act professionally during internship, something that became complicated when supervisors took shortcuts or skipped guidelines. Sometimes this led to a complex change in mindset about the professional role as students did not want to question the supervisors openly.

“Sometimes it has also been like this:’You see that I have gloves on me, ok’, although they don´t have gloves,’for educational purposes I have gloves, you know now, okay’.“ (Student no 25).

Reality shock

Some clinical placements were described as being charged with a negative atmosphere including staff who acted negligently or carelessly. It was concluded that the nurse core competencies were an excellent theoretical model, but some of them were regarded impossible to maintain. For example, students’ estimations of patients’ safety in clinics ranged from dangerous to secure. An unsafe environment was explained as a consequence of exhausted staff and lack of time. Students were annoyed with the amount of documentation and non-appropriate software, stealing time from patient care. Instances of hierarchical thinking were mentioned as a minor problem, primarily experienced in meetings with employees close to retirement age.

“You want so incredibly much, and you have your high ambition when you go out [in the clinic] and so, and then there is no time or something, it was kind of quite scary to come out and see how it actually is in reality” (Student no 10).

Learning practical skills was described as exhausting since trained staff offered diverse methods, sometimes lacking in evidence. Students also voiced problems identifying ‘the correct way’ to perform medical technical. Additionally, students did not want to oppose their supervisors but rather sought their guidance and support.

“It was tough to have such a long internship, it was absolutely dreadful … and then you are new and should be so damn alert… because it is our own responsibility, our own learning of course, you want so much… I was actually completely exhausted” (Student no 33).

In the fourth interview, the students were aware that their education was coming to an end, and they were about to leave the student role. Students highlighted that even if they felt prepared to work as RN:s, they did not consider themselves fully trained.

Feeling prepared

Students expressed having learnt the professional role, being equipped, and having trust in their own competence and ability. Competence was referred to as a personal capacity, including both professional skills and abilities. Students also testified to having an insight into the necessary knowledge of an RN and expressed gratitude to persistent lecturers pushing them to learn things they initially did not understand.

“From not really knowing what I got myself into, to knowing I have an ethical compass, and I can question certain actions or prescriptions that I am not sure about, that I wish the patient well, that I can see it” (Student no 27).

Influences of reality

Students reflected on poor terms of employment, mentioning issues of low salary, lack of time and poor working environments. These concerns were strengthened by internship experiences of working alongside tired staff or those only waiting for retirement. Students also reflected on societal values that have a negative impact on RNs, for example increased ethnocentrism, and an overall hardening climate. Moreover, students voiced fears of becoming bored and not caring about their work, linking back to encounters with tired and overworked nurses at the clinic.

“I saw staff who didn´t have time to eat lunch and such, it may not be a major part of the profession itself but more healthcare in general and that is probably what I have thought about a lot, will it be like that when I finish and have to work for well, thirty more years” (Student no 13).

Exciting and scary

Despite describing a conviction of being able to work as an RN, emotions of insecurity were voiced in terms of an unknown future regarding both graduation and being employed. Worries about ending up in a non-functional workplace were voiced as well as the importance and purpose of collaboration. Having observed teams of varying functionality students also talked about the importance of belonging to a purposeful team. To take on a leading role of an interprofessional team was considered to be both exiting and scary. Additionally, students underscored the advantage of participating in an introductory program when applying for employment, along with a strategy to change workplace if they felt dissatisfied.

“It feels scary at the same time as it feels really fun and fine to finally finish, I aim for advanced studies eventually, but I want to work to feel a bit more confident” (Student no 8).

Personal development

Students reported an increased level of personal awareness in terms of having developed humility and ability to identify their own shortcomings. Reflections on supervisors working against regulations due to lack of time or laziness, led to reasoning about the risk of ending up the same way, not taking care of patients in an evidence-based and secure way. Another opinion was that the education offered too little time to develop the ability to handle future professional challenges.

“I have gained a lot of knowledge, but also that you grow a lot as a person and as a human, in what you do you learn a lot about yourself “ (Student no 24).

Overarching theme: ready but not fully trained

The interviews revealed emotions of being competent but also of lacking knowledge and skills; students considered that continued learning and development was necessary to work as a professional RN. The students pointed out that they would give up working as an RN if they felt there was no need for further learning, because there will always be room for improvement, leading to the overarching theme; Ready but not fully trained as students explained that the nursing profession implies lifelong learning and lifelong improvement.

Findings from this study describe students perceived gradual transformation of becoming a professional RN. In particular our findings indicate that students entering higher education sometimes have a naive or idealized view of the nursing profession, driven by dreams such as helping people, developing a career and delivering excellent nursing, as found by ten Hoeve et al. [ 30 ]. Similar to Lindberg et al. [ 31 ] we found that today’s entrants to nursing education believe in themselves and their ability to make an impact.

During the first year students were primarily focused on acquiring theoretical knowledge to develop a solid basis. After having completed a year of theoretical education, they felt prepared to test their theoretical knowledge in practice. Moreover, due to the first theoretical year, students’ self-esteem had increased even if they were not always aware of their progress until they had had time to reflect and look back. Their own professional development became tangible when they started to compare their current skills and competence with the experiences they had at the outset of education, a “delayed” professional understanding. Our findings advance earlier work on delayed understanding that refers to a situation in which students taking a particular course have difficulty understanding topics introduced in the teaching, and why particular things should be learned [ 32 ]. Later on, they do see the point of taking the course, but this understanding can sometimes be substantially delayed, which may cause some students to experience considerable frustration.

When entering clinical practice students are theoretically equipped, but most students lack practical experience, they are on a Novice level [ 11 ]. In the second year, after practicing their skills in clinical environments, students described how theory and practice were joined to become a whole. Our study indicate that the students’ expectations constituted motivation for theoretical studies, which in turn provided readiness for practical training with the support of acquired theoretical knowledge. The experiential learning in clinic seems to give the students possibility to enter the level of Advanced beginner [ 11 ].

The clinical environment was sometimes a rough wake-up call when students’ experiences did not quite meet their dreams and expectations, previously described by ten Hoeve et al. [ 30 ]. Even so, this study revealed that students testified to experiences of having been able to train according to guidelines, although the staff worked according to routines without practicing person-centered care. Students’ professional development became obvious when they reflected on, and assessed, the behaviors and actions of the clinical staff. Interestingly, students used the experience of meeting supervisors lacking in professional competency as “bad examples” which led to a personal goal not to act in a similar way. From these observations it is clear that learning occurs in all areas, also when there are discrepancies and gaps [ 33 ]. Despite the negative experiences of students, our findings suggest that students did mature as human beings, identifying changes in their own behavioral patterns, indicating they were involved in a transformative learning process [ 34 ]. Gaining experience from both work and personal life seemed to be beneficial to professional development. Furthermore, during the clinical education, students deepened their understanding through experiential learning and at the time of graduation, the students had developed a professional insight. Benner describes that newly graduated nurses are mostly Advanced beginners [ 11 ], but our results suggests that many students have reached the level Competent.

Students professional development became visible in how they transformed their understanding of the six core competencies: person-centered care, evidence-based practice, teamwork and collaboration, safety, quality improvement and informatics [ 10 ]. In the early interviews, students spontaneously ranked the importance of each competency, some considered more essential and others less significant. At the end of the program students described a pattern of connection between all core competencies, implying that if one was missing it would be to the detriment of the others. Students’ ability to connect the core competencies as parts forming a coherent whole revealed their understanding of the complexity of the nursing profession as described by Guaroni et al. and Lindberg et al. [ 31 , 35 ]. Similar to findings reported by Manninen et al. [ 36 ] our results showed students’ focus on professional development shifting from managing medical-technical skills to the capability of using a person-centered and holistic perspective when interacting with patients. Our findings of students’ ability to overview the context and achieve a holistic understanding of the core competencies reveals a clear progression in their professional development. The findings presented here indicate that students experience insecurity at the end of their education as they realize they have to master nursing care as well as be able to co-ordinate the professional team, an observation which has previously been reported by Lindberg et al. [ 31 ]. These dichotomous emotions of excitement and fear at time of graduation could be connected to the fact that the biggest step from being a student to a professional RN involves taking independent responsibility as shown by Kumaran and Carneys [ 37 ]. Additionally, students’ observation that an RN always needs further development clearly indicate that the interviewees reflected on their own professional competence as well as nursing competence in general. This is an important reminder for employers and managers to sanction time for staff professional development activities.

Strengths and limitations

This study offered longitudinal insights into a sample of 34 students followed throughout their education. Different measures were taken to enhance trustworthiness including dependability and credibility [ 23 ]. All students who had entered the nursing program, regardless of previous experiences, were invited to participate. The same interview guide was used on each occasion although students started their studies at different times. All interviews were carried out by the first author, who had a pre-understanding working as a lecturer at the university. To reduce impact on students’ participation no interviews were performed in the semester when the first author graded the students. The interviews took place at one specific university and these contextual boundaries need to be taken into consideration in assessing the transferability of the results to other contexts. However, the Swedish nursing program is regulated by national guidelines, likewise to nursing education globally which suggests that these findings may be of relevance to programs of a similar kind. The findings presented here make important connections the more general concept of authenticity and Benner´s [ 11 ] nursing theory and Mezirows theory of transformative learning [ 34 ] which may potentially enhance the generalizability of the results.

The process of developing a professional competence as a nurse progresses gradually. Upon graduation, students feel ready but not fully trained, which signifies a professional approach in which an RN can always improve academic and clinical skills. A solid theoretical knowledge contributes to students reflecting on both their own role and the nurse’s role in clinical settings. Our findings indicate a discrepancy between the content of the theoretical education and the clinical settings since students identified a lack of evidence-based practice. It is clear that students could benefit from increased collaborative work between clinical supervisors and faculty staff at the university.

Availability of data and materials

The datasets generated and/or analyzed during the current study are not publicly available due to that the material may contain details about participants that might need to be anonymized but are available from the corresponding author on reasonable request.

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Acknowledgements

We thank the students for giving their time and valuable information.

Open access funding provided by Karolinska Institute. Supported by grants provided by the Stockholm County Council (ALF-project) and the Sophiahemmet Research Foundation, Sweden.

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Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, 171 77, Stockholm, Sweden

Susanne Lundell Rudberg & Hanna Lachmann

Department of Health Promoting Science, Sophiahemmet University, P. O. Box 5605, 114 86, Stockholm, Sweden

Susanne Lundell Rudberg & Taina Sormunen

Department of Nursing Science, Sophiahemmet University, P. O. Box 5605, 114 86, Stockholm, Sweden

Margareta Westerbotn

Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, 118 83, Stockholm, Sweden

Department of Education of Stockholm University, 106 91, Stockholm, Sweden

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Contributions

HL designed the study. SLR performed interviews and analyses. SLR, HL, TS, MW and MS drafted and revised the manuscript. All authors read and approved the manuscript.

Corresponding author

Correspondence to Susanne Lundell Rudberg .

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Lundell Rudberg, S., Westerbotn, M., Sormunen, T. et al. Undergraduate nursing students’ experiences of becoming a professional nurse: a longitudinal study. BMC Nurs 21 , 219 (2022). https://doi.org/10.1186/s12912-022-01002-0

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Interventions, methods and outcome measures used in teaching evidence-based practice to healthcare students: an overview of systematic reviews

• Lea D. Nielsen 1 ,
• Mette M. Løwe 2 ,
• Francisco Mansilla 3 ,
• Rene B. Jørgensen 4 ,
• Asviny Ramachandran 5 ,
• Bodil B. Noe 6 &
• Heidi K. Egebæk 7  

BMC Medical Education volume  24 , Article number:  306 ( 2024 ) Cite this article

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To fully implement the internationally acknowledged requirements for teaching in evidence-based practice, and support the student’s development of core competencies in evidence-based practice, educators at professional bachelor degree programs in healthcare need a systematic overview of evidence-based teaching and learning interventions. The purpose of this overview of systematic reviews was to summarize and synthesize the current evidence from systematic reviews on educational interventions being used by educators to teach evidence-based practice to professional bachelor-degree healthcare students and to identify the evidence-based practice-related learning outcomes used.

