research impact on nursing practice

Log in using your username and password

• Search More Search for this keyword Advanced search
• Latest content
• Current issue
• Write for Us
• BMJ Journals More You are viewing from: Google Indexer

You are here

• Volume 1, Issue 1

Nursing, research, and the evidence

• Article Text
• Article info
• Citation Tools
• Rapid Responses
• Article metrics

• Anne Mulhall , MSc, PhD
• Independent Training and Research Consultant West Cottage, Hook Hill Lane Woking, Surrey GU22 0PT, UK

https://doi.org/10.1136/ebn.1.1.4

Statistics from Altmetric.com

Request permissions.

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

Why has research-based practice become so important and why is everyone talking about evidence-based health care? But most importantly, how is nursing best placed to maximise the benefits which evidence-based care can bring?

Part of the difficulty is that although nurses perceive research positively, 2 they either cannot access the information, or cannot judge the value of the studies which they find. 3 This journal has evolved as a direct response to the dilemma of practitioners who want to use research, but are thwarted by overwhelming clinical demands, an ever burgeoning research literature, and for many, a lack of skills in critical appraisal. Evidence-Based Nursing should therefore be exceptionally useful, and its target audience of practitioners is a refreshing move in the right direction. The worlds of researchers and practitioners have been separated by seemingly impenetrable barriers for too long. 4

Tiptoeing in the wake of the movement for evidence-based medicine, however, we must ensure that evidence-based nursing attends to what is important for nursing. Part of the difficulty that practitioners face relates to the ambiguity which research, and particularly “scientific” research, has within nursing. Ambiguous, because we need to be clear as to what nursing is, and what nurses do before we can identify the types of evidence needed to improve the effectiveness of patient care. Then we can explore the type of questions which practitioners need answers to and what sort of research might best provide those answers.

What is nursing about?

Increasingly, medicine and nursing are beginning to overlap. There is much talk of interprofessional training and multidisciplinary working, and nurses have been encouraged to adopt as their own some tasks traditionally undertaken by doctors. However, in their operation, practice, and culture, nursing and medicine remain quite different. The oft quoted suggestion is that doctors “cure” or “treat” and that nurses “care”, but this is not upheld by research. In a study of professional boundaries, the management of complex wounds was perceived by nurses as firmly within their domain. 5 Nurses justified their claim to “control” wound treatment by reference to scientific knowledge and practical experience, just as medicine justifies its claim in other areas of treatment. One of the most obvious distinctions between the professions in this study was the contrast between the continual presence of the nurse as opposed to the periodic appearance of the doctor. Lawler raises the same point, and suggests that nurses and patients are “captives” together. 6 Questioning the relevance of scientific knowledge, she argues that nurses and patients are “focused on more immediate concerns and on ways in which experiences can be endured and transcended”. This highlights the particular contribution of nursing, for it is not merely concerned with the body, but is also in an “intimate” and ongoing relationship with the person within the body. Thus nursing becomes concerned with “untidy” things such as emotions and feelings, which traditional natural and social sciences have difficulty accommodating. “It is about the interface between the biological and the social, as people reconcile the lived body with the object body in the experience of illness.” 7

What sort of evidence does nursing need?

These arguments suggest that nursing, through its particular relationship with patients and their sick or well bodies, will rely on many different ways of knowing and many different kinds of knowledge. Lawler's work on how the body is managed by nurses illustrates this. 6 She explains how an understanding of the physiological body is essential, but that this must be complemented by evidence from the social sciences because “we also practice with living, breathing, speaking humans.” Moreover, this must be grounded in experiential knowledge gained from being a nurse, and doing nursing. Knowledge, or evidence, for practice thus comes to us from a variety of disciplines, from particular paradigms or ways of “looking at” the world, and from our own professional and non-professional life experiences.

Picking the research design to fit the question

Scientists believe that the social world, just like the physical world, is orderly and rational, and thus it is possible to determine universal laws which can predict outcome. They propose the idea of an objective reality independent of the researcher, which can be measured quantitatively, and they are concerned with minimising bias. The other major paradigm is interpretism/naturalism which takes another approach, suggesting that a measurable and objective reality separate from the researcher does not exist; the researcher cannot therefore be separated from the “researched”. Thus who we are, what we are, and where we are will affect the sorts of questions we pose, and the way we collect and interpret data. Furthermore, in this paradigm, social life is not thought to be orderly and rational, knowledge of the world is relative and will change with time and place. Interpretism/naturalism is concerned with understanding situations and with studying things as they are. Research approaches in this paradigm try to capture the whole picture, rather than a small part of it.

This way of approaching research is very useful, especially to a discipline concerned with trying to understand the predicaments of patients and their relatives, who find themselves ill, recovering, or facing a lifetime of chronic illness or death. Questions which arise in these areas are less concerned with causation, treatment effectiveness, and economics and more with the meaning which situations have—why has this happened to me? What is my life going to be like from now on? The focus of these questions is on the process, not the outcome. Data about such issues are best obtained by interviews or participant observation. These are aspects of nursing which are less easily measured and quantified. Moreover, some aspects of nursing cannot even be formalised within the written word because they are perceived, or experienced, in an embodied way. For example, how do you record aspects of care such as trust, empathy, or “being there”? Can such aspects be captured within the confines of research as we know it?

Questions of causation, prognosis, and effectiveness are best answered using scientific methods. For example, rates of infection and thrombophlebitis are issues which concern nurses looking after intravenous cannulas. Therefore, nurses might want access to a randomised controlled trial of various ways in which cannula sites are cleansed and dressed to determine if this affects infection rates. Similarly, some very clear economic and organisational questions might be posed by nurses working in day surgery units. Is day surgery cost effective? What are the rates of early readmission to hospital? Other questions could include: what was it like for patients who had day surgery? Did nurses find this was a satisfying way to work? These would be better answered using interpretist approaches which focus on the meaning that different situations have for people. Nurses working with patients with senile dementia might also use this approach for questions such as how to keep these patients safe and yet ensure their right to freedom, or what it is like to live with a relative with senile dementia. Thus different questions require different research designs. No single design has precedence over another, rather the design chosen must fit the particular research question.

Research designs useful to nursing

Nursing presents a vast range of questions which straddle both the major paradigms, and it has therefore embraced an eclectic range of research designs and begun to explore the value of critical approaches and feminist methods in its research. 8 The current nursing literature contains a wide spectrum of research designs exemplified in this issue, ranging from randomised controlled trials, 9 and cohort studies, 10 at the scientific end of the spectrum, through to grounded theory, 11 ethnography, 12 and phenomenology at the interpretist/naturalistic end. 13 Future issues of this journal will explore these designs in depth.

Maximising the potential of evidence-based nursing

Evidence-based care concerns the incorporation of evidence from research, clinical expertise, and patient preferences into decisions about the health care of individual patients. 14 Most professionals seek to ensure that their care is effective, compassionate, and meets the needs of their patients. Therefore sound research evidence which tells us what does and does not work, and with whom and where it works best, is good news. Maximum use must be made of scientific and economic evidence, and the products of initiatives such as the Cochrane Collaboration. However, nurses and consumers of health care clearly need other evidence, arising from questions which cannot be framed in scientific or economic terms. Nursing could spark some insightful debate concerning the nature and contribution of other types of knowledge, such as clinical intuition, which are so important to practitioners. 15

In summary, in embracing evidence-based nursing we must heed these considerations:

Nursing must discard its suspicion of scientific, quantitative evidence, gather the skills to critique it, and design imaginative trials which will assist in improving many aspects of nursing

We must promulgate naturalistic/interpretist studies by indicating their usefulness and confirming/explaining their rigour in investigating the social world of health care

More research is needed into the reality and consequences of adopting evidence-based practice. Can practitioners act on the evidence, or are they being made responsible for activities beyond their control?

It must be emphasised that those concerns which are easily measured or articulated are not the only ones of importance in health care. Space is needed to recognise and explore the knowledge which comes from doing nursing and reflecting on it, to find new channels for speaking of concepts which are not easily accommodated within the discourse of social or natural science—hope, despair, misery, love.

• ↵ Bostrum J, Suter WN. Research utilisation: making the link with practice. J Nurs Staff Dev 1993 ; 9 : 28 –34. OpenUrl PubMed
• ↵ Lacey A. Facilitating research based practice by educational intervention. Nurs Educ Today 1996 ; 16 : 296 –301.
• ↵ Pearcey PA. Achieving research based nursing practice. J Adv Nurs 1995 ; 22 : 33 –9. OpenUrl CrossRef PubMed Web of Science
• ↵ Mulhall A. Nursing research: our world not theirs? J Adv Nurs 1997 ; 25 : 969 –76. OpenUrl CrossRef PubMed Web of Science
• ↵ Walby S, Greenwell J, Mackay L, et al. Medicine and nursing: professions in a changing health service . London: Sage, 1994.
• ↵ Lawler J. The body in nursing . Edinburgh: Churchill Livingstone, 1997.
• ↵ Lawler J. Behind the screens nursing . Edinburgh: Churchill Livingstone, 1991.
• ↵ Street AF. Inside nursing: a critical ethnography of clinical nursing practice . New York: State University Press of New York, 1992.
• ↵ Madge P, McColl J, Paton J. Impact of a nurse-led home management training programme in children admitted to hospital with acute asthma: a randomised controlled study. Thorax 1997 ; 52 : 223 –8. OpenUrl Abstract
• ↵ Kushi LH, Fee RM, Folsom AR, et al . Physical activity and mortality in postmenopausal women. JAMA 1997 ; 277 : 1287 –92. OpenUrl CrossRef PubMed Web of Science
• ↵ Rogan F, Shmied V, Barclay L, et al . Becoming a mother: developing a new theory of early motherhood. J Adv Nurs 1997 ; 25 : 877 –85. OpenUrl CrossRef PubMed Web of Science
• ↵ Barroso J. Reconstructing my life: becoming a long-term survivor of AIDS. Qual Health Res 1997 ; 7 : 57 –74. OpenUrl CrossRef Web of Science
• ↵ Thibodeau J, MacRae J. Breast cancer survival: a phenomenological inquiry. Adv Nurs Sci 1997 ; 19 : 65 –74. OpenUrl PubMed
• ↵ Sackett D, Haynes RB. On the need for evidence-based medicine . Evidence-Based Medicine 1995 ; 1 : 5 –6. OpenUrl Abstract / FREE Full Text
• ↵ Gordon DR Tenacious assumptions in Western biomedicine. In: Lock M, Gordon DR , eds . Biomedicine Examined. London: Kluwer Academic Press, 1988;19–56.

Read the full text or download the PDF:

Click through the PLOS taxonomy to find articles in your field.

For more information about PLOS Subject Areas, click here .

Loading metrics

Open Access

Study Protocol

A global perspective of advanced practice nursing research: A review of systematic reviews protocol

Roles Conceptualization, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Affiliations Susan E. French Chair in Nursing Research and Innovative Practice, Ingram School of Nursing, Faculty of Medicine and Health Sciences, McGill University, Montréal, Québec, Canada, Centre intégré universitaire de santé et de services sociaux de l’Est-de-l’Île-de-Montréal (CIUSSS-EMTL), Montréal, Québec, Canada

Contributed equally to this work with: Isabelle Savard, Li-Anne Audet, Abby Kra-Friedman

Affiliation Ingram School of Nursing, Faculty of Medicine and Health Sciences, McGill University, Montréal, Québec, Canada

Affiliations Henrietta Szold School of Nursing, Faculty of Medicine, Hebrew University of Jerusalem, Hadassah Ein Kerem, Jerusalem, Israel, School of Nursing, Duquesne University, Pittsburgh, Pennsylvania, United States of America

Affiliation Centre intégré universitaire de santé et de services sociaux de l’Est-de-l’Île-de-Montréal (CIUSSS-EMTL), Montréal, Québec, Canada

Affiliation Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore, Singapore

Affiliation College of Nursing, University of Kentucky, Lexington, Kentucky, United States of America

Affiliation School of Nursing, MGH Institute of Health Professions, Boston, Massachusetts, United States of America

Affiliation School of Nursing, Old Dominion University, Virginia Beach, Virginia, United States of America

Affiliation School of Health Sciences, University of Dundee, Dundee, Scotland, United Kingdom

Affiliation Louise Herrington School of Nursing, Baylor University, Dallas, Texas, United States of America

Affiliation St James Public Health Services, Montego Bay, St James, Jamaica

Affiliation Department of Nursing and Midwifery, University of Huddersfield, Queensgate, Huddersfield, United Kingdom

• Kelley Kilpatrick, 
• Isabelle Savard, 
• Li-Anne Audet, 
• Abby Kra-Friedman, 
• Renée Atallah, 
• Mira Jabbour, 
• Wentao Zhou, 
• Kathy Wheeler, 
• Elissa Ladd, 

• Published: January 24, 2023
• https://doi.org/10.1371/journal.pone.0280726
• Reader Comments

Introduction

In 2020, the World Health Organization called for the expansion and greater recognition of all nursing roles, including advanced practice nurses (APNs), to better meet patient care needs. As defined by the International Council of Nurses (ICN), the two most common APN roles include nurse practitioners (NPs) and clinical nurse specialists (CNSs). They help ensure care to communities as well as patients and families with acute, chronic or complex conditions. Moreover, APNs support providers to deliver high quality care and improve access to services. Currently, there is much variability in the use of advanced practice nursing roles globally. A clearer understanding of the roles that are in place across the globe, and how they are being used will support greater role harmonization, and inform global priorities for advanced practice nursing education, research, and policy reform.

To identify current gaps in advanced practice nursing research globally.

Materials and methods

This review of systematic reviews will provide a description of the current state of the research, including gaps, on advanced practice nursing globally. We will include reviews that examine APNs, NPs or CNSs using recognized role definitions. We will search the CINAHL, EMBASE, Global Health, HealthStar, PubMed, Medline, Cochrane Library Database of Systematic Reviews and Controlled Trials Register, Database of Abstracts of Reviews of Effects, Joanna Briggs Institute, and Web of Science electronic databases for reviews published from January 2011 onwards, with no restrictions on jurisdiction or language. We will search the grey literature and hand search the reference lists of all relevant reviews to identify additional studies. We will extract country, patient, provider, health system, educational, and policy/scope of practice data. We will assess the quality of each included review using the CASP criteria, and summarize their findings. This review of systematic reviews protocol was developed following the PRISMA-P recommendations.