An overview of systematic reviews. Four databases (PubMed/Medline, CINAHL, ERIC and the Cochrane library) were searched from May 2013 to January 25th, 2024. Additional sources were checked for unpublished or ongoing systematic reviews. Eligibility criteria included systematic reviews of studies among undergraduate nursing, physiotherapist, occupational therapist, midwife, nutrition and health, and biomedical laboratory science students, evaluating educational interventions aimed at teaching evidence-based practice in classroom or clinical practice setting, or a combination. Two authors independently performed initial eligibility screening of title/abstracts. Four authors independently performed full-text screening and assessed the quality of selected systematic reviews using standardized instruments. Data was extracted and synthesized using a narrative approach.

A total of 524 references were retrieved, and 6 systematic reviews (with a total of 39 primary studies) were included. Overlap between the systematic reviews was minimal. All the systematic reviews were of low methodological quality. Synthesis and analysis revealed a variety of teaching modalities and approaches. The outcomes were to some extent assessed in accordance with the Sicily group`s categories; “skills”, “attitude” and “knowledge”. Whereas “behaviors”, “reaction to educational experience”, “self-efficacy” and “benefits for the patient” were rarely used.

Conclusions

Teaching evidence-based practice is widely used in undergraduate healthcare students and a variety of interventions are used and recognized. Not all categories of outcomes suggested by the Sicily group are used to evaluate outcomes of evidence-based practice teaching. There is a need for studies measuring the effect on outcomes in all the Sicily group categories, to enhance sustainability and transition of evidence-based practice competencies to the context of healthcare practice.

Peer Review reports

Evidence-based practice (EBP) enhances the quality of healthcare, reduces the cost, improves patient outcomes, empowers clinicians, and is recognized as a problem-solving approach [ 1 ] that integrates the best available evidence with clinical expertise and patient preferences and values [ 2 ]. A recent scoping review of EBP and patient outcomes indicates that EBPs improve patient outcomes and yield a positive return of investment for hospitals and healthcare systems. The top outcomes measured were length of stay, mortality, patient compliance/adherence, readmissions, pneumonia and other infections, falls, morbidity, patient satisfaction, patient anxiety/ depression, patient complications and pain. The authors conclude that healthcare professionals have a professional and ethical responsibility to provide expert care which requires an evidence-based approach. Furthermore, educators must become competent in EBP methodology [ 3 ].

According to the Sicily statement group, teaching and practicing EBP requires a 5-step approach: 1) pose an answerable clinical question (Ask), 2) search and retrieve relevant evidence (Search), 3) critically appraise the evidence for validity and clinical importance (Appraise), 4) applicate the results in practice by integrating the evidence with clinical expertise, patient preferences and values to make a clinical decision (Integrate), and 5) evaluate the change or outcome (Evaluate /Assess) [ 4 , 5 ]. Thus, according to the World Health Organization, educators, e.g., within undergraduate healthcare education, play a vital role by “integrating evidence-based teaching and learning processes, and helping learners interpret and apply evidence in their clinical learning experiences” [ 6 ].

A scoping review by Larsen et al. of 81 studies on interventions for teaching EBP within Professional bachelor-degree healthcare programs (PBHP) (in English undergraduate/ bachelor) shows that the majority of EBP teaching interventions include the first four steps, but the fifth step “evaluate/assess” is less often applied [ 5 ]. PBHP include bachelor-degree programs characterized by combined theoretical education and clinical training within nursing, physiotherapy, occupational therapy, radiography, and biomedical laboratory students., Furthermore, an overview of systematic reviews focusing on practicing healthcare professionals EBP competencies testifies that although graduates may have moderate to high level of self-reported EBP knowledge, skills, attitudes, and beliefs, this does not translate into their subsequent EBP implementation [ 7 ]. Although this cannot be seen as direct evidence of inadequate EBP teaching during undergraduate education, it is irrefutable that insufficient EBP competencies among clinicians across healthcare disciplines impedes their efforts to attain highest care quality and improved patient outcomes in clinical practice after graduation.

Research shows that teaching about EBP includes different types of modalities. An overview of systematic reviews, published by Young et al. in 2014 [ 8 ] and updated by Bala et al. in 2021 [ 9 ], synthesizes the effects of EBP teaching interventions including under- and post graduate health care professionals, the majority being medical students. They find that multifaceted interventions with a combination of lectures, computer lab sessions, small group discussion, journal clubs, use of current clinical issues, portfolios and assignments lead to improvement in students’ EBP knowledge, skills, attitudes, and behaviors compared to single interventions or no interventions [ 8 , 9 ]. Larsen et al. find that within PBHP, collaboration with clinical practice is the second most frequently used intervention for teaching EBP and most often involves four or all five steps of the EBP teaching approach [ 5 ]. The use of clinically integrated teaching in EBP is only sparsely identified in the overviews by Young et al. and Bala et al. [ 8 , 9 ]. Therefore, the evidence obtained within Bachelor of Medicine which is a theoretical education [ 10 ], may not be directly transferable for use in PBHP which combines theoretical and mandatory clinical education [ 11 ].

Since the overview by Young et al. [ 8 ], several reviews of interventions for teaching EBP used within PBHP have been published [ 5 , 12 , 13 , 14 ].

We therefore wanted to explore the newest evidence for teaching EBP focusing on PBHP as these programs are characterized by a large proportion of clinical teaching. These healthcare professions are certified through a PBHP at a level corresponding to a University Bachelor Degree, but with strong focus on professional practice by combining theoretical studies with mandatory clinical teaching. In Denmark, almost half of PBHP take place in clinical practice. These applied science programs qualify “the students to independently analyze, evaluate and reflect on problems in order to carry out practice-based, complex, and development-oriented job functions" [ 11 ]. Thus, both the purpose of these PBHP and the amount of clinical practice included in the educations contrast with for example medicine.

Thus, this overview, identifies the newest evidence for teaching EBP specifically within PBHP and by including reviews using quantitative and/or qualitative methods.

We believe that such an overview is important knowledge for educators to be able to take the EBP teaching for healthcare professions to a higher level. Also reviewing and describing EBP-related learning outcomes, categorizing them according to the seven assessment categories developed by the Sicily group [ 2 ], will be useful knowledge to educators in healthcare professions. These seven assessment categories for EBP learning including: Reaction to the educational experience, attitudes, self-efficacy, knowledge, skills, behaviors and benefits to patients, can be linked to the five-step EBP approach. E.g., reactions to the educational experience: did the educators teaching style enhance learners’ enthusiasm for asking questions? (Ask), self-efficacy: how well do learners think they critically appraise evidence? (Appraise), skills: can learners come to a reasonable interpretation of how to apply the evidence? (Integrate) [ 2 ]. Thus, this set of categories can be seen as a basic set of EBP-related learning outcomes to classify the impact from EBP educational interventions.

Purpose and review questions

A systematic overview of which evidence-based teaching interventions and which EBP-related learning outcomes that are used will give teachers access to important knowledge on what to implement and how to evaluate EBP teaching.

Thus, the purpose of this overview is to synthesize the latest evidence from systematic reviews about EBP teaching interventions in PBHP. This overview adds to the existing evidence by focusing on systematic reviews that a) include qualitative and/ or quantitative studies regardless of design, b) are conducted among PBHP within nursing, physiotherapy, occupational therapy, midwifery, nutrition and health and biomedical laboratory science, and c) incorporate the Sicily group's 5-step approach and seven assessment categories when analyzing the EBP teaching interventions and EBP-related learning outcomes.

The questions of this overview of systematic reviews are:

Which educational interventions are described and used by educators to teach EBP to Professional Bachelor-degree healthcare students?

What EBP-related learning outcomes have been used to evaluate teaching interventions?

The study protocol was guided by the Cochrane Handbook on Overviews of Reviews [ 15 ] and the review process was reported in accordance with The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement [ 16 ] when this was consistent with the Cochrane Handbook.

Inclusion criteria

Eligible reviews fulfilled the inclusion criteria for publication type, population, intervention, and context (see Table  1 ). Failing a single inclusion criterion implied exclusion.

Search strategy

On January 25th 2024 a systematic search was conducted in; PubMed/Medline, CINAHL (EBSCOhost), ERIC (EBSCOhost) and the Cochrane library from May 2013 to January 25th, 2024 to identify systematic reviews published after the overview by Young et al. [ 8 ]. In collaboration with a research librarian, a search strategy of controlled vocabulary and free text terms related to systematic reviews, the student population, teaching interventions, teaching context, and evidence-based practice was developed (see Additional file 1 ). For each database, the search strategy was peer reviewed, revised, modified and subsequently pilot tested. No language restrictions were imposed.

To identify further eligible reviews, the following methods were used: Setting email alerts from the databases to provide weekly updates on new publications; backward and forward citation searching based on the included reviews by screening of reference lists and using the “cited by” and “similar results” function in PubMed and CINAHL; broad searching in Google Scholar (Advanced search), Prospero, JBI Evidence Synthesis and the OPEN Grey database; contacting experts in the field via email to first authors of included reviews, and by making queries via Twitter and Research Gate on any information on unpublished or ongoing reviews of relevance.

Selection and quality appraisal process

Database search results were merged, duplicate records were removed, and title/abstract were initially screened via Covidence [ 17 ]. The assessment process was pilot tested by four authors independently assessing eligibility and methodological quality of one potential review followed by joint discussion to reach a common understanding of the criteria used. Two authors independently screened each title/abstract for compliance with the predefined eligibility criteria. Disagreements were resolved by a third author. Four authors were paired for full text screening, and each pair assessed independently 50% of the potentially relevant reviews for eligibility and methodological quality.

For quality appraisal, two independent authors used the AMSTAR-2 (A MeaSurement Tool to Assess systematic Reviews) for reviews including intervention studies [ 18 ] and the Joanna Briggs Institute Checklist for systematic reviews and research Synthesis (JBI checklist) [ 19 ] for reviews including both quantitative and qualitative or only qualitative studies. Uncertainties in assessments were resolved by requesting clarifying information from first authors of reviews and/or discussion with co-author to the present overview.

Overall methodological quality for included reviews was assessed using the overall confidence criteria of AMSTAR 2 based on scorings in seven critical domains [ 18 ] appraised as high (none or one non-critical flaw), moderate (more than one non-critical flaw), low (one critical weakness) or critically low (more than one critical weakness) [ 18 ]. For systematic reviews of qualitative studies [ 13 , 20 , 21 ] the critical domains of the AMSTAR 2, not specified in the JBI checklist, were added.

Data extraction and synthesis process

Data were initially extracted by the first author, confirmed or rejected by the last author and finally discussed with the whole author group until consensus was reached.

Data extraction included 1) Information about the search and selection process according to the PRISMA statement [ 16 , 22 ], 2) Characteristics of the systematic reviews inspired by a standard in the Cochrane Handbook (15), 3) A citation index inspired by Young et al. [ 8 ] used to illustrate overlap of primary studies in the included systematic reviews, and to ensure that data from each primary study were extracted only once [ 15 ], 4) Data on EBP teaching interventions and EBP-related outcomes. These data were extracted, reformatted (categorized inductively into two categories: “Collaboration interventions” and “  Educational interventions ”) and presented as narrative summaries [ 15 ]. Data on outcome were categorized according to the seven assessment categories, defined by the Sicily group, to classify the impact from EBP educational interventions: Reaction to the educational experience, attitudes, self-efficacy, knowledge, skills, behaviors and benefits to patients [ 2 ]. When information under points 3 and 4 was missing, data from the abstracts of the primary study articles were reviewed.

Results of the search

The database search yielded 691 references after duplicates were removed. Title and abstract screening deemed 525 references irrelevant. Searching via other methods yielded two additional references. Out of 28 study reports assessed for eligibility 22 were excluded, leaving a total of six systematic reviews. Screening resulted in 100% agreement among the authors. Figure  1 details the search and selection process. Reviews that might seem relevant but did not meet the eligibility criteria [ 15 ], are listed in Additional file 2 . One protocol for a potentially relevant review was identified as ongoing [ 23 ].

PRISMA flow diagram on search and selection of systematic reviews

Characteristics of included systematic reviews and overlap between them

The six systematic reviews originated from the Middle East, Asia, North America, Europe, Scandinavia, and Australia. Two out of six reviews did not identify themselves as systematic reviews but did fulfill this eligibility criteria [ 12 , 20 ]. All six represented a total of 64 primary studies and a total population of 6649 students (see Table  2 ). However, five of the six systematic reviews contained a total of 17 primary studies not eligible to our overview focus (e.g., postgraduate students) (see Additional file 3 ). Results from these primary studies were not extracted. Of the remaining primary studies, six were included in two, and one was included in three systematic reviews. Data from these studies were extracted only once to avoid double-counting. Thus, the six systematic reviews represented a total of 39 primary studies and a total population of 3394 students. Nursing students represented 3280 of these. One sample of 58 nutrition and health students and one sample of 56 mixed nursing and midwife students were included but none from physiotherapy, occupational therapy, or biomedical laboratory scientists. The majority ( n  = 28) of the 39 primary studies had a quantitative design whereof 18 were quasi-experimental (see Additional file 4 ).

Quality of systematic review

All the included systematic reviews were assessed as having critically low quality with 100% concordance between the two designed authors (see Fig.  2 ) [ 18 ]. The main reasons for the low quality of the reviews were a) not demonstrating a registered protocol prior to the review [ 13 , 20 , 24 , 25 ], b) not providing a list of excluded studies with justification for exclusion [ 12 , 13 , 21 , 24 , 25 ] and c) not accounting for the quality of the individual studies when interpreting the result of the review [ 12 , 20 , 21 , 25 ].

Overall methodological quality assessment for systematic reviews. Quantitative studies [ 12 , 24 , 25 ] were assessed following the AMSTAR 2 critical domain guidelines. Qualitative studies [ 13 , 20 , 21 ] were assessed following the JBI checklist. For overall classification, qualitative studies were also assessed with the following critical AMSTAR 2 domains not specified in the JBI checklist (item 2. is the protocol registered before commencement of the review, item 7. justification for excluding individual studies and item 13. consideration of risk of bias when interpreting the results of the review)

Missing reporting of sources of funding for primary studies and not describing the included studies in adequate detail were, most often, the two non-critical items of the AMSTAR 2 and the JBI checklist, not met.

Most of the included reviews did report research questions including components of PICO, performed study selection and data extraction in duplicate, used appropriate methods for combining studies and used satisfactory techniques for assessing risk of bias (see Fig.  2 ).

Main findings from the systematic reviews

As illustrated in Table  2 , this overview synthesizes evidence on a variety of approaches to promote EBP teaching in both classroom and clinical settings. The systematic reviews describe various interventions used for teaching in EBP, which can be summarized into two themes: Collaboration Interventions and Educational Interventions.

Collaboration interventions to teach EBP

In general, the reviews point that interdisciplinary collaboration among health professionals and/or others e.g., librarian and professionals within information technologies is relevant when planning and teaching in EBP [ 13 , 20 ].

Interdisciplinary collaboration was described as relevant when planning teaching in EBP [ 13 , 20 ]. Specifically, regarding literature search Wakibi et al. found that collaboration between librarians, computer laboratory technicians and nurse educators enhanced students’ skills [ 13 ]. Also, in terms of creating transfer between EBP teaching and clinical practice, collaboration between faculty, library, clinical institutions, and teaching institutions was used [ 13 , 20 ].

Regarding collaboration with clinical practice, Ghaffari et al. found that teaching EBP integrated in clinical education could promote students’ knowledge and skills [ 25 ]. Horntvedt et al. found that during a six-week course in clinical practice, students obtained better skills in reading research articles and orally presenting the findings to staff and fellow students [ 20 ]. Participation in clinical research projects combined with instructions in analyzing and discussing research findings also “led to a positive approach and EBP knowledge” [ 20 ]. Moreover, reading research articles during the clinical practice period enhances the students critical thinking skills. Furthermore, Horntvedt et al. mention, that students found it meaningful to conduct a “mini” – research project in clinical settings, as the identified evidence became relevant [ 20 ].

Educational interventions

Educational interventions can be described as “Framing Interventions” understood as different ways to set up a framework for teaching EBP, and “  Teaching methods ” understood as specific methods used when teaching EBP.

Various educational interventions were described in most reviews [ 12 , 13 , 20 , 21 ]. According to Patelarou et al., no specific educational intervention regardless of framing and methods was in favor to “ increase knowledge, skills and competency as well as improve the beliefs, attitudes and behaviors of nursing students”  [ 12 ].

Framing interventions

The approaches used to set up a framework for teaching EBP were labelled in different ways: programs, interactive teaching strategies, educational programs, courses etc. Approaches of various durations from hours to months were described as well as stepwise interventions [ 12 , 13 , 20 , 21 , 24 , 25 ].

Some frameworks [ 13 , 20 , 21 , 24 ] were based on the assessments categories described by the Sicily group [ 2 ] or based on theory [ 21 ] or as mentioned above clinically integrated [ 20 ]. Wakibi et al. identified interventions used to foster a spirit of inquiry and EBP culture reflecting the “5-step approach” of the Sicily group [ 4 ], asking PICOT questions, searching for best evidence, critical appraisal, integrating evidence with clinical expertise and patient preferences to make clinical decisions, evaluating outcomes of EBP practice, and disseminating outcomes useful [ 13 ]. Ramis et al. found that teaching interventions based on theory like Banduras self-efficacy or Roger’s theory of diffusion led to positive effects on students EBP knowledge and attitudes [ 21 ].

Teaching methods

A variety of teaching methods were used such as, lectures [ 12 , 13 , 20 ], problem-based learning [ 12 , 20 , 25 ], group work, discussions [ 12 , 13 ], and presentations [ 20 ] (see Table  2 ). The most effective method to achieve the skills required to practice EBP as described in the “5-step approach” by the Sicely group is a combination of different teaching methods like lectures, assignments, discussions, group works, and exams/tests.

Four systematic reviews identified such combinations or multifaceted approaches [ 12 , 13 , 20 , 21 ]. Patelarou et al. states that “EBP education approaches should be blended” [ 12 ]. Thus, combining the use of video, voice-over, PowerPoint, problem-based learning, lectures, team-based learning, projects, and small groups were found in different studies. This combination had shown “to be effective” [ 12 ]. Similarly, Horntvedt et al. found that nursing students reported that various teaching methods improved their EBP knowledge and skills [ 20 ].

According to Ghaffari et al., including problem-based learning in teaching plans “improved the clinical care and performance of the students”, while the problem-solving approach “promoted student knowledge” [ 25 ]. Other teaching methods identified, e.g., flipped classroom [ 20 ] and virtual simulation [ 12 , 20 ] were also characterized as useful interactive teaching interventions. Furthermore, face-to-face approaches seem “more effective” than online teaching interventions to enhance students’ research and appraisal skills and journal clubs enhance the students critically appraisal-skills [ 12 ].

As the reviews included in this overview primarily are based on qualitative, mixed methods as well as quasi-experimental studies and to a minor extent on randomized controlled trials (see Table  2 ) it is not possible to conclude of the most effective methods. However, a combination of methods and an innovative collaboration between librarians, information technology professionals and healthcare professionals seem the most effective approach to achieve EBP required skills.

EBP-related outcomes

Most of the systematic reviews presented a wide array of outcome assessments applied in EBP research (See Table  3 ). Analyzing the outcomes according to the Sicily group’s assessment categories revealed that assessing “knowledge” (used in 19 out of 39 primary studies), “skills” (used in 18 out of 39 primary studies) and “attitude” (used in 17 out of 39) were by far the most frequently used assessment categories, whereas outcomes within the category of “behaviors” (used in eight studies) “reaction to educational experience” (in five studies), “self-efficacy” (in two studies), and “benefits for the patient” (in one study), were used to a far lesser extent. Additionally, outcomes, that we were not able to categorize within the seven assessment categories, were “future use” and “Global EBP competence”.

The purpose of this overview of systematic reviews was to collect and summarize evidence of the diversity of EBP teaching interventions and outcomes measured among professional bachelor- degree healthcare students.

Our results give an overview of “the state of the art” of using and measuring EBP in PBHP education. However, the quality of included systematic reviews was rated critically low. Thus, the result cannot support guidelines of best practice.

The analysis of the interventions and outcomes described in the 39 primary studies included in this overview, reveals a wide variety of teaching methods and interventions being used and described in the scientific literature on EBP teaching of PBHP students. The results show some evidence of the five step EBP approach in accordance with the inclusion criteria “interventions aimed at teaching one or more of the five EBP steps; Ask, Search, Appraise, Integrate, Assess/evaluate”. Most authors state, that the students´ EBP skills, attitudes and knowledge improved by almost any of the described methods and interventions. However, descriptions of how the improvements were measured were less frequent.

We evaluated the described outcome measures and assessments according to the seven categories proposed by the Sicily group and found that most assessments were on “attitudes”, “skills” and “knowledge”, sometimes on “behaviors” and very seldom on” reaction to educational experience”, “self-efficacy” and “benefits to the patients”. To our knowledge no systematic review or overview has made this evaluation on outcome categories before, but Bala et al. [ 9 ] also stated that knowledge, skills, and attitudes are the most common evaluated effects.

Comparing the outcomes measured between mainly medical [ 9 ] and nursing students, the most prevalent outcomes in both groups are knowledge, skills and attitudes around EBP. In contrast, measuring on the students´ patient care or on the impact of the EBP teaching on benefits for the patients is less prevalent. In contrast Wu et al.’s systematic review shows that among clinical nurses, educational interventions supporting implementation of EBP projects can change patient outcomes positively. However, they also conclude that direct causal evidence of the educational interventions is difficult to measure because of the diversity of EBP projects implemented [ 26 ]. Regarding EBP behavior the Sicily group recommend this category to be assessed by monitoring the frequency of the five step EBP approach, e.g., ASK questions about patients, APPRAISE evidence related to patient care, EVALUATE their EBP behavior and identified areas for improvement [ 2 ]. The results also showed evidence of student-clinician transition. “Future use” was identified in two systematic reviews [ 12 , 13 ] and categorized as “others”. This outcome is not included in the seven Sicily categories. However, a systematic review of predictive modelling studies shows, that future use or the intention to use EBP after graduation are influenced by the students EBP familiarity, EBP capability beliefs, EBP attitudes and academic and clinical support [ 27 ].

Teaching and evaluating EBP needs to move beyond aiming at changes in knowledge, skills, and attitudes, but also start focusing on changing and assessing behavior, self-efficacy and benefit to the patients. We recommend doing this using validated tools for the assessment of outcomes and in prospective studies with longer follow-up periods, preferably evaluating the adoption of EBP in clinical settings bearing in mind, that best teaching practice happens across sectors and settings supported and supervised by multiple professions.

Based on a systematic review and international Delphi survey, a set of interprofessional EBP core competencies that details the competence content of each of the five steps has been published to inform curriculum development and benchmark EBP standards [ 28 ]. This consensus statement may be used by educators as a reference for both learning objectives and EBP content descriptions in future intervention research. The collaboration with clinical institutions and integration of EBP teaching components such as EBP assignments or participating in clinical research projects are important results. Specifically, in the light of the dialectic between theoretical and clinical education as a core characteristic of Professional bachelor-degree healthcare educations.