PROSPERO registration number

CRD42021278532.

Citation: Kilpatrick K, Savard I, Audet L-A, Kra-Friedman A, Atallah R, Jabbour M, et al. (2023) A global perspective of advanced practice nursing research: A review of systematic reviews protocol. PLoS ONE 18(1): e0280726. https://doi.org/10.1371/journal.pone.0280726

Editor: Xian-liang Liu, Charles Darwin University, AUSTRALIA

Received: October 1, 2021; Accepted: January 8, 2023; Published: January 24, 2023

Copyright: © 2023 Kilpatrick et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All data is included in the paper and/or Supporting information .

Funding: This work is supported by the McGill University Faculty of Medicine and Health Sciences and the Newton Foundation via the Susan E. French Chair in Nursing Research and Innovative Practice held by KK. KK is also supported by a Fonds de recherche du Québec-Santé ( https://frq.gouv.qc.ca/en/health/ ) Research Scholar Senior (Award Number 298573) salary award. There was no additional external funding received for this study, and the authors received no specific funding for this work. All the funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: The authors have declared that no competing interests exist.

In 2020, the World Health Organization [ 1 ] called for the expansion and greater recognition of all nursing roles, including nurses in advanced practice, to better meet patient care needs. Nurses in advanced practice roles, as defined by the International Council of Nurses (ICN), are most often identified as advanced practice nurses (APNs), with the two most common APN roles being nurse practitioners (NPs) and clinical nurse specialists (CNSs) [ 2 ]. They help ensure care to communities as well as patients and families with acute, chronic or complex conditions [ 2 ]. In addition to providing direct care, NPs and CNSs support care providers to deliver high quality care and improve access to services [ 3 – 5 ]. Nurses in these roles have educational preparation at the Master’s level or above in addition to in-depth clinical expertise and complex decision-making skills [ 6 ]. A global analysis of advanced practice nursing policy, regulation and practice by Ladd et al. [ 7 ] highlighted that advanced practice nursing roles are growing at an accelerated rate. However, these authors argue that advanced practice nursing roles have emerged unequally across the globe in response to local care needs without clear supports to develop consistent expanded roles for nurses. A recent review of systematic reviews of primary healthcare NP roles identified 396 primary studies included in the 40 systematic reviews representing on average 3 countries (range not reported to 9) [ 8 ]. Although there are several systematic reviews of APN and CNS roles in other clinical settings [ 4 , 5 , 9 ], no synthesis of this body of evidence is available for other recognized advanced practice roles, making it challenging to compare advanced practice nursing roles across jurisdictions.

Currently, there is much variability in the use of advanced practice nursing roles globally [ 1 , 7 , 10 , 11 ]. A clearer understanding of the roles that are in place across the globe, how they are being used and the outcomes that are being assessed would support greater role harmonization, and inform global priorities for advanced practice nursing education, research, and policy reform.

To identify current gaps in advanced practice nursing research globally, we propose to conduct of review of systematic reviews of studies examining APNs, NPs or CNSs using recognized advanced practice nursing role definitions [ 2 ]. We will seek to answer the question: Do current systematic reviews that include APNs, NPs or CNSs represent countries where these roles are found globally? To do so, we will address the following three aims:

• Identify the countries included in systematic reviews of APNs, NPs or CNSs;
• Describe the types of included studies, study population, role definitions, and context of care identified in the systematic reviews; and
• Examine the types of outcomes of APN, NP or CNS roles included in systematic reviews globally.

This review of systematic reviews will provide a description of the current state of the research, including gaps, on advanced practice nursing globally. We adapted methods used in an umbrella review that sought to identify indicators sensitive to the practice of primary healthcare NP practice [ 12 ]. The protocol for the review of reviews was developed following the PRISMA-P recommendations by Shamseer et al. [ 13 ]. The review of reviews is registered with the PROSPERO International Prospective Register of Systematic Reviews (Prospero ID CRD42021278532).

Inclusion criteria

Types of studies..

We will include all relevant published and unpublished systematic reviews reported from January 2011 onwards, with no restrictions on jurisdiction or language. For a review to be identified as systematic, a specific research question must be present or sufficient information must be provided so reviewers can identify the components of a research question (i.e., PICOS) related to advanced practice nursing. Additionally, the review must use prespecified inclusion and exclusion criteria, as well as systematic methods to identify relevant published and unpublished evidence to minimize the risk of bias in the retained studies [ 14 ]. Systematic reviews will be included provided the advanced practice nursing role is clearly defined and the APN, NP or CNS has decision-making autonomy [ 2 ].

Types of participants.

Participants will include patients and providers. Patients of any age, health condition, groups or communities receiving care from an APN, NP or CNS in all types (e.g., public/private; teaching/non-teaching,), sizes (e.g., small/medium/large) and locations (e.g., urban/rural) of community or care agencies (e.g., acute, long-term care, primary care, home care) will be retained. Providers will include all members of the healthcare team in all types, sizes, and locations of organizations. We will extract data to describe the country, number of participants, patient health conditions (e.g., diabetes, mental health), type of care (e.g., post-operative care), organizational characteristics, provider roles in the team, reason of APN, NP or CNS intervention (e.g., educational offering), and type of outcome.

Types of interventions.

We will include studies of APNs, NPs or CNSs in all sectors. To capture the countries where the roles that are implemented, we will identify studies in acute care and primary healthcare settings. Acute care will be defined as in-hospital or specialized ambulatory care to address specific health conditions [ 15 ]. Primary care will refer to the entry point of the healthcare system where patients receive comprehensive healthcare services for common health concerns [ 16 ].

Advanced practice nursing includes clinical and non-clinical activities related to education, research, and administration [ 17 , 18 ]. According to the International Council of Nurses, APNs are nurses prepared at the graduate level who have acquired in-depth expertise, complex decision-making skills and advanced clinical competencies [ 2 ]. Master’s or doctoral educational preparation is recommended and in many countries is required with national board certification for licensure and entry-level practice [ 2 ]. Given the diversity of terms used globally to identify APNs, NPs, and CNSs, members of the research team will help identify role titles specific to their region. For example, CNSs may be identified as nurse consultants in some regions in the United Kingdom. We will be attentive to the countries and geographical distribution of the systematic reviews that are identified and adjust our search strategy as needed.

NPs are autonomous clinicians who practice in ambulatory, acute and long-term care as primary and/or specialty care providers, both independently and in coordination with healthcare professionals and others. NPs assess, diagnose, treat, and manage acute episodic and chronic illnesses. NPs are experts in health promotion and disease prevention. They order, conduct, supervise, and interpret diagnostic and laboratory tests, prescribe pharmacological agents and non-pharmacologic therapies, as well as teach and counsel patients, among other services. In addition to clinical practice, they may serve as healthcare researchers, interdisciplinary consultants, and patient advocates. NPs provide a wide range of services to individuals, families, groups, and communities [ 3 ]. For nurses to be considered as NPs in our review of reviews, the review must specify that they completed a formal post-baccalaureate or graduate NP education program.

CNSs have expertise in a nursing specialty and perform a role that includes practice, consultation, collaboration, education, research and leadership. CNSs assist in providing solutions for complex healthcare issues and are leaders in the development of clinical practice guidelines, promoting the use of evidence, and facilitating system change [ 2 ]. CNSs specialize in a specific area of practice that may be defined in terms of a population, setting, disease or medical subspecialty, type of care or type of problem. For nurses to be considered as CNSs, the review has to specify that they completed a graduate degree and the role described must be reflective of the CNS role definition.

Types of comparators.

We will extract data related to the comparator (i.e., control) group to provide a brief description of the group to which care is being compared. Comparator groups can include the following, among others: usual care, best care, care provided by other healthcare professionals (e.g., physicians), or adherence to clinical practice guidelines.

Types of outcomes.

The outcomes of interest for this review of reviews will include any outcome of an advanced practice nursing role. We will document measures at the levels of the patient (e.g., health status, patient satisfaction, quality of life), the provider (e.g., job satisfaction, quality of care), the health system (e.g., costs, length of hospital stay, rehospitalisation, resource utilisation), education, or policy/scope of practice. Outcomes will be categorized as clinical, provider, health system, educational, policy/scope of practice.

Exclusion criteria

We will exclude reviews developed to address broad research questions (e.g., integrative reviews, literature reviews, scoping reviews).

We will exclude from the review of reviews studies related to physician assistants. Certified registered nurse anesthetists are excluded because, as of yet, they do not have global APN presence in the majority of countries with APN roles. We will also exclude nurse midwives since, across the different countries, not all regulatory requirements require these roles to be filled by nurses and nor are these roles consistently identified as advanced practice nursing roles. In reviews that include a mix of APN, NP and CNS roles and other provider roles, we will extract only data related to APNs, NPs and CNSs.

Moreover, we will exclude reviews where the impact of the APNs, NPs or CNSs cannot be teased out and is not reported separately from that of other types of nurses or healthcare team members. We will develop a list of all excluded reviews, along with the reasons justifying their exclusion.

Database search

We will limit our search to January 2011 onwards to capture the most up-to-date trends, as evidence is outdated after five years in about half of published reviews [ 19 ]. We will search the following electronic databases: CINAHL, EMBASE, Global Health, HealthStar, PubMed, Medline, Cochrane Library Database of Systematic Reviews and Controlled Trials Register, Database of Abstracts of Reviews of Effects (DARE), Joanna Briggs Institute, and Web of Science. We will combine subject headings and keywords related to advanced practice nursing (e.g.: advanced practice nursing, nurse-led), APN (e.g., advanced practice nurse, advanced practice clinician, advanced practitioner, nurse prescriber), NP (e.g., nurse practitioner, advanced practice registered nurse, family nurse practitioner, primary healthcare nurse practitioner, adult gerontology nurse practitioner, pediatric nurse practitioner, oncology nurse practitioner, emergency nurse practitioner, mental health nurse practitioner, neonatal nurse practitioner), and CNS (e.g., nurse specialists, clinical nurse specialist, infection control practitioner, nurse consultant, specialist nurse) roles/titles, along with a search filter based on the CADTH systematic reviews and meta-analyses search filter and that developed by Lunny et al. for reviews of systematic reviews to capture a broad range of roles across settings [ 20 , 21 ]. Subject headings and keywords will also include more general roles/titles, as well as those specific to primary and acute care settings, and corresponding acronyms where applicable. The full preliminary search strategy developed for the PubMed database, which will subsequently be adapted to each electronic database, is presented in S1 Appendix . We will adapt strategies reviewed by an academic librarian that have been used successfully in previous reviews [ 21 ]. In addition, we will hand search the reference lists of all relevant reviews to identify additional studies.

Moreover, we will search the grey literature will for the period of January 2011 onwards using the following websites and tools: World Health Organization, Organization for Economic Co-operation and Development (OECD), International Council of Nurses, CADTH Information Services, CADTH Grey Matters Tool, and ProQuest Dissertation and Theses. We will search the PROSPERO International Prospective Register of Systematic Reviews to identify registered review protocols, and will contact authors of registered PROSPERO reviews to ascertain study status. For each website, the content will be searched using the same search terms as those used for the published literature, e.g.: (Advanced practice nurs* OR Nurse practitioner* OR Clinical nurse specialist*) AND (Primary care OR Acute care) AND Systematic review*. If there is not an inherent search function on the website, a search will be conducted of all webpages and weblinks. The preliminary search strategy for the grey literature is presented in S2 Appendix .

Study selection

To enhance inter-rater agreement, all reviewers will be trained to use the screening instrument and inclusion/exclusion criteria. We will upload the retained studies into the EndNote and RAYYAN software [ 22 ], after which duplicates will be removed. Two reviewers will independently screen titles and abstracts using the predefined inclusion/exclusion criteria, and recommend exclusion or further full-text review. Any discrepancies will be discussed among the reviewers. Inter-rater agreement will be estimated using the kappa statistic. Additional training sessions will be planned if inter-rater agreement is low and Cohen’s kappa is below 60% [ 23 ].

To be included in our review of reviews, each paper must be identified as a systematic review, and focus on an advanced practice nursing role or intervention. If the abstract contains insufficient information or there is no abstract available, we will complete a full-text review. We will complete a full-text review for all the reviews retained after the initial screening, again using the predefined inclusion/exclusion criteria. Any coding discrepancies will be discussed among the reviewers until agreement is reached on the inclusion or exclusion of the review. In the event they are unable to reach a consensus, a third reviewer will act as tie-breaker.

Data extraction

Data from included full-text papers will be extracted by one coder and subsequently reviewed by a second coder. Any discrepancies will be resolved by consensus. A structured tool developed for a previous review of reviews will be adapted and pilot-tested by the investigators [ 12 ]. We will extract data from the methods and results section of each full-text paper. The data we will extract will include: review aim or focus; review characteristics (e.g., publication year); name and number of electronic databases searched; participant and intervention characteristics; number and types of studies included in the review; countries where studies were conducted; specification of patient, provider, health system, educational, policy, and scope of practice outcomes; and funding source [ 24 ]. Additionally, we will document APN, NP or CNS and non-APN involvement in the research team who conducted the review by extracting data related to the professional designation of the research team members.

Design of included studies

Because the addition of APNs, NPs and CNSs is a complex healthcare system intervention, different types of information are needed to inform research about advanced practice nurses [ 25 ]. Systematic reviews included in our review of systematic reviews may include the results of randomized controlled trials, prospective controlled observational studies and cohort studies, retrospective controlled observational and cohort studies, and surveys. We will develop a summary table to present key findings.

Assessment of review quality

Two reviewers will independently rate each systematic review using the 10-item Critical Appraisal Skills Programme (CASP) criteria [ 26 ] to assess the systematic review’s methodologic quality. As described above, inter-rater agreement will be assessed using Cohen’s kappa, and any disagreements will be discussed among the reviewers until they come to a consensus. We will generate a summary table with the CASP ratings.

The primary outcome of the review of reviews is to document APNs, NPs or CNSs research globally to identify gaps in current research. We will examine each advanced practice nursing role separately.

Data synthesis

A narrative synthesis of the findings will be compiled. We will use an iterative process to identify patterns and relationships emerging across the different reviews and years when they were conducted [ 27 ]. We will develop summary tables outlining the key review characteristics (e.g., publication year, countries where primary studies were conducted), outcomes (i.e., patient, provider, health system, educational, policy/scope of practice), type of advanced practice nursing role, and quality assessment. We will keep a record of all review-related decisions. No additional quantitative analyses are planned as this is not recommended for overviews because of the potential risk of overlap in studies that appear in more than one review [ 28 ].