Our study has some limitations that need consideration when interpreting the results. A search in the EMBASE and Scopus databases was not added in the search strategy, although it might have been able to bring additional sources. Most of the 22 excluded reviews included primary studies among other levels/ healthcare groups of students or had not critically appraised their primary studies. This constitutes insufficient adherence to methodological guidelines for systematic reviews and limits the completeness of the reviews identified. Often, the result sections of the included reviews were poorly reported and made it necessary to extract some, but not always sufficient, information from the primary study abstracts. As the present study is an overview and not a new systematic review, we did not extract information from the result section in the primary studies. Thus, the comprehensiveness and applicability of the results of this overview are limited by the methodological limitations in the six included systematic reviews.

The existing evidence is based on different types of study designs. This heterogeneity is seen in all the included reviews. Thus, the present overview only conveys trends around the comparative effectiveness of the different ways to frame, or the methods used for teaching EBP. This can be seen as a weakness for the clarity and applicability of the overview results. Also, our protocol is unpublished, which may weaken the transparency of the overview approach, however our search strategies are available as additional material (see Additional file 1 ). In addition, the validity of data extraction can be discussed. We extracted data consecutively by the first and last author and if needed consensus was reached by discussion with the entire research group. This method might have been strengthened by using two blinded reviewers to extract data and present data with supporting kappa values.

The generalizability of the results of this overview is limited to undergraduate nursing students. Although, we consider it a strength that the results represent a broad international perspective on framing EBP teaching, as well as teaching methods and outcomes used among educators in EBP. Primary studies exist among occupational therapy and physiotherapy students [ 5 , 29 ] but have not been systematically synthesized. However, the evidence is almost non-existent among midwife, nutrition and health and biomedical laboratory science students. This has implications for further research efforts because evidence from within these student populations is paramount for future proofing the quality assurance of clinical evidence-based healthcare practice.

Another implication is the need to compare how to frame the EBP teaching, and the methods used both inter-and mono professionally among these professional bachelor-degree students. Lastly, we support the recommendations of Bala et al. of using validated tools to increase the focus on measuring behavior change in clinical practice and patient outcomes, and to report in accordance with the GREET guidelines for educational intervention studies [ 9 ].

This overview demonstrates a variety of approaches to promote EBP teaching among professional bachelor-degree healthcare students. Teaching EBP is based on collaboration with clinical practice and the use of different approaches to frame the teaching as well as different teaching methods. Furthermore, this overview has elucidated, that interventions often are evaluated according to changes in the student’s skills, knowledge and attitudes towards EBP, but very rarely on self-efficacy, behaviors, benefits to the patients or reaction to the educational experience as suggested by the Sicily group. This might indicate that educators need to move on to measure the effect of EBP on outcomes comprising all categories, which are important to enhance sustainable behavior and transition of knowledge into the context of practices where better healthcare education should have an impact. In our perspective these gaps in the EBP teaching are best met by focusing on more collaboration with clinical practice which is the context where the final endpoint of teaching EBP should be anchored and evaluated.

Availability of data and materials

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

Abbreviations

Evidence-Based Practice

Professional bachelor-degree healthcare programs

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Acknowledgements

The authors would like to acknowledge research librarian Rasmus Sand for competent support in the development of literature search strategies.

This work was supported by the University College of South Denmark, which was not involved in the conduct of this study.

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Nielsen, L.D., Løwe, M.M., Mansilla, F. et al. Interventions, methods and outcome measures used in teaching evidence-based practice to healthcare students: an overview of systematic reviews. BMC Med Educ 24 , 306 (2024). https://doi.org/10.1186/s12909-024-05259-8

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A world-class city filled with art and culture and an incredible campus that offers cutting edge resources–that’s what students receive at Penn Nursing. And that’s just the start. Penn Nursing and the wider university offer something for everyone, as well as a lifelong community.

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Undergraduate Research

Make research an integral part of your education at msu.

Michigan State University considers inclusion of undergraduate students in research a high priority. Through MSU’s Undergraduate Research program, students have increased opportunities to engage in scholarship with expert faculty and partners in a variety of academic disciplines. The College of Nursing offers opportunities for undergraduate students to become involved in nursing research through coursework and mentored research experiences.

Competitive project stipends are available — up to $1,500 — for undergraduate nursing students to assist a faculty member with research or a scholarly project.

What you’ll discover:

• Gain an understanding of the research process,
• Develop your own research interest, and to
• Disseminate findings via poster presentation at a regional conference or publication in a student journal

How you’ll benefit:

• Receive a project stipend
• Meet and interact with leaders in the nursing research profession
• Engage with faculty in small group settings
• Work with faculty to complete meaningful research/scholarship

Who is eligible:

Students should plan to be enrolled in the nursing program during the subsequent academic year, have a minimum cumulative undergraduate GPA of 3.0, and a strong interest in nursing research and scholarship.

How to apply

• Complete the  Undergraduate Nursing Research Application  and submit it by May 1.
• Applicants will be notified of acceptance by MSU email in early September.

Selection process:

• Each student will receive a plan, developed with a faculty mentor, outlining the research project and your planned role in the project. You must sign the plan and return by the due date. 
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• Once the student has signed the plan and met with the faculty member the project stipend will be disbursed into the student’s MSU account.
• Student will be required to produce either a journal article about the project for a student journal or a scientific poster submitted for presentation at the University Undergraduate Research and Arts Forum (UURAF).

Nursing 220: Introduction to Nursing Scholarship

This 2-credit course is offered during fall and spring semester each year. This course prepares you to become a consumer of research who critically evaluates and bases nursing care on evidence and who uses methodologies essential to providing evidence-based nursing care.

Upon completion of this course, you will be able to:

• Explain the importance of nursing research and its relationship to evidence-based practice.
• Describe and apply the basic steps of the research process utilizing appropriate terminology.
• Evaluate the level of evidence, validity, reliability and quality of research articles.
• Use critical appraisal skills to evaluate research findings in nursing and related fields with respect to the problem, methods and findings.

There are no pre-requisites for enrollment in this course. Contact the Office of Student Support Services for assistance enrolling in this course.

Nursing 221: Future of Nursing: Explore Potential Career Opportunities and Graduate Education

Spring of every year. 2(2-0) R: Open to students in the Nursing or Prenursing Major or approval of college. Fosters student motivation in pursuing advanced degrees in nursing. The course will examine perspectives related to the future of nursing and provide the opportunity for students to explore post-BSN career opportunities and the options for graduate education in nursing.

Effective Spring Semester 2023

Nursing 451: Honors Research Internship This 2-3 variable credit course is offered on demand. This course provides you with an immersion in the research process in the College of Nursing working directing with a nurse researcher in the context of a funded/non-funded research team.

• Develop an appreciation for the importance of nursing research.
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You are eligible to take this course upon successful completion of Nursing 220 Introduction to Nursing Scholarship. In addition, prior to taking this course, you will need to provide a supervising faculty member with evidence of completing Human Subjects and HIPAA training. Contact the Office of Student Support Services for assistance enrolling in this course

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Doctoral Student Selected for 2023-24 Research Scholar Program

By Renee Douglas / 03/26/2024 College of Health and Human Sciences , Social Work , The Graduate College

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EAST GREENSBORO, N.C. (March 22, 2024) – A student from North Carolina Agricultural and Technical State University has been chosen as a scholar for the 2023-24 All of Us Research Scholar Program. 

This initiative, backed by the National Institutes of Health, pairs early career investigators with health research professionals to advance precision medicine research. The program is dedicated to high school, undergraduate, or graduate/professional students who aspire to pursue careers in the health field. 

Dawson, a Ph.D. candidate in the Joint Program in Social Work between N.C. A&T and with the University of North Carolina Greensboro, is passionately committed to paving her path as a future health researcher. She holds an MSW from East Carolina University and a B.A. in psychology from the University of North Carolina at Chapel Hill. She successfully defended her dissertation in February and will graduate in May from A&T.

Prior to embarking on her doctoral degree, Dawson established herself as a licensed clinical social worker and clinical addiction specialist, with experience across various clinical, leadership and administrative roles. She is also a minority fellow of the Council of Social Work Education Program who is committed to furthering the mission of the Substance Abuse and Mental Health Services Administration (SAMHSA) to diminish the impact of substance abuse and mental illness in American communities.

Dawson will learn how to conduct scientific research using the All of Us Data Browser and Research Workbench, creating a specific project and poster, while sharpening the skills needed to support the future of biomedical research.

Her research interests span health equity, digital health interventions, social determinants of health and disparities among marginalized groups with chronic illnesses and mental health disorders.

Media Contact Information: [email protected]

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Registration for the Duke Undergraduate Research Symposium is now open to all undergraduates!

• Share This: Share Registration for the Duke Undergraduate Research Symposium is now open to all undergraduates! on Facebook Share Registration for the Duke Undergraduate Research Symposium is now open to all undergraduates! on LinkedIn Share Registration for the Duke Undergraduate Research Symposium is now open to all undergraduates! on X

The Duke Undergraduate Research Symposium (formerly known as Visible Thinking) will take place in-person on Monday, April 15th from 4:00-6:00pm in Karsh Alumni Center.  We are so excited for the opportunity to showcase ongoing undergraduate student research from across disciplines to the larger Duke community!

We are currently accepting registration from all undergraduate researchers, regardless of whether you have received funding from URS this academic year.  You are invited to present your research in the form of a poster (or volunteer to help run the event) at our Duke Undergraduate Research Symposium. This research can be in progress and doesn’t need to be a completed story.  Note that space for presenting is limited this year, and registration will close by  April 1st at 11:59pm , or when we have reached capacity , whichever comes first.  

If you are interested in presenting your work:

• You are required to have your faculty mentor approve the submission of your abstract before you register. Please discuss this with them prior to registering and uploading your abstract. 
• Please use  https://duke.qualtrics.com/jfe/form/SV_7TXqElCNbM8JivQ  to register, choose your time to present (4:00-4:45pm or 5:15-6pm), and submit your abstract no later than April 1st.
• Your abstract will go into our Undergraduate Research Symposium Abstract Book that will be publicly available online. Abstracts should be a single paragraph, with no references, of no more than 2500 characters (including spaces and excluding title and authors).  Please do not use Greek letters or other symbols.   
• Posters should be no larger than 48×36. 
• Note that your faculty research mentor will receive a follow up email with a copy of everything once you submit the registration form. 
• If you have a poster that you have used to present your research at a previous symposium, you are welcome to use that.
• If you would like to print a new poster, URS will cover these costs. Please indicate on your registration that you would like to print a new poster. From there, the URS Team will add you to the PhD Posters group “Duke URS” and you will be able to print your poster using our saved payment method. 
• Please note: posters must be submitted through the Duke URS group account by Wednesday, April 10. Posters will be delivered by PhD Posters to Karsh Alumni and Visitors Center on the day of the Symposium (April 15). 

If you have any questions or concerns, please reach out to the  URS Office.

Use of research in undergraduate nursing students' theses: A mixed methods study

Affiliations.

• 1 Faculty of Social Sciences, Oslo and Akershus University College of Applied Sciences, P.O. Box 4, St. Olavs plass, N-0130 Oslo, Norway. Electronic address: [email protected].
• 2 Faculty of Health Sciences, University College of Southeast Norway, P.O. Box 235, N-3603 Kongsberg, Norway. Electronic address: [email protected].
• 3 Faculty of Health Sciences, University College of Southeast Norway, P.O. Box 235, N-3603 Kongsberg, Norway. Electronic address: [email protected].
• PMID: 28646707
• DOI: 10.1016/j.nedt.2017.06.001

Background: Health care personnel are expected to be familiar with evidence-based practice (EBP). Asking clinical questions, conducting systematic literature searches and conducting critical appraisal of research findings have been some of the barriers to EBP. To improve undergraduate nurses' research skills, a collaborative library-faculty teaching intervention was established in 2012.

Objectives: The aim of this study was to evaluate how the collaborative library-faculty teaching intervention affected the nursing students' research skills when writing their final theses.

Design and setting: Both quantitative and qualitative data collection and analysis were used. The study focused on a final year undergraduate nurse training programme in Norway.

Participants: 194 theses submitted between 2013 and 2015 were collected and assessed. The students were exposed to the intervention for respectively one, two and three years during this period.

Methods: Descriptive statistics were used to compare each year's output over the three-year period and to examine the frequency of the use of various databases, types of information and EBP-tools. Qualitative data was used to capture the students' reasoning behind their selection processes in their research.

Results: The research skills with regard to EBP have clearly improved over the three years. There was an increase in employing most EBP-tools and the justifications were connected to important EBP principles. The grades in the upper half of the grading scale increased from 66.7 to 82.1% over the period 2013 to 2015, and a correlation was found between grades and critical appraisal skills.

Conclusions: The collaborative library-faculty teaching intervention employed has been successful in the promotion of nursing student research skills as far as the EBP principles are concerned. Writing a thesis in the undergraduate nursing programme is important to develop and practice these research skills.

Keywords: Collaboration; Curriculum development; Education – Nursing; Interprofessional relations; Library user education; Nursing practice - evidence-based; Students – Nursing; Teaching methods.

Copyright © 2017 Elsevier Ltd. All rights reserved.

• Academic Dissertations as Topic / standards*
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Undergraduate Research Study Project Explores Do-It-Yourself Extremism

Pardee students probe hard-to-track online radicalization, say thwarting violence requires reorienting the common view of terrorists to deal with the social and mental challenges in their lives

Combating terrorism requires rebooting our moralistic take on terrorists as pure evil, says Jack Martin (Pardee’25), who did undergraduate research on the topic.

Rich Barlow

Cydney scott.

Payton Gendron, who as a teen murdered 10 African American grocery shoppers in Buffalo two years ago, typifies domestic terrorism. White supremacy is the biggest terror threat domestically, law enforcement says. Gendron reflects another disturbing trend: he didn’t need the middleman of a terrorist group to set him on his rampage. He imbibed racist ideology trawling online platforms .

Such terrorists “often receive labels of ‘crazy’ or ‘barbarian,’ language that reduces their motivations to an irrational bloodlust,” writes Jack Martin (Pardee’25). In a funding proposal for his ongoing Undergraduate Research Opportunities Program (UROP) project, Martin says this approach “risks dangerously oversimplifying” the frequent engines of terrorism—“social isolation, mental illness, and trauma.” 

The first stage of his UROP research, done with Jasmin Tagijeva (Pardee’25), probes the nexus of these problems and DIY radicalization online. 

Their study for UROP, which sponsors faculty-mentored undergraduate inquiry, was overseen by Jessica Stern , a research professor at the Pardee School of Global Studies. Their work is part of a broader study—by Stern and Harvard colleagues into the roots of radicalization—that recently received a Guggenheim Distinguished Scholar grant. The research is vital, Stern says, because “the FBI reports that lone actors are much harder to identify and stop before they carry out acts of violence.

“It is illegal to join ISIS, raise money for ISIS, recruit for ISIS, etc., because ISIS is a listed ‘foreign terrorist organization,’” Stern notes, adding that “there is no analogous list of domestic terrorist organizations, and the First Amendment protects individuals who spread the ideology of such organizations.” While it’s illegal for domestic groups to commit terrorism, she says, “it is not illegal to join, raise money for, spread propaganda, or recruit for a domestic terrorist group such as a neo-Nazi organization.”  

Thwarting violence requires reorienting the common view of terrorists to deal with the social and mental challenges in their lives, Martin argues.

“Most of the time, it’s not just this person spontaneously decided to become an extremist,” he says. “There’s stuff that leads up to that—trauma, family issues.…They are committing horrific acts, and there’s no justification for that.” But in the cases he and Tagijeva analyzed for their UROP project, “Either their parents were never close to them, they never had any friends, they had a history of mental illness, like autism, that made it more difficult to form meaningful connections with their schoolmates.” 

“There’s always something that is separating them from the rest of society that makes them think that that society is prejudiced against them,” Martin says. “Those ideologies that so concretely construct an ‘other’ that’s out to get you, that’s out to control the world—that’s extremely persuasive to someone who already kind of feels like that in their personal life.”

For their project, Martin and Tagijeva poured through hundreds of interview transcripts with 58 individuals in the database of the Tennessee nonprofit Parents For Peace , which works to wean people off of budding radicalism. Most of the individuals were Americans; perhaps 80 percent involved US-grown white nationalism, Martin estimates. Most of the rest were in thrall to Islamic extremism.

“A lot of the cases are of teenagers or people in their early 20s,” he says. “They’re not necessarily full members of extremist organizations.” Many “have contact with members of extremist organizations, but a lot of them are kind of in the earlier stages of radicalization.…A lot of the organization [of violent extremism] comes in the form of online communities, on forums, on message boards like 4chan.

“Most people aren’t joining these groups,” like the Proud Boys or Oath Keepers, he notes. “They aren’t becoming radical because they have some inner sociopathic instincts or are super-convinced by the ideology. It’s because, a lot of times, they feel lonely or are separated from a sense of community in their family or their school or their personal life, and are looking for something to latch onto.” 

Picking a terrorist group isn’t like choosing a college. “No one starts out by looking for the Proud Boys or al Qaeda,” Martin says. “Most of the time, it’s a slow radicalization process.”

No one starts out by looking for the Proud Boys or al Qaeda. Most of the time, it’s a slow radicalization process. Jack Martin

Crucially, he says, the individuals in the Parents For Peace database hadn’t yet committed any attacks. The vast research into terrorism after the fact “can really bias the group of people you’re looking at in order to make generalizations about who becomes an extremist.” 

What’s to be done? Social media companies could better police their users’ posting, Martin says. But his personal opinion—admittedly the “squishiest, most social science answer that might not be most practically implemented”—is a social reset on how we see terrorists.

“These aren’t animals. They’re not intrinsically violent,” he says. “They’re people who had understandable, realistic struggles in their life, and turned to extremist groups for community that the rest of us find in other, healthier outlets.…It’s difficult to have empathy for people who believe abhorrent things. [But] you have to have a certain sense of analytic empathy that doesn’t treat them with contempt.” The hatreds unleashed by the Gaza war, he says, demonstrate the limits of not understanding extremists’ grievances.

Martin knows their UROP project findings might be fodder for Second Amendment fundamentalists, who argue that mental illness and not a lack of sensible gun safety laws underlies America’s shooting violence. To which he replies, “It’s an awful rhetorical strategy. You can obviously do both things at once.”

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Attitudes and perceptions of undergraduate nursing students towards the nursing profession

Irene mildred neumbe.

1 Department of Nursing, Busitema University Faculty of Health Sciences, Mbale, Uganda

Lydia Ssenyonga

David jonah soita.

2 Department of Community and Public Health, Busitema University Faculty of Health Sciences, Mbale, Uganda

Jacob Stanley Iramiot

3 Department of Microbiology and Immunology, Busitema University Faculty of Health Sciences, Mbale, Uganda

Rebecca Nekaka

Associated data.

The datasets generated and/or analysed during the current study are available in the OSF repository, https://doi.org/10.17605/OSF.IO/TXDC6 .

Nursing students either possess positive or negative attitudes and perceptions about the nursing profession. Their attitudes towards the profession depict the quality of care they will offer to patients upon qualification. This study aimed to determine the attitudes and perceptions of undergraduate nursing students towards their profession.

This equal-status mixed methods study involved a census sample of 165 nursing students from year one to year four in two public universities in Uganda. Attitude Scale for Nursing Profession was used to collect quantitative data in the period between 20/11/2021 and 22/01/2022. Focus group discussions were held to collect qualitative data about the perceptions.

Majority of the students (81.8%) had positive attitudes towards the nursing profession. There was a significant difference in attitudes based on year of study and entry scheme (R2 = 0.12, F = 2.21, p = 0.01). Nursing was perceived as a poorly remunerated, unpopular profession with bias towards recruitment of lower cadres.

The results of this study showed that the attitudes of undergraduate nursing students towards the nursing profession were positive but their perceptions about the nursing profession were negative. An interventional study is recommended to facilitate a more positive change among nursing students.

Although nurses constitute the largest group of healthcare providers, there is a worldwide suffering from the shortage of nurses to meet the demand of healthcare settings [ 1 ].

The World Health Organization International Council of Nurses discussion paper in 2020 estimated the global shortfall of nurses to have been 5.9 million in 2020 and projected it would rise to 10.6 million by 2030 [ 2 ]. The shortfall is most severe in Africa, South East Asia, and the Eastern Mediterranean [ 3 ]. Uganda is challenged by nursing shortage, especially at graduate level. Certificate and diploma nurses form a large proportion of the nursing workforce in Ugandan healthcare facilities, with only 3.24% of the total nursing workforce comprising graduate nurses [ 4 ].

The Nursing profession provides holistic care to the entire population through advocacy, disease prevention, health promotion, health education, counseling, collaboration, research and administration [ 5 ]. Despite their enormous contribution, nurses are not adequately recognized. They are exposed to difficult working conditions resulting in stress and fatigue [ 6 ]. It is estimated that 30% of the nurses do not like the nursing profession because of low pay, bad administrative system, and work overload [ 7 ].

Resolving nurses’ attitudes towards the profession is an essential aspect of understanding the issue of nursing shortage since nursing education is negatively affected by negative attitudes towards the profession [ 7 , 8 ]. Nursing students are the upcoming contributors to the nursing workforce [ 9 ] and their attitudes towards the profession depict the quality of care they will offer to patients upon qualification [ 10 ].

Nursing students either possess positive or negative attitudes [ 6 ], which change over time during their study. At Hue University in Vietnam, over half (62.07%) of the students had a favorable attitude towards the nursing profession [ 11 ]. However, in South Valley University Egypt, over half (57.9%) of the students had negative attitudes towards nursing [ 12 ]. It has been demonstrated that attitudes of nursing students towards the nursing profession can be affected by gender [ 12 , 13 ], year of study [ 14 ], family support [ 15 ], observation of senior nurses [ 16 ] and personal experiences with nurses [ 17 ].

Nursing students’ perceptions about the nursing profession are based on personal experiences and observation of nurses’ behavior, however superficial. The profession is poorly perceived yet the job is very hard [ 18 ]. Outgoing nursing students in Punjab, India had divergent perceptions of the profession. The majority (81.9%) perceived that there is opportunity for personal growth in the profession, while 23.9% disagreed. Nearly half (51.5%) believed that the profession does not provide any opportunity to get a better marriage partner but provides better opportunities abroad (86.8%) [ 19 ]. At the University of Jos, Nigeria, the nursing profession was perceived as stressful but offers good pay, good job security and self-actualization [ 20 ].

Nurses are viewed as subordinates of the physician, an inferior profession whose destiny is to obey the doctor’s orders [ 21 , 22 ]. In ancient societies, nursing was a female role that required no formal education. Organized groups of nurses came into existence in the early Christian era [ 23 ]. Reforms in nursing were introduced by Florence Nightingale in the nineteenth century. In Uganda, nursing training was started by Katherine Cook in 1931 at enrolled level and the first class qualified in 1933 [ 5 ].

The Uganda Nurses and Midwives Council (UNMC) is responsible for regulating nursing and midwifery standards as governed by the Nurses and Midwives Act, 1996. An individual holding a qualification recognized by UNMC applies for registration, upon which they are registered and offered a practicing license. Such a person can then be referred to as a Registered Nurse [ 24 ].

The Bachelor of Science in Nursing, introduced in 1993, is a 4-year program in nursing schools affiliated with universities in Uganda. At Busitema University and Makerere University, nursing students take the same basic courses as medical students during the first two years [ 25 ], mainly taught by medical doctors rather than nurse educators. During the final two years of full-time clinical placement, nursing staff in the teaching hospitals, most of whom are diploma-level nurses, serve as clinical instructors for the students [ 26 ].

Ugandan universities enroll students according to the students’ applications and its enrolment plan. Students with high scores in the Uganda Advanced Certificate of Education examination have more opportunities of enrolment. Those who do not meet admission requirements because of low scores end up applying to other universities or unpopular courses [ 27 ]. Therefore, most of the students who study nursing do so after failing to make it to the popular medicine and pharmacy courses.