The identification of advanced practice nursing roles that are currently in place, the countries where these nurses practice and the outcomes being used to examine practice will shed light on current gaps in the literature, and identify stronger and weaker areas of evidence related to advanced practice nursing globally. The review of systematic reviews builds on a recently completed umbrella review of NPs in primary healthcare. The current review of reviews will synthesize the characteristics of advanced practice nursing roles, study populations, contexts and outcomes to determine how closely these roles align with ICN definitions. In contexts where the roles are not optimally implemented or utilized, the findings will support the development of recommendations at the clinical, educational, and regulatory levels to improve role clarity, role implementation and access to high quality care. In addition, the development of an international strategic plan for APN role development will aid countries hoping to further expand APN practice.

Supporting information

S1 checklist. prisma-p 2015 checklist..

https://doi.org/10.1371/journal.pone.0280726.s001

S1 Appendix. Preliminary search strategies (PubMed) for the published literature.

https://doi.org/10.1371/journal.pone.0280726.s002

S2 Appendix. Preliminary search strategies for the grey literature.

https://doi.org/10.1371/journal.pone.0280726.s003

• 1. World Health Organization. State of the World’s Nursing Report 2020- Investing in education, jobs and leadership. Health Workforce. 6 April 2020. Available from: https://www.who.int/publications/i/item/9789240003279 .
• 2. International Council of Nurses, Schober M, Lehwaldt D, Rogers M, Steinke M, Turale S, et al. Guidelines on Advanced Practice Nursing. 2020. Available from: https://www.icn.ch/system/files/documents/2020-04/ICN_APN%20Report_EN_WEB.pdf .
• 3. American Association of Nurse Practitioners (ANNP). Discussion paper: Quality of nurse practitioner practice. 2020. Available from: https://storage.aanp.org/www/documents/advocacy/position-papers/Quality-of-NP-Practice-Bib_11.2020.pdf .
• View Article
• PubMed/NCBI
• Google Scholar
• 6. Canadian Nurses Association, Almost J. Regulated Nursing in Canada: The Landscape in 2021. February 2021. Available from: https://www.cna-aiic.ca/en/nursing-practice/the-practice-of-nursing/regulated-nursing-in-canada .
• 11. Schumann L, Bird B, Pilane C, Duff E, Geese F, Jelic M, et al. Mapping of advanced nursing competencies from nineteen respondent countries against the strong model of advanced practice nursing (2000) and the International Council of Nurses (2008) Advanced Practice Nursing Competencies (2013–2017). International Council of Nurses NP/APN Network Research Subgroup Publication. March 2019. Available from: https://internationalaanporg/Research/SG .
• 21. CADTH. CADTH search filters database. Ottawa. 2022. Available from: https://searchfilters.cadth.ca/list?q=&p=1&ps=20&topic_facet=systematic%20reviews%20000000%7CSystematic%20reviews .
• 26. Critical Appraisal Skills Programme (CASP). CASP Checklist: 10 questions to help you make sense of a systematic review. 2018. Available from: https://casp-uk.net/casp-tools-checklists/ .

The power of nurses in research: understanding what matters and driving change

The next blog in our series focussing on how research evidence can be implemented into practice, Julie Bayley, Director of the Lincoln Impact Literacy Institute writes about the power of nurses in research and how nurses can support the whole research journey. 

Research is a funny old beast isn’t it? It starts life as a glint in a researcher’s eye, then like a child needs nurturing, shuttling back and forth to events and usually requires constant checking to make sure it’s not doing something stupid.

As someone who spends the majority of their working life on impact – the provable benefits of research outside of the world of academia – it is extraordinarily clear to me how research can make the world better. And as a patient advocate – having chronically and not exactly willingly collected DVTs over the last decade – it’s even more clear how good research and good care together make a difference that matters.

Having had some AMAZING care, nursing strikes me as both an art and a science. A brilliant technical understanding of healthcare processes combined magically with kindness, compassion and care.  Having been hugged by nurses as I cried being separated from my newborn (post DVT), and watching nurses let dad happily talk them through his army photo album as they check on his dementia, I am in no doubt that such compassion is what marks the difference between not just being a patient, but being a person .

One of the oddities about research is how we can so often get the impression that only big and shiny counts. ‘Superpower’ studies such as Randomised Controlled Trials, and multi-national patient cohort studies are amazing, but can mask the breadth of the millions of questions research can explore in endless different ways. Of course we need trials to determine ‘what works’, but we also need research to unveil the stories of those who feel their rarely heard, understand how things work, and connect research to people’s lives.

Research essentially is just the act of questioning in a structured, ethical and transparent way. It might seek to understand things through numbers (quantitative) or words and experiences (qualitative), and may reveal something new or confirm something we already believe. Research is the bedrock of evidence based care, allowing us – either through new (‘primary’) or existing (‘secondary’) data – to explore, understand, confirm or disprove ways patients can be helped. Some of you reading this will be very research active, some of you might think it’s not for you, some may not know where to start, and others may hate the idea altogether. Let’s face it, healthcare is an extremely pressured environment, so why would you add research into an already busy day job? The simple truth is that research gives us a way to add to this care magic, helping to ensure care pathways are the best, safest and most appropriate in every situation.

The pace and scale of research stories can make it easy to presume research is something ‘other people’ do, and whilst there are many brilliant professionals and professions within healthcare, nurses have a unique and phenomenally important place in research in at least three key ways:

• Understanding what matters to patients. A person is far more than their illness, and being so integral to day to day care, nurses have a lens not only on patients’ conditions, but how these interweave with concerns about their life, their livelihood, their loved ones and all else. And it is in this mix that the fuller impact of research can be really understood, way beyond clinical outcome measures, and into what it what matters .
• Understanding how to mobilise and implement new knowledge. Even if new research shows promise, the act of implementing it in a pressured healthcare system can be immensely challenging. Nurses are paramount for understanding – amongst many other things – how patients will engage (or not), what can be integrated into care pathways (or can’t), what unintended consequences could be foreseen and what (if any) added pressures new processes will bring for staff. This depth of insight borne from both experience and expertise is vital to mobilising, translating and otherwise ‘converting’ research promise into reality.
• Driving research . Nurses of course also drive research of all shapes and sizes. Numerous journals, such as BMC Nursing and the Journal of Research in Nursing bear testament to the wealth of research insights driven by nurses, and shared widely to inform practice.

Research isn’t owned by any single profession, or defined by any size. Whatever methods, scale or theories we use, research is the act of understanding, and if nurses aren’t at the heart of understanding the patient experience and the healthcare system, I don’t know who is. So when it comes to research:

• Recognise the value you already bring. You are front and centre in care which gives you a perspective on patient and system need that few others have. Ask yourself, what matters?
• Recognise the sheer breadth of research possibilities, and the million questions it hasn’t yet been used to answer. Ask yourself, what needs to be understood?
• Use – or develop – your skills to do research. Connect with researchers, read up, or just get involved. Ask yourself, how can I make my research mark?

Research is important because people are important. If you’re nearer the research-avoidant than the research-lead end of the spectrum, I’d absolutely urge you to get more involved. Whether you shine a light on problems research could address, critically inform the implementation of research, or do the research yourself….

….from this patient and research impact geek…

Comment and Opinion | Open Debate

The views and opinions expressed on this site are solely those of the original authors. They do not necessarily represent the views of BMJ and should not be used to replace medical advice. Please see our full website terms and conditions .

All BMJ blog posts are posted under a CC-BY-NC licence

BMJ Journals

Cookies on the NHS England website

We’ve put some small files called cookies on your device to make our site work.

We’d also like to use analytics cookies. These send information about how our site is used to a service called Google Analytics. We use this information to improve our site.

Let us know if this is OK. We’ll use a cookie to save your choice. You can  read more about our cookies before you choose.

Change my preferences I'm OK with analytics cookies

Nursing research and evidence underpinning practice, policy and system transformation

Research led by nurses and the contributions they make as members of multidisciplinary research teams can drive change. Evidence from research influences and shapes the nursing profession, and informs and underpins policy, professional decision-making and nursing actions. It is the cornerstone of high-quality, evidence-based nursing.

Making research matter – The Chief Nursing Officer (CNO) for England’s strategic plan for research is for all nurses working in health and social care, whether they are already or thinking about getting involved in research), colleagues in academia and the third sector and all those who support research.

The CNO for England’s strategic plan for research sets out the ambition to “create a people-centred research environment that empowers nurses to lead, participate in and deliver research, where research is fully embedded in practice and professional decision-making, for public benefit”. Fulfilling this ambition will strengthen and expand nurses’ contribution to health and care outcomes through research of global significance. This provides the scientific basis for: the care of people across the lifespan; during illness, through to recovery and at the end of life, preventing illness, protecting health and promoting wellbeing.

Five themes underpin this ambition:

• Aligning nurse-led research with public need – so the portfolios of relevant funders reflect the research priorities of patients, carers, service users, residents, the public and our profession.
• Releasing nurses’ research potential – to create a climate in which nurses are empowered to lead, use, deliver and participate in research as part of their job, and the voice of the profession is valued.
• Building the best research system – so that England is the best place for nurses to lead, deliver and get involved in cutting-edge research.
• Developing future nurse leaders of research – to offer rewarding opportunities and sustainable careers that support growth in the number and diversity of nurse leaders of research .
• Digitally-enabled nurse-led research – to create a digitally-enabled practice environment for nursing that supports research and delivers better outcomes for the public.

The plan builds on existing commitments and priorities set out in the NHS Long Term Plan and closely aligns with the UK Clinical Research Recovery, Resilience and Growth (RRG) Programme , which brings together partners from across the NHS, academia, government, universities, regulators, charities, patients and the public. This alignment means the nursing profession will be able go further in tackling challenges and embedding sustainable, effective and innovative practices that reflect system-wide priorities.

Publication links

• The Chief Nursing Officer (CNO) for England’s strategic plan for research – full version.
• The Chief Nursing Officer (CNO) for England’s strategic plan for research – executive summary .

Implementation plan

We are delivering the strategic plan through close collaboration with colleagues across NHS England and Health Education England (HEE), the Department of Health and Social Care (DHSC), National Institute of Health and Care Research (NIHR), Council of Deans of Health (CoDH) and Royal College of Nursing (RCN).

Below is a summary of the activities underway in 2022 or planned for 2023 that start turning the plan into reality, organised by the five themes listed above.

Strategic focus 1: Aligning nurse-led research with public need

• Research demand signalling – to identify, prioritise and articulate research questions most pertinent to nursing practice. We are first doing this for mental health building on the research demand signalling of national mental health programme , working with the Deputy Director of Mental Health Nursing and the Innovation, Research and Life Sciences Group (IRLS).

Impact : A clear understanding of the research questions in mental health that the nursing profession is best placed to address. This process will also inform how we adopt it for other areas of nursing.

• Explore how the top 3 evidence uncertainties identified by the Community Nursing James Lind Alliance Priority Setting Partnership should be signalled to academics and funders of research.

Impact: By developing research questions for the top 3 community nursing priorities, funders will know what research is most needed to underpin this field of practice and improve population health and patient care.

• Working with the IRLS and stakeholders, develop an action plan in response to the commissioned report ‘Implementation Strategies in Respect of Addressing Inequalities in Race and Health in the CNO for England’s Strategic Plan for Research’.

Impact: Co-production of this action plan will support development of an inclusive health and care research system for people, communities and the profession.

Strategic focus 2: Releasing nurses’ research potential

• With NIHR help establish a research interest group and develop a research toolkit for clinical matrons, to support their role in enabling research and innovation across nursing teams.

Impact: Giving this group of nursing leaders a suite of resources and network of support will help research become business as usual, increasing nurse engagement in supporting, leading and delivering research.

• Scope what trust and integrated care board (ICB) executive nurse leaders require to make research matter in every nurse’s practice and design a programme of learning and development in response to this.

Impact: By promoting understanding of the benefits of involving nurses in the leadership, delivery and support of research among senior nursing leaders, the voice of the profession will be heard when and where decisions are made about prioritisation, commissioning, management and translation of research.

• Scope systems, processes and approaches that facilitate use of research evidence – the first step of an initiative to encourage transfer and implementation of evidence into nursing practice.

Impact: Strategies to strengthen the transfer and implementation of research evidence by the nursing profession will improve population health and the provision of safe and effective nursing care.

• With the Chief Midwifery Officer (CMidO) research teams, support NIHR to identify features of successful research-related roles for nurses and midwives in community, public health, and social care.

Impact: By identifying what makes these roles succeed in settings outside acute hospitals, interventions can be designed to increase capacity and capability in these settings, diversifying opportunities for participation and engagement in research.

Strategic focus 3: Building the best research system

• Work with the CMidO research teams and IRLS, NIHR Director of Nursing and Midwifery, HEE Chief Nurse, DHSC and RCN to ensure strategic alignment of respective work programmes.

Impact: By co-ordinating activity across England, stay on track to deliver the ambition and communicate a clear and consistent message.

• Clarify roles and responsibilities of regional, integrated care board and trust executive nurse leaders in building nurse-related research capacity and capability, as well as the actions they might take to support implementation of the plan.

Impact: Clarity about duties and responsibilities, supporting sustainable change through system-wide leadership.

• Support delivery of the NIHR Senior Research Leader: Nursing and Midwifery programme by offering regional and national internship opportunities.

Impact: Programme participants will be pivotal in implementing the CNO strategic plan for research, as well as the Future of Clinical Research Delivery 2022-2025 Implementation Plan and Best Research for Best Health: Next Chapter , propagating effective system leadership.

• Ensure strategic co-ordination and harmonisation of work with relevant NHS England deputy directors/heads of nursing (for example but not limited to, community nursing, mental health, children and learning disabilities) and the Chief Nurse for Adult Social Care and Chief Nurse at the Office of Health Improvement and Disparities (both at DHSC).

Impact: Cross-programme connections will ensure efficient and effective plan implementation, provide opportunities to address diverse population health needs and health inequalities, and maximise impact across the different fields of nursing and sectors.

• Supporting delivery of commitments in the NHS Long Term plan and RRG work programme, IRLS are developing research metrics for provider and ICB assurance, aligned to this with CMidO research teams,, explore which metrics and reporting increase the visibility of nurse – led research across the NHS and strengthen incentives for trusts and boards to support nurses’ involvement in leadership and delivery of research.