Nursing training institutions experience pressure from healthcare organizations and communities to increase student enrollment and graduate more nurses to fill current vacancies in preparation for the future need. Currently, 30% of approved nursing positions are still vacant [ 28 ]. Although greater enrollment may be the solution, it may not be sufficient since some students admitted to nursing education drop out or leave the profession after graduation upon realizing that nursing is not meant for them [ 29 ].

There are limited studies available in Uganda to know the current generations’ attitudes and perceptions towards the nursing profession. Hence, this study aimed to answer the following research questions: First, what are the attitudes of undergraduate nursing students towards the nursing profession and second, what the perceptions of undergraduate nursing students about the nursing profession?

Study design

An equal-status mixed methods design was used.

Study setting and period

The study was carried out in two accredited public Universities in Uganda, Busitema University Faculty of Health Sciences and Makerere University College of Health Sciences, in the period between 20/11/2021 and 22/01/2022.

Busitema University Faculty of Health Sciences is located within Mbale Regional Referral Hospital along Pallisa Road, Mbale City, Eastern Uganda approximately 220 kilometers north-east of Kampala, the capital city of Uganda. The faculty was established in 2013. The Bachelor of Science in Nursing program was introduced in 2015 and has an average enrolment of 22 students per intake.

Makerere University College of Health Sciences is a semi-autonomous college of Makerere University located on Mulago Hill between the new and old Mulago Hospital in northeast Kampala, the capital city of Uganda. The Bachelor of Science in Nursing Program was introduced in 1993 in the then Faculty of Medicine and has an average enrolment of 25 students per intake.

Study population

Bachelor of Science in Nursing students from first to fourth year at the two universities

Sampling strategy

All nursing students in the two universities were invited to participate in the census survey in the quantitative arm of the study since they were only 180 in number.

Participants for the qualitative arm were obtained by purposive sampling. Two students were selected from each year of study considering the gender and entry scheme of the student.

Data collection methods and tools

Quantitative data collection

A structured self-administered questionnaire was utilized consisting of three sections. The socio-demographic section included the independent variables; age, gender, religion, marital status, home area, the institution of study, year of study, entry scheme, father’s level of education, and source of funding for the academic program. The second section was developed to assess the students’ ranking of the nursing profession and their plans after graduation based on a literature review of published studies [ 13 , 21 , 23 ].

The third section about attitudes was adopted from the Attitude Scale for the Nursing profession (ASNP) developed by Coban and Kasikci in 2011, consisting of 40 items. The attitude subscales are; properties of the nursing profession (1–18), preference to the nursing profession (19–31), and general position of the nursing profession (32–40). It is a five-point Likert-type scale with a minimum score of 40 and maximum of 200. A total score of 120 and above indicates a positive attitude towards the profession [ 30 ]. For this study, a 4-point Likert scale was used where 1 signified strongly disagree and 4 signified strongly agree. Cronbach’s Alpha internal consistency coefficient of the scale is 0.91.The Cronbach’s Alpha coefficient for this study was 0.79.

Participant recruitment occurred during study sessions where the researcher distributed questionnaires after providing information about the study. Participants were allowed time to fill and return filled questionnaires to the researcher. In some classes, class leaders collected filled questionnaires and delivered them to the researcher. No one involved in student teaching or assessment was involved in recruitment or data collection. The study response rate was 91.6%.

A pilot study was carried out involving 15% (n = 24) of nursing students from Soroti University however the response rate was 33.3%.

Qualitative data collection

Qualitative data was collected using a structured interview guide in two focus group discussions conducted in English by trained and experienced researchers. Participants voluntarily provided verbal informed consent before the start of the discussion. Each discussion involved a representative sample of eight participants both male and female, direct entry and diploma entry students from each year of study. Audio recordings were put in place to gather all the data. The standard of focus group discussions was data saturation. To ensure validity, reliability and worthiness, the researcher provided clear information to the participants, established a relationship based on trust, accurately recorded and compared findings between the two groups. The participants chosen were able to provide relevant data to the study since they were knowledgeable and willing to respond.

Data analysis

Quantitative data analysis

Quantitative data was cleaned and entered into an excel sheet which was exported to Stata version 15 statistical software for analysis. Univariate findings were described using frequency, proportions, and measures of central tendency.

Association between attitudes of participants was assessed using the Kruskal-Wallis one-way analysis of variance and t-test. A p -value of <0.05 was considered statistically significant.

Qualitative data analysis

Qualitative data was analyzed by thematic analysis as follows; Data collected was transcribed from audio recording to text and compiled into transcripts that were assigned to another researcher who was a co-coder. Before coding, the researcher read through the scripts to fully understand what was discussed.The transcripts were coded based on phrases, sentences, and paragraphs [ 31 ]. The two researchers discussed and generated a final list of codes. Similar codes were identified and these were used to generate themes. Emerging themes were presented as a percentage of students in each theme. Verbatim quotes were also presented to back up the themes.

Ethics statement

Ethical clearance was obtained from Mbale Regional Referral Hospital Review Ethical Committee, IRB approval number MRRH-2021-89. Administrative clearance was obtained from the Dean of Makerere University College of Health Sciences to carry out the study at Makerere University. The respondents provided written informed consent after providing information about the study. Participants were assured of confidentiality, their name and registration numbers were not included anywhere in the questionnaire.

Quantitative results

Socio-demographic characteristics of the nursing students.

Out of the 165 participants who responded to the study, 86 (52.4%) were female. One hundred and ten (66.7%) were in the age group 20–24 years with a mean age of 25.3±5.5 years (minimum 20, maximum 60). The majority 103 (80.6%) were single and 147 (89.1%) were Christians. Ninety-five participants (57.6%) were from urban areas and their fathers had attained tertiary education (55.2%). Eighty-four students (50.9%) were from Busitema University. Forty-seven participants (28.5%) were in the third year of study. One hundred twenty-four participants (75.2%) joined through direct entry scheme. Furthermore, fifty-six participants (33.9%) obtained financial support to pursue the program through government sponsorship ( Table 1 ).

Nursing students’ ranking of the nursing profession and plans after graduation

Seventy-four participants (44.9%) ranked the nursing profession second choice, followed by sixty-seven (40.6%) ranking it first choice. Seventy-four participants (44.9%) plan for higher education, followed by 21.8% for nursing administration (n = 36), 15.8% for teaching institution (n = 26), while 19 (11.5%) plan to change careers and only 10 (6.1%) plan to join bedside nursing after graduation.

Attitudes of nursing students towards the nursing profession

One hundred thirty-five students (81.8%) had positive attitudes towards the Nursing profession. The mean attitude score was 129.9±12.3 (minimum 87, maximum 153). Items in “Properties of the Nursing profession” attracted the highest mean score of 61.9(SD 5.9) and items in the General position of the Nursing profession had the lowest mean score of 27.5(SD 2.6) ( Table 2 ).

When results of the t-test were examined, there were significant differences in attitudes according to the year of study and entry scheme. (R2 = 0.12, F = 2.21, p = 0.01). The year of study and entry scheme explained 12% of the total variance in attitudes of the students ( Table 3 ).

Observations = 165 R2 = 0.1256 F = 2.212 p = 0.0198

The father’s education level and the source of funding did not have influence on the nursing students’ attitudes towards the nursing profession ( Table 4 ).

Qualitative results

Out of the sixteen participants for the focus group discussions, 8(50%) were female. Eight (50%) were from Busitema University and nine (56.25%) were aged between 20–24 years.

Choice of the nursing profession

Nursing students had numerous reasons for choosing the nursing profession. Three participants (18.75%) chose nursing because of interest and considered it as their first choice.

“I had the interest in nursing so I applied for it without applying for other courses and indeed I was taken on merit because . It was my favorite .” (APN2)

Three participants (18.75%) chose nursing based on their academic performance. Some participants were academically weak and their admission to study nursing was a privilege, a divine intervention, which would not have been possible without God.

“ I used to pray to God to give me any medical course be it Medicine , Nursing , Anesthesia , because I was not very good at school so I knew my weakness . When I joined , many people were telling me to change the course because it is not good but , I know myself .” (APN3)

Seven participants (43.75%) had mixed reasons for choosing the nursing profession such as, availability of the course, admission on merit, low cut-off points, parents’ choice, and desire to pursue a course from a specific institution. Of these, the desire to pursue a course at a particular institution dominated and was the main reason for their motivation to study nursing.

“I did not decide to do nursing myself; I was given nursing at the University . Also , since the admission document showed that I was given nursing , it was the best option at the moment . I got converted and had to pursue it since I wanted a course from Makerere .” (APN9) “I wanted to deal with human beings but still I only wanted to study at Busitema University . Looking at the cut-off points , I knew nursing would be assured so I applied for only nursing at Busitema .” (APN7)

Three participants (18.75%) were straightforward about choosing the nursing profession because it was the last option after failing to get admitted for Medicine and Surgery. At the time of admission, these participants were not happy but later accepted and found comfort in the fact that nursing is also a profession in the health sector.

“When I was studying , my interest was to do medicine and surgery but many times things do not turn out the way you expect so since I failed to get admitted for medicine and surgery , I resorted to joining . In a nutshell , nursing was the last resort to entering the medical field .” (APN8)

Perceptions of nursing students about the nursing profession

Perceptions of the participants about the nursing profession are shown in Table 5 .

Nursing is a good profession that provides an opportunity to interact with patients . Overall, the respondents perceived nursing as a good and enjoyable profession, which imparts knowledge needed to care for patients and manage illnesses. Nursing facilitates interaction with patients as nurses are the first caregivers and spend more time with patients.

“It has been my favorite , am proud of it and want to explore more about how lives are saved , and how to care for the sick . To me it is good because we are working to take care of the patient , irrespective of what one is doing , we are all geared towards a common goal .” (APN2)

A great number of negative perceptions were identified as presented below;

The image of the nursing profession . Nursing students had a very poor image of the nursing profession. The participants saw no specific role they play in practice and would not advance with a career in nursing because of fear to progress and yet remain nothing.

“There is a problem with the people in nursing; lack of creativity and leaning more on history . We keep on looking at people with ancient ideas and yet they decide what we have to practice so we are always rotating around the same axis. There are things, which should change such as the way senior nurses expect to be treated.” (APN9)

The participants perceived nursing as a profession that is not popular among the public.

“ People are not sensitized enough about this profession , when you say you’re a nurse at Bachelor’s level , someone wonders what you do . People are discouraged from joining the profession . With time students will even stop enrolling into the profession because of fear of what they are going to go through .” (APN10)

They narrated that the various stakeholders marginalize the nursing profession.

“It is very unfortunate that people do not appreciate or recognize you . Respective authorities marginalize the nursing profession . This is expected because this seems to be a female-dominated profession and anything that is comprised of women , people under look it .” (APN6)

The participants stated that other health professional students, educators, and senior nurses minimized them. The senior nurses tend to respect other health professional students and treasure them while looking down on nursing students.

“As a student , am under looked by physicians on the ward and wherever we are . The medical students look at us like a class lower than them . Even the nurses , our colleagues already in the field consider students of other courses to be more important than us .” (APN5)

Nursing is a hectic and traumatizing profession . Nursing was described as a very hectic profession where nurses spend a lot of time with patients and lack time for themselves and their families. The profession was labeled one that exposes nurses to vast challenges ranging from personal safety threats to torture. Bedside nurses and nursing students are more vulnerable to torture.

“Bedside nursing is one of the most hectic activities that a nurse has to undergo because it is a close relationship between you and the patient and you always need to do the needful . This ranges from turning the patient , wound dressing . You always have to be on standby .” (APN2) “Nursing students , if you’re not strong you may even leave the profession . There is a feeling of a minority like when a person tells you , “Oh you are doing nursing , sorry for you” so it creates an inferiority complex , someone feels they will not succeed in this world .” (APN4)

Nurses are not allowed to practice what they learn at school . The nursing profession was displayed to have restrictions about what a nurse can and cannot do, although nursing students are equipped with information, skills, and confidence to practice during the training. Additionally, most nurses upon qualification choose to work in the clinical setting and neglect the other fields of nursing such as research and leadership in nursing.

“At the end of it all , what you are taught is not what you are going to practice . It may end in school , you are not going to clerk a patient , you are just going to be looking through the notes a doctor has made .” (APN8)

Bias towards employing lower cadres in nursing compared to the graduate nurses.

“You’re studying but people are telling you , where will you get a job , private sector employs certificate nurses , only the government employs bachelor nurses , who will connect you to get a government job . You need money to get a government job , where will you get the money .” (APN4)

Leadership in nursing . The participants described the leadership in nursing as a broken leadership that does not fight for the rights and safety of nurses. The nursing leaders as stated do not mentor the young generation and instead make decisions that lead to the suffering of members of the profession.

“ If there is even a chance to fight for their rights , you know every human being must come out to fight for their rights but sometimes they tend to say such statements , ‘For me , I was called to love and serve’ which is okay but if something needs action , you should come and act . ” (APN9)

Poor remuneration of the nurses . Additionally, the participants expressed that the pay nurses receive is too little and not realistic yet they do a lot of work.

“Jobs are there but is the juice worth the squeeze ? Is the pay worth the work you are going to do , if someone has seen that going the other side is a better place for them , why settle for less somewhere where you are not even appreciated ?” (APN9) “Many of us after finishing opt for other fields outside nursing just because we know we shall be underpaid yet we have invested a lot to study . Now , we are nursing students but at the end of it all , we are going to join the nurses out there . If those people are crying , do you think we shall yearn to join them and also cry , no .” (APN10)

Majority (81.8%) of the students had positive attitudes towards the Nursing profession. This finding was higher than that reported by another study carried out at Hue University of Medicine and Pharmacy, Vietnam in which only 62.07% of the students had favorable attitudes towards the nursing profession [ 11 ]. This may be due to the influence of family and friends on the students who decided to study nursing yet they had no aspirations and interest to practice in hospital. In contrast, the students in this study had interest in nursing among other reasons such as academic performance. Therefore, influence from friends and family was not the main reason they decided to join the nursing profession.

Items in “Properties of the Nursing profession” attracted the highest mean score and items in the General position of the Nursing profession had the lowest mean score. This is consistent with a study carried out in Western Turkey [ 14 ] where characteristics of the nursing profession attained the highest mean score and the general position of the nursing profession the lowest mean score.

Properties of the nursing profession create an impression of nursing as a noble profession centered around education, advocacy, and care for patients [ 32 , 33 ]. On the other hand, the low mean score of attitudes towards the general position of the nursing profession can be explained by the public view of nursing as a troubled profession that is not independent [ 34 , 35 ] which creates a feeling of inferiority among the nursing students.

The current study revealed a significant difference in attitudes according to the year of study. Attitudes of nursing students towards the nursing profession vary as they progress from preclinical to clinical years of study, becoming more favorable [ 14 ] or less favorable [ 36 ] with increasing years in school. Students in clinical years of study undergo a hectic clinical practicum and stressful experiences such as being under looked by doctors and senior nurses on the wards. Nursing students sometimes have high expectations when joining the university, which are shattered as they encounter real experiences in the profession, which require difficult interventions.

Nursing students who join the university through the diploma entry scheme have prior exposure to nursing practice and knowledge about the profession and therefore have more interest and satisfaction with the profession compared to direct entry students whose view of the nursing profession depends on experiences and advice from others hence a significant difference in attitudes between the two groups.

Students join nursing education with different ideas about nursing due to limited public knowledge about the nursing profession [ 37 ]. Participants in this study joined with perceptions of nursing as a weak course. Occasionally, such preconceived perceptions about nursing are not realistic and therefore altered by the reality of practice during or after the course of study.

In clinical practice, the roles of a nurse are limited to administering prescribed drugs, damp dusting and patient monitoring. Nurses are not allowed to prescribe drugs and have to wait for a doctor to make the prescription. This causes frustration especially among graduate nurses, who feel they should play a bigger role than they do according to their scope of practice.

Nursing students ranked the nursing profession second choice. These results are in agreement with a similar study carried out in Egypt and Jordan where the students ranked the nursing profession second after the medical profession [ 38 ]. This highlights the reality that most of the students enroll for nursing after failing to meet the minimum requirements for Bachelor of Medicine and Surgery, which is usually the first choice. Some students join nursing because of lack of other opportunities while others are forced to join the profession [ 39 ] because of anticipated availability of jobs. Interest and motivation can be promoted by providing access to the right information and knowledge about the profession [ 40 ].

Only 6.1% of nursing students planned to join bedside nursing after graduation. This can be explained by the students’ description of bedside nursing as the most hectic experience, associated with poor working conditions, unfair treatment, lack of time for personal responsibilities and family, and low pay. Therefore, nursing students leave the profession in search of opportunities with better pay, where they get value for the time they spend working in comfortable conditions. Similar studies have reported that nursing students were reluctant to join bedside nursing [ 41 ] especially because of negative experiences during clinical areas leading many of them to exit the profession.

The participants in this study expressed that nurses’ pay is too little and not proportionate with the work they do. These findings are in agreement with a study [ 42 ] where 72% of nurses wanted to leave the profession because of low salaries. Proper remuneration improves nurses’ performance and motivation. More employees are attracted to join and get retained in the profession [ 43 ].

The ratio of graduate nurses to lower cadre nurses in practice is low, partly because graduates are discouraged because of the low pay but most commonly because the employers prefer to employ nurses with certificate and diploma levels of qualification as opposed to graduates. Non-Government Organizations, teaching institutions and research centers, employ graduate nurses yet patients in the general healthcare system would greatly benefit from their critical thinking and specialized skills.

The results of this study showed that the attitudes of undergraduate nursing students towards the nursing profession were positive but their perceptions about the nursing profession were negative. This provides an opportunity for nursing training institutions to develop interventions purposed to change the negative perceptions of nursing students about their profession. This will enable students to choose the nursing profession willingly and experience a higher level of satisfaction with their practice as a nurse after graduation.

Limitations to the study

The findings from this study cannot be generalized because of the small sample size.

Although the new tool used in this study demonstrated reasonable internal consistency, further construct validation with a larger cohort is required.

Implications of this study

Nursing training institutions should ensure that nursing students acquire and maintain an accurate perception of the nursing profession.

Recommendations

An interventional study is recommended to facilitate a more positive change among nursing students. The study also recommends a four-year longitudinal study to determine how the attitudes and perceptions change over time.

Acknowledgments

We acknowledge support from the Department of Nursing of Busitema University, Department of Nursing of Makerere University, Uganda Nurses and Midwives Council and our dear participants who gave us their honest views about the nursing profession.

Abbreviations

Funding statement.

Research reported in this publication was supported by the Fogarty International Center of the National Institutes of Health, U.S. Department of State’s Office of the U.S. Global AIDS Coordinator and Health Diplomacy (S/GAC), and President’s Emergency Plan for AIDS Relief (PEPFAR) under Award Number 1R25TW011213. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Data Availability

• PLoS One. 2023; 18(7): e0280700.

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PONE-D-23-00352Choice, Attitudes, and Perceptions of Undergraduate Nursing Students towards the Nursing ProfessionPLOS ONE

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Additional Editor Comments:

This is well written paper that highlights choices, attitudes and perceptions of nursing students towards nursing profession.

The methodology, especially for the qualitative section needs to be improved to include reliability , validity and trustworthiness. Ae you sure a pilot study was done? If so, this is a mini study and their findings should also be published.

What was the response rate? How many students were enrolled per class? In the methodology, preferably mention proportionate sampling , if it was done

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Reviewer's Responses to Questions

Comments to the Author

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Reviewer #1: Yes

Reviewer #2: Partly

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #2: No

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Reviewer #2: Yes

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The manuscript describes the context and approach of the study and is conducted in a rigorous manner. The data provided supports the conclusions. The statistical analysis if rigorously conducted and presentation is appropriate for the type of data being presented. The authors have provided a link for the data access for scrutiny. It is written in standard English with very few grammatical errors. The language is clear. The manuscript will contribute to this area of scientific research if published in the website. The authors have consulted a wide range of current works that has been publish to support the study and findings.

Reviewer #2: Dear authors,

Thank you for giving me such great opportunity to review this manuscript.

In general, the topic is interesting one and there is a much effort undertaken. I have some inquires and some comments that will strengthen your manuscript.

I need to know why researchers conduct this study in Uganda. Numerous studies conducted and published concerning attitudes and perceptions of nursing students toward nursing profession. Also, factors shaping these attitudes and perceptions were also investigated too much. Results of the current study are the case of the vast majority of studies concerning attitudes and perceptions of students toward nursing profession. Is the context of nursing profession in Uganda is different?- what are the factors that make researchers to address this issue now in Uganda despite availability of solid background regarding attitudes and perceptions of different stakeholders of healthcare toward nursing profession.

This manuscript is too long and need major revision.

I know the effect of mixed research design in writing manuscript but this manuscript could be focused and summarized.

Please follow the following comments;

- Sampling technique and timing of data collection need to be given.

Introduction:

- Context of nursing profession in Uganda should be reflected enough ( regulation of profession, admission criteria, vital statistics, role of nursing in healthcare delivery system in Uganda)

- What about the attitudes and perceptions of students toward nursing profession from other regions?

- Conceptual framework not clear( on which base researchers develop this framework)

- Dependent and independent variables need to be addressed in introduction

- I find results about determinants of attitudes of students toward nursing which is not reflected clearly in the aim of study

- Why researchers ignore to add research question in this study?

- Why researchers choose the purposive sampling to select participants of focus group?

- Recruitment measures for participants should be mentioned - Sample representativeness, response rate is needed.

- Timing of conducting the study should be stated

- What are the measures used to ensure validity and trustworthy of data collected from subjects?

- What is the standard of focus group discussions; is it just point of view telling or data saturation?

- What about the structure of interview questions used in focus group discussion?

- Qualitative results need to be summarized ( many verbatim quotes not needed )

- I feel if quantitative analysis used to reflect percent of students in each theme of attitudes yielded from focus group, it will give powerful impression since researchers depend only on 16 nurses to give us results about perceptions and attitudes which is questionable

- Comparison of attitudes obtained from ASNP using mean scores did not give value to the readers. It is better to use mean score percent.

- What is the meaning of "relationship between students gender, marital status, religion, entry scheme and their attitudes was negligible but significant" ?

Discussion:

- It cannot find an interesting effective debate in discussion (researchers must keep their own voice too much using effective debate guidelines).

- Some results need to be discussed as why 6.1% only of students plan to join bedside nursing after graduation

Implications:

- What are the implications from this study for both clinicians and healthcare leaders?

6. PLOS authors have the option to publish the peer review history of their article ( what does this mean? ). If published, this will include your full peer review and any attached files.

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Reviewer #1:  Yes:  Jane W Kabo

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Author response to Decision Letter 0

29 Apr 2023

PONE-D-23-00352 Choice, Attitudes, and Perceptions of Undergraduate Nursing Students towards the Nursing Profession

Response to Reviewers

1. When submitting your revision, we need you to address these additional requirements. Please ensure that your manuscript meets PLOS ONE's style requirements, including file naming.

Response: These additional requirements have been addressed

2. Please provide additional details regarding participant consent. In the ethics statement in the Methods and online submission information, please ensure that you have specified what type you obtained (for instance, written or verbal, and if verbal, how it was documented and witnessed).

Response: Written consent was obtained. The Informed consent form had provision for the participants to acknowledge consent by appending a signature and the date.

3. Your ethics statement should only appear in the Methods section of your manuscript

Response: The ethics statement has been moved to the Methods selection on page 6.