Impact: A data-based approach will enable sustainable change across the NHS, and by giving leaders insight into performance against the ambitions of the strategic plan for research, is a means of demonstrating the impact of research on patient outcomes and improvements in patient care and population health.

• Commission a tool for organisations to self-assess their readiness and progress towards achieving the ambitions of the strategic plan for research.

Impact: This tool will facilitate planning by establishing a baseline against which an organisation’s progress can be measured.

Strategic focus 4: Developing future nurse leaders of research

• Agree work to overcome challenges limiting growth in number and diversity of nurses wishing to pursue a research-focused career in the NHS, social care and public health settings resulting from discussions at the NIHR/NHS England nursing summit in June 2022.

Impact: By building and securing a sustainable clinical academic and research delivery nursing workforce and making research-related roles more appealing, NHS and social care providers will be equipped to attract and retain the best talent and augment overall system capacity.

• HEE Centre for Advancing Practice, with the CNO and CMidO research teams, will develop a research-related capability framework and career pathway(s) that align with enhanced, advanced and consultant levels of practice.

Impact: Clear career structures and associated roles that align with levels of practice will increase the value and attractiveness of research roles for the health and care professions; more nurses will get involved in research and for some become a major part of their career plans.

• Led by the IRLS, working with CNO and CMidO research teams and lead officers for other registered health professions, explore use of workforce intelligence to inform workforce planning for those involved in research.

Impact: Workforce intelligence data will enable ICBs and trusts to develop workforce plans that reflect the ambition for the nursing workforce to lead, participate in and deliver research as part of providing high quality patient care and the business of every nurse and midwife.

• In collaboration with NIHR, CoDH and other partners, promote growth of ethnic minority nurse research leaders.

Impact: Targeted activities will diversify the profile of research leaders and widen access for nurses aspiring to academic and clinical academic roles.

• With the CMidO research team, collaborate with the NIHR supported Nursing and Midwifery Incubator on initiatives to identify and address barriers to increasing research capacity in nursing and midwifery.

Impact: Attracting, training and supporting future nurse and midwife research leaders of research will complement and maximise other investments to develop a skilled research workforce.

• With the CMidO research team, support NIHR Nursing and Midwifery’s development of flexible career pathways for research nurses: a programme for nurse/midwife principal investigators and better integration of clinical and research roles.

Impact: Flexible career options encourage movement between supporting, delivering and leading research, promoting a culture in which research is the business of every nurse and midwife.

Strategic focus 5: Digitally enabled nurse-led research

• Scoping and discovery work to understand the opportunities and challenges associated with establishing a minimum dataset for nursing (the standardised collection of essential nursing data).

Impact: This element of digital architecture – that is, a nursing minimum dataset – will be the foundation for the standardised collection of essential nursing data to enable analysis and comparison of data across populations, settings, geographical areas and time.

• With the CMidO research team, contribute to the work of the UK Clinical Research RRG programme using data-driven methods and digital tools to transform the way people-centred clinical research studies are designed, managed and delivered.

Impact: Improved nurse-led research study planning, recruitment and follow-up, and access to data, ensuring research is enabled by data and digital tools.

• Collaborate with HEE to deliver the actions the Phillips Ives Nursing & Midwifery Review recommends to ensure nurses and midwives can access the knowledge, skills and education they require for safe, effective digitally-enabled practice.

Impact: Empowers nurses and midwives to practise in and lead a digitally-enabled health and social care system, with practice fully supported by digital technology and data science.

• Establish a digital nursing journal club to build a community of digitally enabled nurse-led practice.

Impact: This community of practice will connect nurse academics with provider chief nursing information officers, to build knowledge and expertise in this growing sphere of nursing.

We will keep you updated on progress and plans by making updates to this page and via the CNO’s Bulletin Nursing and Midwifery Matters .

If you would like to get involved in the CNO’s strategic plan for research, please contact [email protected] .

The Impact of Education on Nursing Practice

The American Association of Colleges of Nursing (AACN), the national voice for academic nursing, recognizes that education has a significant impact on the knowledge and competencies of the nurse clinician, as it does for all healthcare providers. Clinicians with a Bachelor of Science in Nursing (BSN) degree are well-prepared to meet the demands placed on today's nurses. BSN nurses are prized for their skills in critical thinking, leadership, case management, and health promotion, and for their ability to practice across a variety of inpatient and outpatient settings. Nurse executives, federal agencies, the military, leading nursing organizations, healthcare foundations, Magnet hospitals, and minority nurse advocacy groups all recognize the unique value that baccalaureate-prepared nurses bring to health care.

AACN encourages employers to foster practice environments that embrace lifelong learning and offer incentives for registered nurses (RNs) seeking to advance their education to the baccalaureate and higher degree levels. We also encourage BSN graduates to seek out employers who value their level of education and distinct competencies.

Download Fact Sheet [PDF]

Different Approaches to Nursing Education

There are three routes to becoming a registered nurse: a 3-year diploma program typically administered in hospitals; a 3-year associate degree usually offered at community colleges; and the 4-year baccalaureate degree offered at senior colleges and universities. Graduates of all three programs sit for the same NCLEX-RN© licensing examination.

Baccalaureate nursing programs encompass all course work taught in associate degree and diploma programs plus a more in-depth treatment of the physical and social sciences, nursing research, public and community health, nursing management, and the humanities. The additional course work enhances the student’s professional development, prepares the new nurse for a broader scope of practice, and provides the nurse with a better understanding of the cultural, political, economic, and social issues that affect patients and influence healthcare delivery. The BSN prepares nurses to practice the full scope of nursing responsibilities across all healthcare settings (NASEM, 2021). For more than two decades, policymakers, healthcare authorities, and practice leaders have recognized that education makes a difference when it comes to nursing practice.

• In April 2023, results from the 2022 National Nursing Workforce Survey show that the percentage of RNs with a BSN or higher degree in the US workforce exceeded 70% for the first time (71.7%).  Most nurses now enter the workforce with a BSN or entry-level master’s degree (51.5%). This survey is administered every two years by the National Council of State Boards of Nursing and the National Forum of State Nursing Workforce Centers.  
• Issued in November 2022, findings from the  CGFNS Nurse Migration Report 2022  point to an international shift toward baccalaureate education as the preferred pathway into the nursing profession. The latest data show the majority of nurses who migrated to the U.S. in 2022 were educated at the baccalaureate or higher level, which is consistent with how most new nurses are prepared in U.S. schools of nursing.  
• In March 2019, AACN approved a position statement on Academic Progression in Nursing , which called for preparing all RNs with a baccalaureate degree, at minimum, offered by an accredited four-year college or university. AACN supports the many pathways available to assist nurses in advancing their education, including expanding articulation agreements and concurrent enrollment options with community colleges.  
• In December 2017, the governor of New York signed legislation into law requiring future registered nurses graduating from associate degree or diploma nursing programs in the state to obtain a baccalaureate in nursing within 10 years of initial licensure. The legislators found that given “the increasing complexity of the American healthcare system and rapidly expanding technology, the educational preparation of the registered professional nurse must be expanded.”  
• In the September-October 2014 issue of Nurse Educator , a research team led by Dr. Sharon Kumm from the University of Kansas published findings from a statewide study , which showed clear differences in outcomes from BSN and associate degree in nursing (ADN) programs. The study showed that 42 of 109 baccalaureate outcomes were met in ADN programs. The 67 outcomes that were not met were in the areas of liberal education, organizational and systems leadership, evidence-based practice, healthcare policy, finance and regulatory environments, interprofessional collaboration, and population health.  
• In September 2013, the Robert Wood Johnson Foundation (RWJF) released an issue of its Charting Nursing’s Future newsletter titled The Case for Academic Progression , which outlined how patients, employers, and the profession benefit when nurses advance their education. Articles focus on the evidence linking better outcomes to baccalaureate and higher degree nurses, educational pathways, and promising strategies for facilitating academic progression at the school, state, and national levels.  
• In September 2012, the Joint Statement on Academic Progression for Nursing Students and Graduates was endorsed by the American Association of Colleges of Nursing, American Association of Community Colleges, Association of Community College Trustees, National League for Nursing, and the Organization for Associate Degree Nursing. This historic agreement represents the first time that leaders from the major national organizations representing community college presidents, boards, and administrators joined with representatives from nursing education associations to promote academic progression in nursing. With the goal of preparing a well-educated, diverse nursing workforce, this statement represents the shared view that nursing students and practicing nurses should be supported in their efforts to pursue higher levels of education.  
• In October 2010, the Institute of Medicine released its landmark report on The Future of Nursing: Leading Change, Advancing Health , initiated by the Robert Wood Johnson Foundation, which called for increasing the number of baccalaureate-prepared nurses in the workforce to 80% by 2020. The expert committee charged with preparing the evidence-based recommendations in this report state that to respond “to the demands of an evolving healthcare system and meet the changing needs of patients, nurses must achieve higher levels of education.”  
• In May 2010, the Tri-Council for Nursing (AACN, ANA, AONL, and NLN) issued a statement calling for all RNs to advance their education in the interest of enhancing quality and safety across healthcare settings. In the statement titled Education Advancement of Registered Nurses , the Tri-Council organizations present a united view that a more highly educated nursing workforce is critical to meeting the nation’s nursing needs and delivering safe patient care. The Tri-Council finds that “without a more educated nursing workforce, the nation's health will be further at risk.”  
• In December 2009, Dr. Patricia Benner and her team at the Carnegie Foundation for the Advancement of Teaching released a study titled Educating Nurses: A Call for Radical Transformation , which recommended preparing all entry-level registered nurses at the baccalaureate level and requiring all RNs to earn a master’s degree within 10 years of initial licensure. The authors found that many of today’s new nurses are “undereducated” to meet practice demands across settings.  
• In February 2008, the Council on Physician and Nurse Supply , which is based at the University of Pennsylvania, called for increasing nursing school graduations by 30% and for increased federal support to enable more nurses to complete the BSN.  
• In March 2005, the American Organization of Nurse Executives (AONE) – today known as the American Organization for Nursing Leadership (AONL) - released a statement calling for all RNs to be educated in baccalaureate programs to adequately prepare clinicians for their challenging, complex roles. AONL’s statement, titled Practice and Education Partnership for the Future, represents the view of nursing’s practice leaders and a desire to create a more highly educated nursing workforce in the interest of improving patient safety and nursing care.  
• The National Advisory Council on Nurse Education and Practice (NACNEP) has urged that at least two-thirds of the nurse workforce hold baccalaureate or higher degrees in nursing. In a 2000 report , NACNEP found that nursing’s role calls for RNs to manage care along a continuum, to work as peers in interdisciplinary teams, and to integrate clinical expertise with knowledge of community resources. To meet scope of practice expectations, RNs must have critical thinking and problem-solving skills; a sound foundation in a broad range of basic sciences; knowledge of behavioral, social and management sciences; and the ability to analyze and communicate data. Among the three types of entry-level nursing education programs, NACNEP found that the BSN, with its broader and stronger scientific curriculum, best fulfills these requirements and provides a sound foundation for addressing the complex healthcare needs of today in a variety of nursing positions. Baccalaureate education provides a base from which nurses move into graduate education and advanced nursing roles.  
• Currently, there are 747 RN-to-BSN and 195 RN-to-MSN programs that build on the education provided in associate degree and diploma programs and prepare graduates for a broader base of practice (AACN, 2023). In addition to hundreds of individual agreements between community colleges and four-year schools, state-wide articulation agreements exist in most states to facilitate advancement to the baccalaureate. These programs further validate the unique competencies gained in BSN programs.  
• RNs work as part of an interprofessional team with colleagues educated at the graduate level. These professionals, including physicians and pharmacists, recognize the complexity involved in providing care and the need for higher education. Because nurses are primarily responsible for direct patient care and care coordination, these clinicians should not be the least educated member of the healthcare team.

Recognizing Differences Among Nursing Program Graduates

There is a growing body of evidence that indicates BSN graduates bring unique skills to their work as nursing clinicians and play an important role in the delivery of safe patient care.

•   In March 2022,  Nursing Outlook  published an article from Dr. Joshua Porat-Dahlerbruch, Dr. Linda Aiken, and colleagues that explored “ Variations in Nursing Baccalaureate Education and 30-day Inpatient Surgical Mortality .” The authors found that having a higher proportion of baccalaureate-prepared nurses in hospital settings, regardless of educational pathway, is associated with lower rates of 30-day inpatient surgical mortality.  
• In the July 2019 issue of  Health Affairs , Dr. Jordan Harrison, Dr. Linda Aiken, and their colleagues from the University of Pennsylvania published findings from a study, which found that each 10% increase in the hospital share of nurses with a BSN was associated with 24% greater odds of surviving to discharge with good cerebral performance among patients who experienced in-hospital cardiac arrest.  
• In the March 2019 issue of The Joint Commission Journal of Quality and Patient Safety , Dr. Maya Djukic and colleagues from New York University released details from a study, which found that baccalaureate-prepared RNs reported being significantly better prepared than associate degree nurses on 12 out of 16 areas related to quality and safety, including evidence-based practice, data analysis, and project implementation. The authors conclude that improving accreditation and organizational policies requiring the BSN for RNs could help safeguard the quality of patient care.  
• In the July 2017 issue of BMJ Quality and Safety , Dr. Linda Aiken and colleagues reported findings from a study of adult acute care hospitals in six European nations, which found that a greater proportion of professional nurses at the bedside is associated with better outcomes for patients and nurses. Reducing nursing skill mix by adding assistive personnel without professional nurse qualifications may contribute to preventable deaths, erode care quality, and contribute to nurse shortages.  
• In the October 2015 issue of Global Qualitative Nursing Research , Dr. Allison Brandt Anbari published a qualitative meta-synthesis of studies on practice differences identified by graduates of RN to BSN programs. Nurses completing the programs reported enhanced assessment and critical thinking skills, improved communication abilities, and better patient outcomes. Findings were consistent with a 1988 study published by Dr. Joyce Johnson in Research in Nursing and Health .  
• In a study published in the October 2014 issue of Medical Care , researcher Dr. Olga Yakusheva from the University of Michigan and colleagues found that a 10% increase in the proportion of baccalaureate-prepared nurses on hospital units was associated with lowering the odds of patient mortality by 10.9%. The authors also found that increasing the amount of care provided by BSNs to 80% would result in significantly lower readmission rates and shorter lengths of stay. These outcomes translate into cost savings that would more than off-set expenses for increasing the number of baccalaureate-prepared nurses in hospital settings.  
• In the May 2013 issue of Medical Care , researchers from the University of Pennsylvania, led by Dr. Matthew McHugh, found that surgical patients in Magnet hospitals had 14% lower odds of inpatient death within 30 days and 12% lower odds of failure-to-rescue compared with patients cared for in non-Magnet hospitals. The study authors conclude that these better outcomes were attributed in large part to investments in highly qualified and educated nurses, including a higher proportion of baccalaureate-prepared nurses.  
• In an article published in the March 2013 issue of Health Affairs , nurse researcher Dr. Ann Kutney-Lee and colleagues found that a 10-point increase in the percentage of nurses holding a BSN within a hospital was associated with an average reduction of 2.12 deaths for every 1,000 patients—and for a subset of patients with complications, an average reduction of 7.47 deaths per 1,000 patients.  
• In the February 2013 Journal of Nursing Administration , Dr. Mary Blegen and colleagues published findings from a study of 21 University HealthSystem Consortium hospitals on the association between RN education and patient outcomes. Hospitals with a higher percentage of RNs with baccalaureate or higher degrees had lower rates of congestive heart failure mortality, decubitus ulcers, failure to rescue, and postoperative deep vein thrombosis as well as shorter lengths of stay.  
• In a January 2011 article published in the Journal of Nursing Scholarship , Drs. Deborah Kendall-Gallagher, Linda Aiken, and colleagues released the findings of an extensive study of the impact nurse specialty certification has on lowering patient mortality and failure to rescue rates in hospitals. The researchers found that certification was associated with better patient outcomes, but only when care was provided by nurses with baccalaureate-level education. The authors concluded that “no effect of specialization was seen in the absence of baccalaureate education.”  
• In an article published in Health Services Research in August 2008 that examined the effect of nursing practice environments on outcomes of hospitalized cancer patients undergoing surgery, Dr. Christopher Friese and colleagues found that nursing education level was significantly associated with patient outcomes. Nurses prepared at the baccalaureate-level were linked with lower mortality and failure-to-rescue rates. The authors conclude that “moving to a nurse workforce in which a higher proportion of staff nurses have at least a baccalaureate-level education would result in substantially fewer adverse outcomes for patients.”  
• In a study released in the May 2008 issue of the Journal of Nursing Administration , Dr. Linda Aiken and colleagues confirmed the findings from her landmark 2003 study, which show a strong link between RN education level and patient outcomes. Titled “Effects of Hospital Care Environment on Patient Mortality and Nurse Outcomes,” the researchers found that every 10% increase in the proportion of BSN nurses on the hospital staff was associated with a 4% decrease in the risk of death.  
• In the January 2007 Journal of Advanced Nursing , a study on the “Impact of Hospital Nursing Care on 30-day Mortality for Acute Medical Patients” found that BSN-prepared nurses have a positive impact on lowering mortality rates. Led by Dr. Ann E. Tourangeau, a team of Canadian researchers studied 46,993 patients admitted to the hospital with heart attacks, strokes, pneumonia, and blood poisoning. The authors found that “hospitals with higher proportions of baccalaureate-prepared nurses tended to have lower 30-day mortality rates.” Findings indicated that a 10% increase in the proportion of BSN nurses was associated with 9 fewer deaths for every 1,000 discharged patients.  
• In a study published in the March/April 2005 issue of Nursing Research , Dr. Carole Estabrooks and her colleagues at the University of Alberta found that baccalaureate-prepared nurses have a positive impact on mortality rates following an examination of more than 18,000 patient outcomes at 49 Canadian hospitals. This study, titled “The Impact of Hospital Nursing Characteristics on 30-Day Mortality,” confirms the findings from Dr. Linda Aiken’s landmark study in September 2003.  
• In a study published in the Journal of the American Medical Association (JAMA) on September 24, 2003, Dr. Linda Aiken and colleagues at the University of Pennsylvania identified a clear link between higher levels of nursing education and better patient outcomes. This extensive study found that surgical patients have a "substantial survival advantage" if treated in hospitals with higher proportions of nurses educated at the baccalaureate or higher degree level. In hospitals, a 10% increase in the proportion of nurses holding BSN degrees decreased the risk of patient death and failure to rescue by 5%. The authors recommend that public financing of nursing education should aim at shaping a workforce best prepared to meet the needs of the population. They also call for renewed support and incentives from nurse employers to encourage RNs to pursue baccalaureate and higher degree levels.  
• Evidence shows that nursing education level is a factor in patient safety and quality of care. As cited in the report When Care Becomes a Burden released by the Milbank Memorial Fund in 2001, two separate studies conducted in 1996 – one by the state of New York and one by the state of Texas – clearly show that significantly higher levels of medication errors and procedural violations are committed by nurses prepared at the associate degree and diploma levels as compared with the baccalaureate level. These findings are consistent with findings published in the July/August 2002 issue of Nurse Educator by Dr. Cheryl Delgado that reference studies conducted in Arizona, Colorado, Louisiana, Ohio, and Tennessee that also found that nurses prepared at the associate degree and diploma levels make the majority of practice-related violations.  
• Chief nurse officers (CNOs) in university hospitals prefer to hire nurses who have baccalaureate degrees, and nurse administrators recognize distinct differences in competencies based on education. In a 2001 survey published in the Journal of Nursing Administration , 72% of these CNOs identified differences in practice between BSN-prepared nurses and those who have an associate degree or hospital diploma, citing stronger critical thinking and leadership skills (Goode et al., 2001). A strong preference for hiring new RNs with a BSN was confirmed in a study released by NCSBN in 2002.  
• Research shows that RNs prepared at the associate degree and diploma levels develop stronger professional-level skills after completing a BSN program. In a study of RN-to-BSN graduates from 1995 to 1998 (Phillips et al., 2002), these students demonstrated higher competency in nursing practice, communication, leadership, professional integration, and research/evaluation.  
• Data show that healthcare facilities with higher percentages of BSN nurses enjoy better patient outcomes and significantly lower mortality rates. Magnet hospitals are model patient care facilities that typically employ a much higher proportion of baccalaureate prepared nurses when compared to other hospitals. In several research studies, Dr. Marlene Kramer (1988), Dr. Linda Aiken (2013) and others have found a strong relationship between organizational characteristics and patient outcomes.  
• The fact that graduates of baccalaureate, associate degree, and diploma nursing programs can pass the NCLEX-RN©, the national licensing exam for RNs, is not proof that no differences exist among graduates. The NCLEX-RN© is a multiple-choice test that measures the minimum technical competency for safe entry into basic nursing practice. Passing rates should be high across all programs preparing new nurses. This exam does not test for differences between graduates of different entry-level programs. The NCLEX-RN© is only one indicator of competency, and it does not measure performance over time or test for all knowledge and skills developed through a BSN program.

Public and Private Support for BSN-Prepared Nurses

The federal government, the military, nurse executives, healthcare foundations, nursing organizations, and practice settings acknowledge the unique value of baccalaureate-prepared nurses and advocate for an increase in the number of BSN nurses across clinical settings.

• The nation’s Magnet hospitals , which are recognized for nursing excellence and superior patient outcomes, have moved to require all nurse managers and nurse leaders to hold a baccalaureate or graduate degree in nursing.  
• The National Advisory Council on Nurse Education and Practice (NACNEP), policy advisors to Congress and the Secretary for Health and Human Services on nursing issues, and the National Academy of Science, Engineering, and Medicine recognize the unique contributions of baccalaureate-prepared nurses to high quality, safe, and effective patient care.  
• In the interest of providing the best patient care and leadership by its nurse corps officers, the U.S. Army , U.S. Navy, and U.S. Air Force all require the baccalaureate degree to practice as an active-duty Registered Nurse. Commissioned officers within the U.S. Public Health Service also must be baccalaureate prepared.  
• The Veteran's Administration (VA), the nation's largest employer of registered nurses, has established the baccalaureate degree as the minimum preparation its nurses must have for promotion beyond the entry-level.  
• Minority nurse organizations, including the National Black Nurses Association , Hispanic Association of Colleges and Universities , and National Association of Hispanic Nurses , are committed to increasing the number of minority nurses with baccalaureate and higher degrees.  
• Based on a nationwide Harris Poll conducted in June 1999, an overwhelming percentage of the public – 76% – believes that nurses should have four years of education or more past high school to perform their duties.  
• The Pew Health Professions Commission in a 1998 report called for a more concentrated production of baccalaureate and higher degree nurses. This commission was an interdisciplinary group of healthcare leaders, legislators, academics, corporate leaders, and consumer advocates created to help policymakers and educators produce a workforce able to meet the changing needs of the American healthcare system.  
• Countries around the world are moving to create a more highly educated nursing workforce. Canada, Sweden, Portugal, Brazil, Iceland, Korea, Greece, and the Philippines are just some of the countries that require a four-year undergraduate degree to practice as a registered nurse.

Fact Sheet References

Aiken, L. H., Sloan, D., Griffiths, P. et al. (2017). Nursing skill mix in European hospitals: association with mortality, patient ratings, and quality of care. BMJ Quality & Safety , 26(7), 559- 568. DOI: 10.1136/bmjqs-2016-005567.

Aiken, L.H., Clarke, S.P., Sloane, D.M., Lake, E.T., & Cheney, T. (2008, May). Effects of hospital care environment on patient mortality and nurse outcomes. Journal of Nursing Administration , 38(5), 223-229. DOI: 10.1097/01.NNA.0000312773.42352.d7.

Aiken, L.H., Clarke, S.P., Cheung, R.B., Sloane, D.M., & Silber, J.H. (2003, September 24). Educational levels of hospital nurses and surgical patient mortality. Journal of the American Medical Association , 290, 1617-1623. DOI :  10.1001/jama.290.12.1617 .

American Association of Colleges of Nursing. (2023). 2022-2023 Enrollment and graduations in baccalaureate and graduate programs in nursing. Washington, DC: Author.

American Association of Colleges of Nursing. (2019). Academic progression in nursing: Moving together toward a highly educated nursing workforce. Position statement. Available at https://www.aacnnursing.org/Portals/42/News/Position-Statements/Academic-Progression.pdf .

American Association of Colleges of Nursing. (2019). Articulation agreements among nursing education programs. Fact sheet. Available at https://www.aacnnursing.org/News-Information/Fact-Sheets/Articulation-Agreements .

American Association of Colleges of Nursing, American Association of Community Colleges, Association of Community College Trustees, National League for Nursing, National Organization for Associate Degree Nursing. (2012, September). Joint statement on academic progression for nursing students and graduates. Available at https://www.aacnnursing.org/NewsInformation/Position-Statements-White-Papers/Academic-Progression .

American Organization of Nurse Executives. (2005). Practice and education partnership for the future. Washington, DC: American Organization of Nurse Executives.

Brandt Anbari, A. (2015, January-December). The RN to BSN transition: A qualitative systematic review. Global Qualitative Nursing Research, 2, 1-11. DOI: 10.1177/2333393615614306.

Benner, P., Sutphen, M., Leonard, V., & Day, L. (2009). Educating Nurses: A Call for Radical Transformation. Carnegie Foundation for the Advancement of Teach. San Francisco: Jossey-Bass. DOI: 10.3928/01484834-20120402-01.

Blegen, M.A., Goode, C.J., Park, S.H., Vaughn, T., & Spetz, J. (2013, February). Baccalaureate education in nursing and patient outcomes. Journal of Nursing Administration , 43(2), 89-94. DOI: 10.1097/NNA.0b013e31827f2028.

CGFNS International (2022). Eds. Bakhshi, M., Álvarez, T.D., & Cook, K. CGFNS nurse migration report: Trends in healthcare migration to the United States. Online Report. Available at http:// www.cgfns.org/2022nursemigrationreport .

Delgado, C. (2002, July/August). Competent and safe practice: a profile of disciplined registered nurses. Nurse Educator , 27(4), 159-61. DOI: 10.1097/00006223-200207000-00005.

Djukic, M., Stimpfel, A.W., & Kovner, C. (2019, March). Bachelor's degree nurse graduates report better quality and safety educational preparedness than associate degree graduates. Joint Commission Journal on Quality and Patient Safety , 45(3), 180-186. DOI: 10.1016/j.jcjq.2018.08.008.

Estabrooks, C.A., Midodzi, W.K., Cummings, G.C., Ricker, K.L., & Giovanetti, P. (2005, March/April). The impact of hospital nursing characteristics on 30-day mortality. Nursing Research, 54(2), 72-84. DOI: 10.1097/00006199-200503000-00002.

Fagin, C.M. (2001). When care becomes a burden: Diminishing access to adequate nursing. Millbank Memorial Fund, New York, NY. Available at https://www.milbank.org/publications/when-care-becomes-a-burden-diminishing-access-to-adequate-nursing.

Friese, C.R, Lake, E.T., Aiken, L.H., Silber, J.H., & Sochalski, J. (2008, August). Hospital nurse practice environments and outcomes for surgical oncology patients. Health Services Research, 43(4), 1145-1163. DOI: 10.1111/j.1475-6773.2007.00825.x.

Goode, C.J., Pinkerton, S., McCausland, M.P., Southard, P., Graham, R., & Krsek, C. (2001). Documenting chief nursing officers' preference for BSN-prepared nurses. Journal of Nursing Administration, 31(2). 55-59. DOI: 10.1097/00005110-200102000-00002.

Graff, C., Roberts, K., & Thornton, K. (1999). An ethnographic study of differentiated practice in an operating room. Journal of Professional Nursing , 15(6), 364-371. DOI: 10.1016/s8755-7223(99)80067-2.

Harrison, J.M., Aiken, L.H., Sloane, D.M., Brooks-Carthon, J.M., Merchant, R.M., Berg, R.A., & McHugh, M.D. (2019, July). In hospitals with more nurses who have baccalaureate degrees, better outcomes for patients after cardiac arrest. Health Affairs , 38(7), 1087-1094. DOI: 10.1377/hlthaff.2018.05064.

Institute of Medicine. (2010). The Future of Nursing: Leading Change, Advancing Health . Washington, DC: National Academies Press. DOI: 10.17226/12956.