Response: The reference list has been reviewed

This is well written paper that highlights choices, attitudes and perceptions of nursing students towards nursing profession. The methodology, especially for the qualitative section needs to be improved to include reliability, validity and trustworthiness.

Response: Reliability, validity and worthiness have been included in the qualitative methodology on page 6.

Are you sure a pilot study was done? If so, this is a mini study and their findings should also be published. What was the response rate? How many students were enrolled per class? In the methodology, preferably mention proportionate sampling , if it was done

Response: A pilot study was done. 12 students were enrolled, six per class however only four responded giving a response rate of 33.3%. I do not think their findings should be published.

Reviewer #1: The manuscript describes the context and approach of the study and is conducted in a rigorous manner. The data provided supports the conclusions. The statistical analysis if rigorously conducted and presentation is appropriate for the type of data being presented. The authors have provided a link for the data access for scrutiny. It is written in standard English with very few grammatical errors. The language is clear. The manuscript will contribute to this area of scientific research if published in the website. The authors have consulted a wide range of current works that has been publish to support the study and findings.

Reviewer #2: Dear authors, Thank you for giving me such great opportunity to review this manuscript. In general, the topic is interesting one and there is a much effort undertaken. I have some inquires and some comments that will strengthen your manuscript. I need to know why researchers conduct this study in Uganda. Numerous studies conducted and published concerning attitudes and perceptions of nursing students toward nursing profession. Also, factors shaping these attitudes and perceptions were also investigated too much. Results of the current study are the case of the vast majority of studies concerning attitudes and perceptions of students toward nursing profession. Is the context of nursing profession in Uganda is different?- what are the factors that make researchers to address this issue now in Uganda despite availability of solid background regarding attitudes and perceptions of different stakeholders of healthcare toward nursing profession.

Response: This study was conducted because of the low average enrolment of nursing students in Ugandan universities compared to other medical courses and incidences of nursing students changing study programs even after reaching third year of study.

The context of the nursing profession in Uganda is different, nursing students are equally important stakeholders and their views matter because they are directly associated with the profession compared to different stakeholders.

This manuscript is too long and need major revision. I know the effect of mixed research design in writing manuscript but this manuscript could be focused and summarized.

Response: The manuscript has been revised and shortened

Response: The sampling technique and timing have been included

- Context of nursing profession in Uganda should be reflected enough ( regulation of profession,

admission criteria, vital statistics, role of nursing in healthcare delivery system in Uganda)

Response: The context of the nursing profession in Uganda has been incorporated in the background

Response: The attitudes and perceptions of students from other regions has also been included

Response: The conceptual framework has been omitted to shorten the manuscript. However it consisted of independent variables; age, gender, marital status, home area, year of study, institution of study, entry scheme, father’s education level and source of funding. The dependent variables were choice, attitudes and perceptions of undergraduate nursing students towards the nursing profession.

Response: The independent variables have been addressed in the methods section, quantitative data collection methods and tools.

Response: The results have been omitted

Response: Research questions have been added

Response: The participants chosen purposively were willing and able to provide relevant data to the study since they were knowledgeable about the topic

Response: Recruitment measures have been mentioned

Response: Timing of conducting the study has been stated

Response: To ensure validity, reliability and worthiness, the researcher provided clear information to the participants, established a relationship based on trust, accurately recorded and compared findings between the two groups

Response: The standard was data saturation

Response: A structured interview guide was followed

Response: Qualitative results have been summarized

Response: Quantitative analysis has been used to reflect percent of students in each theme

Response: This comment is not well understood

Response: This statement was irrelevant and has been omitted.

Response: Noted.

Response: These results have been discussed

Response: Clinical instructors and lecturers should create awareness programs to equip students with knowledge about the nursing and its importance, focusing on improving the image of the profession.

Health care leaders should advocate for better remuneration and employment of nurses. They should also emphasize and embrace specialty in nursing to increase efficiency and improve quality of service delivery.

Submitted filename: Response to Reviewers29042023.docx

Decision Letter 1

PONE-D-23-00352R1Choice, Attitudes, and Perceptions of Undergraduate Nursing Students towards the Nursing ProfessionPLOS ONE

==============================

Please submit your revised manuscript by Jul 21 2023 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at  gro.solp@enosolp . When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

Additional Editor Comments (if provided):

Please address comments from the third reviewer after the first revision of the initial document

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #2: All comments have been addressed

Reviewer #3: (No Response)

2. Is the manuscript technically sound, and do the data support the conclusions?

Reviewer #3: Partly

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #3: No

4. Have the authors made all data underlying the findings in their manuscript fully available?

5. Is the manuscript presented in an intelligible fashion and written in standard English?

6. Review Comments to the Author

Reviewer #2: Dear Authors Dear authors

I am more than pleased to review this manuscript

Thanks a lot for considering first review comments

This manuscript is now well coordinated, focused, and could be published in PLOS ONE

Absolutely, politicians, healthcare leaders and nursing leaders in Uganda will find a valid evidence to make a sound reform in nursing profession.

Again, thanks a lot for this fruitful paper that try to upgrade nursing profession in Africa countries.

Reviewer #3: Choice, Attitudes, and Perceptions of Undergraduate Nursing Students towards the Nursing Profession

I noticed major issues that needs to be concerned

The Title should be modified as remove as choice, “Attitudes and Perceptions of Undergraduate Nursing Students towards the Nursing Profession “ because they are already engagement of the profession.

Background: please try to describe precise information about perception and attitude and finaly show the gap here

Methods: you describe only Attitude but what about perception related questionnaires, and please incorporate data analysis information in methodology part

Result: first write the prevalence then significant variable. what is your justification:- poor academic performance in high school, desire to pursue a medical course, failure to get admitted for Medicine and Surgery, low cut-off points for the course and interest in nursing.

Attitude result shows 81.8% what about perception and choice?

Conclusion: totally your conclusion wrong <pre-nurse about="" accurate="" acquisition="" an="" and="" counseling="" courses="" enhance="" introductory="" maintenance="" nursing="" of="" perception="" profession="" the="" to=""> they discuss not being included in your finding. Add please concise and short recommendation in the conclusion.

Please describe in detail factors magnitude of attitude, perception in background.

Please replace study setting with study setting and period

Despite you used a self-administered survey that took two months to complete, your sample of 165 people is genuine

Study participants

Please write in the form of source population and study population than study participants.

� Please write sampling strategy in clear and concise way. In general it is not clear the strategy

� I'm not understanding how to take 160 samples please write with evidence based .

� Your sample sizes are not adequate and dose not representative this small size sample. So it is difficult to accept your finding for scientific evidence purpose.

� It is even possible to include other national-level universities.

Sampling procedure

Please write clearly show your sampling procedure in clear and specific schematic way

For attitude type use a five-point Likert-type but what about perception.

Please write attitude and perception tools in a separated and clearly way

The response rate was 91.6%; what had happened prior to these results?

Your Pilot study samples size not be correct. Because 15% of your sample is12 replace by 24

Completely unclear data analysis procedure; please rewrite again; it would be wiser to start with a clean check and enter and so…..

First the prevalence then the response rate in the result?

It is better to write majority 89.1% Christian and Busitema University students around half like (50%) and so….

Marital status and religion should have more than two add others (specify)

Father education level tertiary it need operationalized

Overall, the respondents perceived nursing as a good and enjoyable course (nursing is profession or course) not clear to me

The first paragraph no need of write the objective here it is better to write general information about attitude and perception.

In the second paragraph these results are in agreement with a similar study in choice what is your justification in general your result look like possibility not real finding.

The mean attitude score was 129.9±12.3 (minimum 87, maximum 153).but in data collection show that It is a five-point Likert-type scale with a minimum score of 40 and maximum of 200)

Before compare your result first writes the prevalence and range of attitude

Your study prevalence 81.8% had positive attitudes towards the nursing profession then how 62.07% similar Hue University of Medicine and Pharmacy need clarification

In general the whole discussion need detail description compare and contract

Your conclusion part not be focus your result. Please avoid terms like receive pre-nurse counseling and introductory courses about the profession, to enhance acquisition and maintenance of an accurate perception related variable, and conclude in line with your finding.

The findings cannot be generalized private but also the governmental nursing institutions in Uganda, because your sample size is very small.

In general the implication of your study not based on your results

Most of the reference out dated eg Ref 14,15,23 ….

In general, I am interested in paper and recommend publication with major modifications.</pre-nurse>

7. PLOS authors have the option to publish the peer review history of their article ( what does this mean? ). If published, this will include your full peer review and any attached files.

Submitted filename: Comments plose.docx

Author response to Decision Letter 1

Choice, Attitudes, and Perceptions of Undergraduate Nursing Students towards the Nursing Profession Review

Comments Response to comments Reference page

The title has been modified to remove choice Page 1

Background: please try to describe precise information about perception and attitude and finally show the gap here

The perception and attitudes have been described precisely Page 1

The ASNP is used to measure attitudes towards the nursing profession, it does not measure perceptions and choice.

The results for perceptions are qualitative Page 1

Conclusion: totally your conclusion wrong <pre-nurse counseling and introductory courses about the profession to enhance the acquisition and maintenance of an accurate perception of the nursing profession> they discuss not being included in your finding. Add please concise and short recommendation in the conclusion. A concise recommendation has been added to the conclusion Page 1

Please describe in detail factors magnitude of attitude, perception in background. This has been considered Page 2

Despite you used a self-administered survey that took two months to complete, your sample of 165 people is genuine Study setting has been replaced with study setting and period

The sample size was the total number of nursing students in the two universities. Page 4

Please write in the form of source population and study population than study participants. Study participants has been replaced with study population Page 4

Please write sampling strategy in clear and concise way. In general it is not clear the strategy

I'm not understanding how to take 160 samples please write with evidence based.

Your sample sizes are not adequate and dose not representative this small size sample. So it is difficult to accept your finding for scientific evidence purpose.

It is even possible to include other national-level universities The sample size was the total number of nursing students in the two universities.

All the students were invited to respond to the questionnaire because of the small number.

For the quantitative arm, all students were invited to fill the questionnaire, they were not sampled

Purposive sampling was used for the Focus Group Discussions only Page 4

Your Pilot study samples size not be correct. Because 15% of your sample is12 replace by 24 Perceptions were collected through the Focus Group Discussions. They were qualitative findings of the study

Pilot study sample size has been corrected Page 5

Completely unclear data analysis procedure; please rewrite again; it would be wiser to start with a clean check and enter and so….. The data analysis procedure has been clearly described Page 6

Overall, the respondents perceived nursing as a good and enjoyable course (nursing is profession or course) not clear to me The first section is simply describing the socio-demographics of the participants

There was no other religion noted in the responses, except denominations of Christianity such as Anglicans and Catholics

Nursing is a profession not a course

In general the whole discussion need detail description compare and contract The minimum score one can obtain using the ASNP is 40 and the maximum is 200 but for this study, the minimum score obtained was 87 and the maximum was 153.

Your conclusion part not be focus your result. Please avoid terms like receive pre-nurse counseling and introductory courses about the profession, to enhance acquisition and maintenance of an accurate perception related variable, and conclude in line with your finding. The conclusion has been improved Page 15

The findings cannot be generalized private but also the governmental nursing institutions in Uganda, because your sample size is very small. This limitation has been included Page 15

In general, I am interested in paper and recommend publication with major modifications. Reference 14 is The Uganda Nurses and Midwives Act,1996 which provides for the training, registration, enrollment and discipline of nurses and midwives in Uganda. It was enacted in 1996 and has not been reviewed since then.

Reference 23 is the Attitude Scale for the Nursing Profession which was developed in 2011.

Submitted filename: Response to Reviewers05072023.docx

Decision Letter 2

10 Jul 2023

Attitudes, and Perceptions of Undergraduate Nursing Students towards the Nursing Profession

PONE-D-23-00352R2

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Additional Editor Comments (optional):

Acceptance letter

17 Jul 2023

Attitudes and Perceptions of Undergraduate Nursing Students towards the Nursing Profession

Dear Dr. Iramiot:

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