Johnson, J. (1988). Differences in the performance of baccalaureate, associate degree and diploma nurses: A meta-analysis. Research in Nursing and Health , 11, 183-197. DOI: 10.1002/nur.4770110307.

Kendall-Gallagher, D., Aiken, L., Sloane, D.M., & Cimiotti, J.P. (2011, January). Nurse specialty certification, inpatient mortality, and failure to rescue. Journal of Nursing Scholarship , 43(2), 188- 194. DOI: 10.1111/j.1547-5069.2011.01391.x.

Kramer, M. & Schmalenberg, C. (1988). Magnet hospitals: Part I, Institutions of excellence. Journal of Nursing Administration , 18(1), 13-24. DOI:10.1024/1012-5302/a000216.

Kumm, S., Godfrey, N., Martin, D., Tucci, M., Muenks, M., & Spaeth, T. (2014). Baccalaureate outcomes met by associate degree programs. Nursing Educator , 39(5), 216-220. DOI: 10.1097/NNE.0000000000000060.

Kutney-Lee, A., Sloane, D.M., & Aiken, L. (2003, March). An increase in the number of nurses with baccalaureate degrees is linked to lower rates of post-surgery mortality. Health Affairs , 32(3), 579-586. DOI: 10.1377/hlthaff.2012.0504.

McHugh, M.D., Kelly, L.A., Smith, H.L., Wu, E.S., Vanak, J.M., & Aiken, L.H. (2013, May). Lower mortality in magnet hospitals. Medical Care , 51(5), 382-8. DOI: 10.1097/MLR.0b013e3182726cc5.

National Academy of Science, Engineering, and Medicine. (2021). The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity . Washington, DC: The National Academies Press. DOI: https://doi.org/10.17226/25982.

National Advisory Council on Nurse Education and Practice (2000). Report to the Secretary of the Department of Health and Human Services on the basic registered nurse workforce. Washington, DC: United States Department of Health and Human Services, Health Resources and Services Administration.

National Council of State Boards of Nursing (2002). 2001 Employers survey. Chicago: Author. Available at https://www.ncsbn.org/public-files/RBrief_Employer_053.pdf.

Phillips, C.Y., Palmer, C.V., Zimmerman, B.J., & Mayfield, M. (2002). Professional development: Assuring growth of RN-to-BSN students. Journal of Nursing Education , 41(6), 282-283. DOI: 10.3928/0148-4834-20020601-10.

Porat-Dahlerbruch, J., Aiken, L.H., Lasater, K.B., Sloane, D.M., & McHugh, M.D. (2022, March). Variations in nursing baccalaureate education and 30-day inpatient surgical mortality. Nursing Outlook , 70(2), 300-308. DOI: https://doi.org/10.1016/j.outlook.2021.09.009.

Smiley, R.A., Allgeyer, R.L., Shobo, Y., Lyons, K.C., Letourneau, R., Zhong, E., Kaminski-Ozturk, N., and Alexander, M. (2023, April). The 2022 National Nursing Workforce Survey. Journal of Nursing Regulation , 14(Supplement), S16-S17. DOI: https://doi.org/10.1016/S2155-8256(23)00047-9.

Tourangeau, A.E, Doran, D.M., McGillis Hall, L., O'Brien Pallas, L., Pringle, D., Tu, J.V., & Cranley, L.A. (2007, January). Impact of hospital nursing care on 30-day mortality for acute medical patients. Journal of Advanced Nursing , 57(1), 32-41. DOI: 10.1111/j.1365-2648.2006.04084.x.

Tri-Council for Nursing. (2010, May). Educational advancement of registered nurses: A consensus position. Available at https://www.aacnnursing.org/Portals/42/News/5-10- TricouncilEdStatement.pdf.

Yakusheva, O., Lindrooth, R., & Weiss, M. (2014, October). Economic evaluation of the 80% baccalaureate nurse workforce recommendation: A patient-level analysis. Medical Care , 52(10), 864-869. DOI: 10.1097/MLR.0000000000000189.

Updated: April 2023

Robert Rosseter [email protected]

Baccalaureate-Prepared Nurses are Essential to Quality Health Care   Impactful Nursing 

Discover how nursing education elevates patient outcomes and why BSN-educated nurses play a pivotal role in ensuring healthcare quality. This document is a must-read for healthcare advocates and stakeholders, shedding light on the vital role of baccalaureate-prepared nurses. 

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

• View all journals
• My Account Login
• Explore content
• About the journal
• Publish with us
• Sign up for alerts
• Open access
• Published: 01 March 2024

Impact of professional nursing interventions on clinical outcomes in patients with acute gastric bleeding: a retrospective analysis

• Xueqin Yuan 1   na1 ,
• Fang Yu 1   na1 &
• Shouzhi Fu 1  

Scientific Reports volume  14 , Article number:  5107 ( 2024 ) Cite this article

234 Accesses

1 Altmetric

Metrics details

• Disease prevention
• Health services
• Public health

Acute gastric bleeding (AGB) is a common and potentially serious complication in patients with gastrointestinal disorders. Nursing interventions play a critical role in the management of acute gastric bleeding, but their impact on clinical outcomes is not well understood. The aim of this retrospective analysis was to evaluate the impact of nursing interventions on clinical outcomes in patients with acute gastric bleeding. A retrospective review of medical records was conducted for 220 patients with acute gastric bleeding who were admitted to the hospital between February 2022 and February 2023. Patients were divided into two groups based on whether or not they received nursing interventions during their hospital stay. Clinical outcomes, including length of hospital stay, blood transfusion requirements, and mortality rates, were compared between the two groups using descriptive statistics and logistic regression analysis. Of the 220 patients included in the study, 168 (76.4%) received nursing interventions during their hospital stay. Patients who received nursing interventions had a significantly shorter length of hospital stay (mean = 7.2 days, SD = 2.1) compared to those who did not receive nursing interventions (mean = 10.5 days, SD = 3.4, p  < 0.001). Additionally, the 90-day mortality rate was lower in the group receiving professional nursing interventions (4.2% vs. 15.4%, p  = 0.010). Fewer patients who received nursing interventions required blood transfusions (33.3% vs. 65.2%, p  < 0.001) and mortality rates were lower (6.7% vs. 20.8%, p  = 0.04). Multivariate logistic regression analysis suggested that professional nursing intervention was a protective factor for postoperative rebleeding in patients with gastric hemorrhage (OR 0.727, 95% CI 0.497–0.901, P  < 0.001). The results of this retrospective analysis suggest that nursing interventions are associated with improved clinical outcomes in patients with acute gastric bleeding. The implementation of nursing interventions, such as individualized care plans, monitoring and evaluation, and patient education, should be encouraged to optimize patient outcomes in this population. Further research is needed to identify the most effective nursing interventions and to evaluate their cost-effectiveness.

Similar content being viewed by others

Gastric-tube versus post-pyloric feeding in critical patients: a systematic review and meta-analysis of pulmonary aspiration- and nutrition-related outcomes

Yue Liu, Yanling Wang, … Qian Xiao

The impact of preoperative oral nutrition supplementation on outcomes in patients undergoing gastrointestinal surgery for cancer in low- and middle-income countries: a systematic review and meta-analysis

Stephen R. Knight, Ahmad U. Qureshi, … Ewen M. Harrison

Factors associated with discrepancy between prescribed and administered enteral nutrition in general ICU

Juho Nurkkala, T. Kaakinen, … Janne H. Liisanantti

Introduction

Acute gastric bleeding (AGB) is a common and serious complication in patients with gastrointestinal disorders. It typically requires urgent medical care and may lead to a significant incidence and mortality rate, especially in patients with ulcers, inflammation, or other gastric issues. Early symptoms may include melena, hematemesis, abdominal pain, etc. The detection of AGB usually involves procedures such as endoscopy and imaging studies to identify the source of bleeding and assess the extent of pathology. Treatment modalities encompass drug therapy, endoscopic hemostasis, etc., depending on the cause of bleeding and individual patient conditions 1 , 2 . In recent years, nursing interventions have been increasingly recognized as an important part of the management of AGB 3 . Nurses play a crucial role in the management of patients with Acute Gastric Bleeding (AGB), including closely monitoring vital signs, early identification, and timely reporting of bleeding, as well as assisting physicians in treatment. However, there is still limited evidence on the impact of nursing interventions on clinical outcomes in this patient population.

Some studies have suggested that nursing interventions, such as close monitoring of vital signs, early identification of bleeding, and timely administration of medications, may improve patient outcomes in AGB. For example, A study by Li et al. 4 found that tripartite intensive care significantly reduced the rate of bleeding during hospitalization, as well as reducing the rate of complications, promoting recovery, and improving the quality of life of the patients. Providing care interventions for all patients is crucial, but specific diseases require corresponding specialized nursing interventions to achieve optimal outcomes.

Despite these promising findings, there is still a lack of consensus on the most effective nursing interventions and their impact on clinical outcomes in patients with AGB 5 , 6 . Therefore, further research is needed to evaluate the effectiveness of different nursing interventions and to identify factors that may influence their impact on patient outcomes 7 , 8 , 9 . The present retrospective analysis aimed to evaluate the impact of nursing interventions on clinical outcomes in patients with AGB. We hypothesized that nursing interventions would be associated with improved clinical outcomes, such as shorter hospital stays, fewer blood transfusions, and lower mortality rates. To test this hypothesis, we conducted a retrospective review of medical records for 220 patients with AGB who were admitted to the hospital between February 2022 and February 2023. Patients were divided into two groups based on whether or not they received nursing interventions during their hospital stay. Clinical outcomes were compared between the two groups using descriptive statistics and logistic regression analysis.

By identifying the impact of nursing interventions on clinical outcomes in patients with AGB, this study could provide important insights to guide the development of effective nursing interventions in this patient population. Our primary outcomes include the duration of hospitalization, the proportion of patients requiring transfusion, the occurrence rate of rebleeding, and postoperative complications such as infections, coagulation issues, etc. Secondary outcomes comprise the readmission rates at 30 and 90 days. Furthermore, it could help to enhance our understanding of the complex interplay between nursing interventions and clinical outcomes in patients with AGB. The hypothesis of the study is that professional nursing intervention can improve the primary and secondary outcomes of patients with AGB.

Materials and methods

Patient selection study design and participants.

This study employed a retrospective cohort study design to evaluate the effectiveness of nurse-led interventions in improving outcomes in patients with acute gastric bleeding (AGB). The study participants consist of adult patients (18 years and above) who presented to the emergency department and were diagnosed with AGB, requiring hospitalization for intervention, during a specific time period (e.g., February 2022 to February 2023). The decision for patients to undergo professional nursing interventions is a joint decision between family members and the healthcare team. Both family members and patients have a high degree of autonomy in the decision-making process. AGB is defined as sudden bleeding in the stomach, with causes including gastric ulcers, gastric cancer, and other related conditions. The diagnosis of AGB was determined by collaboration between gastrointestinal surgeons, emergency medicine specialists, and radiologists based on clinical symptoms, X-ray examinations, and gastroscopy reports.

Strict inclusion and exclusion criteria were applied to ensure the integrity of the cases. Inclusion criteria were as follows: (1) age 18 years or above at the time of diagnosis, (2) confirmed diagnosis of AGB through imaging studies and physical examination, (3) absence of significant comorbidities (Including severe cardiovascular diseases, etc.), and (4) first-time occurrence of AGB. Exclusion criteria were: (1) incomplete clinical data, (2) death within 24 h of hospital admission, and (3) history of previous surgeries. This research was performed in accordance with the Declaration of Helsinki and was approved by the Ethics Committee of Affiliated Kunshan Hospital of Jiangsu University [Approve number TH-20211127].

Assessment of severity in acute gastric bleeding

The severity of gastric bleeding is determined based on factors such as the volume of bleeding, rate of bleeding, clinical symptoms, and the presence of complications.

Volume of bleeding

Gastric bleeding refers to damage to the gastric mucosa, leading to localized vascular rupture and bleeding. If the patient experiences a relatively small volume of bleeding, the condition is generally not considered particularly severe. However, if the bleeding volume is substantial, it may lead to shock, indicating a more serious situation.

Rate of bleeding

If the bleeding occurs at a slow rate and the volume is relatively small, the condition is generally not considered particularly severe. Conversely, a faster rate of bleeding, coupled with a larger volume, is indicative of a more severe condition.

Clinical symptoms

The absence of significant discomfort symptoms in the patient generally suggests a less severe condition. On the other hand, the presence of symptoms such as vomiting, melena, fever, etc., usually indicates a more severe situation.

Presence of complications

A smaller volume of bleeding without evident complications is typically not considered particularly severe. However, if the bleeding volume is larger and complications are present, the condition is likely to be more serious.

Sample size and power calculation

Firstly, we utilized experiential judgment for multivariate analysis based on previous BMJ literature 10 . According to the literature, we calculated the number of endpoint events by taking five times the number of independent variables. With 19 independent variables, this equates to 95. In other words, there should be 95 patients with endpoint events. The number of patients recruited in our study who subsequently reached endpoint events exceeds 95, thus confirming this experiential judgment.

Secondly, we employed PASS (version: 11.0) for calculation. Within PASS, we utilized the "Regression" section under "Logistics Regression," setting a two-sided Alpha of 0.05 and Beta of 0.1. The corresponding results were incorporated into the PASS software, yielding a one-sided Sample Size (N) of 33. The sample size we included is greater than 66.

Professional nursing interventions

The non-professional nursing intervention group, serving as the control group, received standard nursing care. This care included the provision of explanations regarding the current treatment methods and their purposes to facilitate patient understanding of the treatment measures. We assisted patients in identifying potential problems that may arise during the treatment process and provided guidance on precautions to be taken. Standard nursing care also involved the continuous monitoring of relevant indicators throughout the treatment period, with prompt communication to the attending physician in case of any abnormalities. The control group received patient education on proper nutrition and medication use, covering information about potential adverse drug reactions and preventive measures.

It is important to note that electrolyte monitoring was a part of the standard nursing care provided to the control group, ensuring the comprehensive evaluation of patients' health status during the treatment period. This approach aims to capture a realistic representation of routine nursing practices in a standard care setting.

The group receiving professional nursing interventions is provided with high-quality professional nursing services delivered by general nurses., including the following aspects:

Psychological care: Many patients with gastric bleeding have misunderstandings about their disease and may experience negative emotions that can aggravate their condition. Therefore, nursing staff should closely monitor patients' psychological changes, provide education on gastric bleeding and its treatment, and offer emotional support to help patients stabilize their emotions and voluntarily cooperate with healthcare personnel. Family members can also be given appropriate nursing guidance to provide effective support for the patient. Fluid intervention: After admission, intravenous access is quickly established, electrolyte changes are tested, and vital signs are closely monitored, including body temperature, pulse, respiration, blood pressure, and other indicators. The amount of vomiting blood, black stool, and 24-h in and out volume are recorded, and hemostatic drugs are administered if necessary. In cases of shock, sodium bicarbonate or saline is used to expand volume, and blood transfusion is administered as needed. For patients with cirrhotic portal hypertension, caution must be taken to avoid rehemorrhage due to increased portal vein pressure from further blood transfusion. The amount of fluid input should be reduced appropriately to avoid excessive input, resulting in acute edema and rehemorrhage. Life care: Patients with acute gastric hemorrhage require strict bed rest, with no food or drink allowed. Electrolyte imbalances must be corrected, and attention should be paid to maintaining an appropriate temperature. Oxygen therapy should be administered to patients with severe bleeding. Diet care: Patients with gastric bleeding should be given a light diet, with regular and moderate intake, and small meals. Patients with nausea and vomiting should be instructed to fast until symptoms disappear and bleeding stops before resuming a proper diet. Exercise care: After the patient's condition stabilizes, exercise should be encouraged to improve body resistance. However, the amount of exercise should follow the principle of gradual progress to avoid sudden increases. Health education: Patients with gastric bleeding should receive detailed information about their disease and preventive measures. For patients with recurring gastric bleeding, education should focus on avoiding causative factors and preventing complications to ensure better control of the condition and self-care.

Nurses' propaganda and education details in professional nursing interventions

Assess patient's understanding and emotional state: Before beginning the mission, nursing staff should talk with patients to find out how much they know about gastric bleeding as well as any misconceptions and anxiety they may have.

Provide education on gastric bleeding and its treatment: Nursing staff should provide patients and their families with basic knowledge about gastric bleeding, including information about causes, symptoms, diagnostic methods, treatment options, and prognosis.

Emphasize the importance of treatment and cooperation: Nursing staff should clearly inform patients of the importance of their treatment and encourage them to actively cooperate with their healthcare provider's treatment plan.

Offer emotional support and reassurance: Since gastric hemorrhage may lead to negative emotions, nursing staff should listen patiently to patients' emotional expressions and understand and respect their feelings.

Instruct family members on effective support methods: Nursing staff can provide guidance to families on how to effectively support the patient, including emotional support, dietary care, and daily living care.

Highlight dietary and lifestyle recommendations: Nursing staff should introduce patients to appropriate diets and lifestyles to help them better manage and prevent stomach bleeding. This includes advice on dietary precautions, meal plans, and regular routines.

Guide rehabilitation exercises gradually: After the patient's condition is stabilized, nursing staff can recommend appropriate rehabilitation exercises to help improve their body's resistance and ability to recover.

Educate on prevention and self-management: For patients with recurrent gastric bleeding, nursing staff should focus on teaching how to avoid triggers and prevent complications to ensure better control and self-care.

Ensure patient's comprehension and application of education: Nursing staff should double-check that patients understand the information provided during the education process and encourage them to apply the knowledge and skills they have learned in real-life situations.

Follow up regularly and address new concerns: Nursing staff should regularly follow up on patients' conditions and treatment progress, answer any new questions they may have in a timely manner, and make any necessary adjustments and additional teachings. In summary, it is important to note that professional nursing interventions are designed to assist and support the treatment plans of the medical team. Nursing interventions are not intended to replace medical treatments but rather to work collaboratively with the physician's treatment, aiming to comprehensively enhance the quality of patient care and treatment outcomes. And both professional nursing interventions and non-professional nursing interventions are provided by general nurses.

Data collection and outcome measures

Data collection for this retrospective analysis involved reviewing medical records of 220 patients with acute gastric bleeding who were admitted to the hospital between February 2022 and February 2023. The following outcome measures were assessed to evaluate the impact of nursing interventions on clinical outcomes:

Length of Hospital Stay: The length of hospital stay was recorded for each patient and compared between the group that received nursing interventions and the group that did not.

Blood Transfusion Requirements: The number of patients requiring blood transfusions was documented for both groups. A comparison was made to determine if nursing interventions had an influence on blood transfusion requirements.

Occurrence of Rebleeding: The incidence of rebleeding, defined as a rebleeding episode that occurs after initial treatment and complete hemostasis, was recorded and compared between the groups that received the nursing intervention and the group that did not receive the nursing intervention.

Mortality Rates: Mortality rates were calculated for patients in both groups to assess the impact of nursing interventions on patient survival.

Data analysis

The data collected from medical records served as the foundation for analyzing and comparing outcome measures between the group that received nursing interventions and the group that did not. Descriptive statistics, including means and standard deviations, were calculated to summarize the data and identify any significant differences. Covariates entered into the multivariate logistic regression analysis were prespecified, and the association between nursing interventions and postoperative rebleeding was assessed while considering potential confounding factors.

All statistical analyses were performed using SPSS 25.0 (IBM, Armonk, New York, USA). A significance level of P  < 0.05 (two-sided) was considered statistically significant. To visually present the results, graphs were created using R language (version 4.0.5) and GraphPad Prism (version: 8.0). Sample size estimation was conducted before the study using PASS (version: 11.0).

Multivariate analysis included the consideration of prespecified covariates to account for potential confounding effects. Specifically, factors such as age, severity of bleeding, and history of gastrointestinal disorders were entered into the logistic regression model to assess their impact on the association between nursing interventions and postoperative rebleeding.

Following discharge from the hospital, all patients were followed up by two trained professionals. They conducted phone interviews with the patients to inquire about their current health status and requested them to visit the hospital for a comprehensive review. During the follow-up period, the professionals collected information regarding any ongoing symptoms, recurrence of gastric bleeding, or other complications. They also assessed the need for additional interventions or treatments. The collected data from the follow-up interviews were analyzed to determine the long-term impact of nursing interventions on patient outcomes, including the recurrence of bleeding and the overall effectiveness of the care provided. The follow-up continued until six months after the patients were discharged.

Ethical approval and consent to participation

Informed consent was obtained from all subjects and/or their legal guardian(s). This research was performed in accordance with the Declaration of Helsinki and was approved by the Ethics Committee of Affiliated Kunshan Hospital of Jiangsu University [Approve number TH-20211127].

Baseline information on acute gastric bleeding with and without skilled nursing interventions

The inclusion and exclusion criteria for this study are outlined in Fig.  1 . There were 168 patients who received Professional nursing intervention and 52 patients who did not receive skilled nursing intervention. All patients were sourced from the general ward. No significant differences were found between the groups in terms of gender, age, BMI, history of gastrointestinal disorders, hypertension, diabetes, coronary artery disease, severity of bleeding, platelet count, and endoscopy findings. Patients who received professional nursing interventions had higher hemoglobin levels (9.8 ± 1.7 g/dL vs. 8.9 ± 2.0 g/dL, p  < 0.001) and lower INR values (1.5 ± 0.3 vs. 1.6 ± 0.4, p  = 0.030). Regarding clinical outcomes, patients with professional nursing interventions had shorter hospital stays (7.2 ± 2.1 days vs. 10.5 ± 3.4 days, p  < 0.001), lower blood transfusion requirements (32.7% vs. 65.4%, p  < 0.001), and lower rebleeding rates (3.6% vs. 9.6%, p  < 0.001). In summary, professional nursing interventions were associated with higher hemoglobin levels, lower INR values, shorter hospital stays (mean difference: 3.3 days), reduced blood transfusion requirements (risk ratio: 0.50), and lower rebleeding rates (risk ratio: 0.37) in patients with acute gastric bleeding (Table 1 ).

Inclusion and exclusion table for AGB patients.

Comparison of AGB complications in professional nursing interventions group and no-professional nursing interventions

There were some differences in perioperative complications between the group with Professional nursing intervention (n = 168) and the group without Professional nursing intervention (n = 52). Significant differences were observed in perioperative complications, including rebleeding of the stomach ( p  < 0.001), coagulation complications ( p  < 0.001), and infection ( p  = 0.003). Patients who received professional nursing interventions had lower rates of rebleeding (10.7% vs. 32.7%) and lower rates of coagulation complications (1.2% vs. 15.4%) compared to those without professional nursing interventions. Rates of stomach pain and bloating were similar between the groups ( p  = 0.160), while no significant differences were found in non-gastrointestinal complications, including circulatory ( p  = 1.000), respiratory ( p  = 0.596), and urinary complications ( p  = 1.000). Furthermore, patients who received professional nursing interventions had significantly lower rates of infection (0.6% vs. 9.6%) compared to those without professional nursing interventions (Table 2 ). The primary source of patient infections is hospital-acquired.

Univariate and multivariate cox proportional hazards regression analyses of rebleeding in AGB patients undergoing radical therapy

In the univariate analysis, Age ( p  = 0.031), history of gastrointestinal disorders ( p  = 0.008), severity of bleeding ( p  < 0.001), and Professional Nursing Interventions ( p  < 0.001) were significantly associated with rebleeding. In the multivariate analysis, Age ( p  < 0.001), history of gastrointestinal disorders ( p  = 0.012), severity of bleeding ( p  < 0.001), and Professional Nursing Interventions ( p  < 0.001) remained significant predictors of rebleeding.

Specifically, patients aged < 60 years had a lower risk of rebleeding compared to those aged ≥ 60 years (OR 1.187, 95% CI 1.076–1.302). Patients without history of gastrointestinal disorders had a lower risk of rebleeding compared to those with history of gastrointestinal disorders (OR 1.288, 95% CI 1.091–1.479). Patients with mild severity of bleeding on admission had a lower risk of rebleeding compared to those with moderate or severe severity of bleeding (moderate: OR 1.213, 95% CI 1.155–1.431; severe: OR 1.455, 95% CI 1.210–1.708). Patients who received professional nursing interventions had a lower risk of rebleeding compared to those who did not (OR 0.727, 95% CI 0.497–0.901).

Other variables such as gender, BMI, Hypertension, Diabetes, Coronary Artery Disease, Endoscopy Findings, and Treatment Modalities were not significantly associated with rebleeding (Table 3 ).

Comparison of the prognosis of patients with acute gastric bleeding in the professional nursing intervention group and the group without professional nursing intervention

The readmission rate for patients who received skilled nursing interventions was 8.3%, which was significantly lower than the 21.2% for patients who did not receive skilled nursing interventions ( P  = 0.021); the 30-day mortality rate for patients who also received skilled nursing interventions was 3.6%, whereas the 30-day mortality rate for those who did not receive skilled nursing interventions was slightly higher at 5.8%, this difference was not statistically significant ( P  = 0.444). However, patients who received skilled nursing interventions had a significantly lower 90-day mortality rate of 4.2%, while patients who did not receive skilled nursing interventions had a higher 90-day mortality rate of 15.4%. The difference in 90-day mortality rate was statistically significant ( P  = 0.010) (Table 4 ).

Effectiveness of integrated nursing interventions on 30-day mortality, 90-day mortality and readmission rates

ROC curves were employed to assess the effectiveness of skilled nursing interventions in predicting short-term clinical prognosis in patients with traumatic brain injury. The ROC curves depicted the relationship between sensitivity and specificity for the prediction of 30-day mortality, 90-day mortality, and readmission rates resulting from skilled nursing interventions. The horizontal axis represented specificity, while the vertical axis indicated sensitivity. The results revealed that the area under the curve (AUC) was 0.553 and 0.709 for the prediction of 30-day mortality and readmission rates, respectively (see Fig.  2 ). For the 90-day mortality rate, the AUC was found to be 0.759.

Effectiveness of professional nursing interventions on 30-day mortality, 90-day mortality and readmission rates.

Acute gastric bleeding (AGB) is a significant complication in patients with gastrointestinal disorders, necessitating urgent medical attention and potentially leading to high morbidity and mortality rates 11 , 12 . Professional nursing interventions by general nurses also play a crucial role in aiding the prognosis of AGB patients, and an increasing number of individuals recognize that nursing interventions are equally critical in the treatment of AGB. This retrospective analysis aims to evaluate the impact of Professional nursing interventions by general nurses on the clinical outcomes of AGB patients and investigate whether these measures can shorten hospital stays, reduce blood transfusions, and lower mortality rates, among other factors.

Our research findings indicate that professional nursing interventions are associated with favorable outcomes in AGB patients. Patients who received professional nursing interventions showed a significant increase in hemoglobin levels and a notable decrease in INR values, suggesting improved control over bleeding and coagulation abnormalities. These results are consistent with previous research; for instance, Jiang et al. 13 studied the impact of nursing interventions on obese type 2 diabetes patients and found that patients receiving nursing interventions experienced improved hemoglobin levels and enhanced blood glucose management. However, our study emphasizes the importance of closely monitoring vital signs and administering timely medication to improve the prognosis of AGB patients.

Importantly, patients who received professional nursing interventions had shorter hospital stays, reduced blood transfusion requirements, and lower rates of rebleeding. The shorter hospitalization duration suggests that professional nursing interventions promote rapid recovery and effective management of AGB. Moreover, the decreased need for blood transfusions in the specialized nursing intervention group indicates effective hemostasis and bleeding management, potentially reducing complications and improving patient outcomes. The lower rebleeding rate in the specialized nursing intervention group further emphasizes the potential benefits of skilled nursing in preventing rebleeding. Early identification of bleeding and timely interventions may help minimize the risk of rebleeding in such patients. Prior research by Qing et al. 14 on emergency nursing for patients with primary hepatocellular carcinoma rupture and bleeding showed a significant decrease in complication rates and mortality in patients who received emergency nursing, along with shorter intraoperative bleeding volume and hospital stays. Similarly, in a historical matched study conducted by Lee et al. 15 the addition of nurse consultants to five clinical specialties had a significant impact on patient health and service outcomes in those departments, leading to reductions in emergency complications, shortened hospital stays, and improved patient satisfaction. The favorable results of the aforementioned nursing interventions align with our study's findings, and therefore, we recommend implementing specialized nursing interventions for emergency AGB patients.

Multivariate analysis confirmed that even after accounting for potential confounding factors such as age, gastrointestinal disease history, and severity of bleeding, specialized nursing interventions remained a significant predictor of rebleeding. This further strengthens the evidence of the positive impact of skilled nursing in managing AGB. ROC curve analysis demonstrated that specialized nursing interventions exhibited moderate to high discriminatory ability in predicting short-term clinical outcomes such as 30-day mortality, 90-day mortality, and readmission rates. Although the AUC values did not approach 1.0, indicating imperfect discriminative ability, they still highlighted the potential role of nursing interventions in assessing and improving the prognosis of AGB patients. Just as Morita et al. 16 found that advanced practice nursing can significantly reduce the 30-day mortality rate in critically ill patients on mechanical ventilation, the authors recommend increased utilization of advanced practice nursing in adult ICUs.

Our study has several limitations that should be considered when interpreting the results. First, the study's retrospective nature may introduce bias and limit the ability to establish causality.

Furthermore, the sample size is relatively small, and the study was conducted at a single center. Additionally, there is a relatively high number of independent variables, posing a risk of overfitting, which may impact the generalizability of the study findings to other centers. Therefore, more prospective studies with larger sample sizes and multi-center collaborations are needed to strengthen the evidence and enhance the generalizability of the results. Furthermore, the specific details of the nursing interventions provided to patients were not explicitly captured, and the extent to which different interventions contributed to the observed outcomes remains unclear.

In conclusion, our retrospective analysis underscores the positive impact of skilled nursing care on clinical outcomes for acute gastric bleeding (AGB) patients. Nursing interventions, vital in early bleeding identification and management, lead to shorter hospital stays, reduced blood transfusions, and lower rebleeding rates. This study sets the groundwork for evidence-based nursing practices to enhance AGB patient prognosis.

Data availability

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

Feinman, M. & Haut, E. R. Upper gastrointestinal bleeding. Surg. Clin. North America 94 (1), 43–53 (2014).

Article   Google Scholar  

Khamaysi, I. & Gralnek, I. M. Acute upper gastrointestinal bleeding (UGIB) - initial evaluation and management. Best Pract. Res. Clin. Gastroenterol. 27 (5), 633–638 (2013).

Article   PubMed   Google Scholar  

Farrar, F. C. Management of acute gastrointestinal bleed. Crit. Care Nurs. Clin. North Am. 30 (1), 55–66 (2018).

Li, C. X. et al. Tripartite intensive intervention for prevention of rebleeding in elderly patients with hypertensive cerebral hemorrhage. World J. Clin. Cases 9 (33), 10106–10115 (2021).

Article   PubMed   PubMed Central   Google Scholar  

Kaldan, G. et al. Evidence characterising skills, competencies and policies in advanced practice critical care nursing in Europe: A scoping review protocol. BMJ Open 9 (9), e031504 (2019).

O’Cathain, A. et al. Guidance on how to develop complex interventions to improve health and healthcare. BMJ Open 9 (8), e029954 (2019).

Catarelli, B. et al. Care, lead, and inspire: Infusing innovation into nursing research and evidence-based practice course. Worldviews Evid.-Based Nursing 20 (3), 281–284 (2023).

Ferreira, R. C. et al. Nursing outcomes for patients with multiple traumas and impaired physical mobility: An integrative review. Int. J. Nurs. Knowl. 34 (2), 133–147 (2023).

Teixeira, A. C., Nogueira, A. & Barbieri-Figueiredo, M. D. C. Professional empowerment and evidence-based nursing: A mixed-method systematic review. J. Clin. Nurs. 32 (13–14), 3046–3057 (2023).

Norman, G., Monteiro, S. & Salama, S. Sample size calculations: Should the emperor’s clothes be off the peg or made to measure?. BMJ (Clin. Res. Ed.) 345 , e5278 (2012).

Google Scholar  

Bazarbashi, A. N. & Ryou, M. Gastric variceal bleeding. Curr. Opin. Gastroenterol. 35 (6), 524–534 (2019).

Article   CAS   PubMed   Google Scholar  

Nelms, D. W. & Pelaez, C. A. The acute upper gastrointestinal bleed. Surg. Clin. North America 98 (5), 1047–1057 (2018).

Jiang, X., Fan, X., Wu, R., Geng, F. & Hu, C. The effect of care intervention for obese patients with type II diabetes. Medicine 96 (42), e7524 (2017).

Qing, Y., Yang, J. & Gu, Y. Emergency nursing countermeasures and experience of patients with primary liver cancer nodule rupture and hemorrhage. Emerg. Med. Int. 2022 , 2744007 (2022).

Lee, D. T. et al. The impact on patient health and service outcomes of introducing nurse consultants: A historically matched controlled study. BMC Health Serv. Res. 13 , 431 (2013).

Morita, K. et al. Association between advanced practice nursing and 30-day mortality in mechanically ventilated critically ill patients: A retrospective cohort study. J. Crit. Care 41 , 209–215 (2017).

Download references

Acknowledgements

Thanks to the nurses in the department for their help with the project.

Author information

These authors contributed equally: Xueqin Yuan and Fang Yu.

Authors and Affiliations

Department of ICU/Emergency, Wuhan Third Hospital, Tongren Hospital of WuHan University, Wuhan, 430074, Hubei, China

Xueqin Yuan, Fang Yu & Shouzhi Fu

You can also search for this author in PubMed   Google Scholar

Contributions

X.Q.Y. wrote the paper. F.Y. provided the ideas. S.Z.F. provided images and interpretation of the data. S.Z.F. reviewed the manuscript. All authors read and approved the manuscript.

Corresponding author

Correspondence to Shouzhi Fu .

Ethics declarations

Competing interests.

The authors declare no competing interests.

Additional information

Publisher's note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ .

Reprints and permissions

About this article

Cite this article.

Yuan, X., Yu, F. & Fu, S. Impact of professional nursing interventions on clinical outcomes in patients with acute gastric bleeding: a retrospective analysis. Sci Rep 14 , 5107 (2024). https://doi.org/10.1038/s41598-024-55558-9

Download citation

Received : 27 November 2023

Accepted : 25 February 2024

Published : 01 March 2024

DOI : https://doi.org/10.1038/s41598-024-55558-9

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Gastric bleeding
• Emergency nursing
• Clinical outcomes
• Nursing intervention

By submitting a comment you agree to abide by our Terms and Community Guidelines . If you find something abusive or that does not comply with our terms or guidelines please flag it as inappropriate.

Quick links

• Explore articles by subject
• Guide to authors
• Editorial policies

Sign up for the Nature Briefing newsletter — what matters in science, free to your inbox daily.

Usefulness of nursing theory-guided practice: an integrative review

Affiliations.

• 1 School of Nursing, Memorial University of Newfoundland, St. John's, NL, Canada.
• 2 Shifa College of Nursing, Islamabad, Pakistan.
• 3 Clinical Nursing Instructor, Nipissing University, North Bay, ON, Canada.
• PMID: 30866078
• DOI: 10.1111/scs.12670

Background: Nursing theory-guided practice helps improve the quality of nursing care because it allows nurses to articulate what they do for patients and why they do it. However, the usefulness of nursing theory-guided practice has been questioned and more emphasis has been placed on evidence-based nursing and traditional practice. Therefore, an examination of experimental studies was undertaken to analyse the extent of use and usefulness of nursing theories in guiding practice. We reviewed experimental studies because in this era of evidence-based practice, these designs are given more weightage over other research designs. This examination would corroborate the usefulness of nursing theory-guided practice compared to traditional practice.

Methods: An integrative review was conducted. Literature search was performed within multiple databases, and 35 studies were reviewed and appraised.

Results: Majority of the studies were from Iran, the United States and Turkey and used Orem's self-care model, Roy's adaptation model and Peplau's theory of interpersonal relations. The effect of theory-guided interventions was evaluated in improving quality of life, self-efficacy, self-care and stress of patients with chronic, acute, cardiac and psychological illnesses. The quality rating was judged to be strong for three studies, moderate for 25 studies and weak for seven studies. All of the strongly rated studies found nursing theory-guided interventions useful. Overall, nursing theory-guided interventions improved all of studied outcomes in 26 studies and at least one outcome in nine studies. None of the studies reported that nursing theory-guided interventions as not useful.

Conclusion: Nursing theories have guided practice in both eastern and Western countries, and theory-guided practice has been found useful compared to traditional nursing practice. Therefore, nurses should continue to guide their nursing practice through the lens of nursing theories and should continue to evaluate the effectiveness of nursing theory-guided practice.

Keywords: experimental studies; nursing theories; nursing theory-guided practice.

© 2019 Nordic College of Caring Science.

Publication types

• Systematic Review
• Attitude of Health Personnel
• Evidence-Based Nursing / methods*
• Middle Aged
• Models, Nursing
• Nurse-Patient Relations
• Nursing Care / psychology*
• Nursing Staff, Hospital / psychology*
• Nursing Theory*

• Open access
• Published: 18 March 2024

Exploring advanced clinical practitioner perspectives on training, role identity and competence: a qualitative study

• Maxine Kuczawski   ORCID: orcid.org/0000-0002-0774-8113 1 ,
• Suzanne Ablard 1 ,
• Fiona Sampson 1 ,
• Susan Croft 1 , 2 ,
• Joanna Sutton-Klein 1 , 3 &
• Suzanne Mason 1  

BMC Nursing volume  23 , Article number:  185 ( 2024 ) Cite this article

312 Accesses

1 Altmetric

Metrics details

Advanced Clinical Practitioners (ACPs) are a new role that have been established to address gaps and support the existing medical workforce in an effort to help reduce increasing pressures on NHS services. ACPs have the potential to practice at a similar level to mid-grade medical staff, for example independently undertaking assessments, requesting and interpreting investigations, and diagnosing and discharging patients. These roles have been shown to improve both service outcomes and quality of patient care. However, there is currently no widespread formalised standard of training within the UK resulting in variations in the training experiences and clinical capabilities of ACPs. We sought to explore the training experiences of ACPs as well as their views on role identity and future development of the role.

Five online focus groups were conducted between March and May 2021 with trainee and qualified advanced clinical practitioners working in a range of healthcare settings, in the North of England. The focus groups aimed to explore the experiences of undertaking ACP training including supervision, gaining competence, role identity and career progression. Thematic analysis of the focus group transcripts was performed, informed by grounded theory principles.

Fourteen advanced clinical practitioners participated. Analysis revealed that training was influenced by internal and external perceptions of the role, often acting as barriers, with structural aspects being significant contributory factors. Key themes identified (1) clinical training lacked structure and support, negatively impacting progress, (2) existing knowledge and experience acted as both an enabler and inhibitor, with implications for confidence, (3) the role and responsibilities are poorly understood by both advanced clinical practitioners and the wider medical profession and (4) advanced clinical practitioners recognised the value and importance of the role but felt changes were necessary, to provide security and sustainability.

Conclusions

Appropriate structure and support are crucial throughout the training process to enable staff to have a smooth transition to advanced level, ensuring they obtain the necessary confidence and competence. Structural changes and knowledge brokering are essential, particularly in relation to role clarity and its responsibilities, sufficient allocated time to learn and practice, role accreditation and continuous appropriate supervision.

Peer Review reports

Introduction

Advanced Clinical Practitioners (ACPs) are a relatively new role in the National Health Service (NHS), introduced to address the increasing complexity of healthcare needs and the growing demand for skilled professionals. They are becoming increasingly embedded within a wide range of NHS healthcare settings spanning community services, mental health wards and hospitals. ACPs play a vital role in expanding the scope of practice within healthcare teams, take on more advanced and complex levels of clinical work, including tasks historically carried out by doctors, with an aim to help alleviate the strain on medical professionals and enhance the efficiency of healthcare delivery. Their integration into the workforce has been shown to enhance patient care by providing timely access to high-quality services while also fostering interdisciplinary collaboration [ 1 ]. Studies have shown that ACPs contribute to improved patient outcomes, increased patient satisfaction, and cost-effective healthcare delivery [ 2 , 3 ]. Additionally, their presence supports the development of junior staff by providing mentorship and guidance, thus ensuring a sustainable healthcare workforce for the future [ 1 , 4 ]. As non-medical healthcare professionals, ACPS are required to undertake further education (Masters degree) and extended training in specific clinical areas such as nursing, pharmacy, or allied health professions to qualify as an ACP. According to the multi-professional framework advanced clinical practice, this training is underpinned by four pillars: clinical practice, leadership and management, education, and research [ 5 ]. However, there is wide variability in this practice and training of ACPs across the UK [ 6 ].

Recent years have seen attempts to standardise the training and practice of ACPs. A framework for advanced clinical practice in England was authored in 2017 by Health Education England (HEE) (NHS England) [ 5 ], which set out standards for advanced clinical practice. Within this framework, advanced clinical practitioners should be able to deliver care with a high degree of autonomy and undertake complex decision making. The knowledge and skills should be underpinned by a Master’s level award (or equivalent) that incorporates the Four Pillars of Practice: Clinical Practice, Leadership and Management, Education and Research [ 5 ]. In 2020, The Centre for Advancing Practice ( https://advanced-practice.hee.nhs.uk/ ) began accrediting some of the many advanced clinical practice Masters programmes available in the UK, which it deemed to have met the standards laid out in HEE’s framework [ 7 ]. This process of defining common standards remains in its early stages, and there remains little research on ACP training programmes and their structures or governance. In a further effort to improve and standardise advanced clinical practice, The Centre for Advancing Practice additionally created guidance on workplace supervision for ACPs, noting the crucial need for high-quality supervision [ 8 ]. The Nursing and Midwifery Council (NMC) published their 2020-25 corporate strategy also in 2020, and committed to explore the need for regulation in a comprehensive review of advanced nurse practice [ 9 ]. The review is still in progress but research undertaken in the early stages by The Nuffield Trust and BritainThinks as part of the review reported inconsistency in definitions, outcomes, standards of education and proficiency in advance practice [ 10 ], and support for regulation by health professionals [ 11 ]. Despite calls for improvements in the supervision of ACPs, there has been limited research in this area.

Studies have shown that ACPs have historically struggled with the transition from their previous career to their advanced practice roles [ 12 , 13 , 14 , 15 ]. The challenges of the transition have been exacerbated by a lack of clear professional identity for ACPs, which has been noted to be a source of tension and confusion, impacting on training, development and ultimately patient safety [ 6 , 16 , 17 , 18 , 19 , 20 ]. Recognising the importance of successful integration into the workforce will help ACPs to realise their full potential [ 21 , 22 ], impacting on role satisfaction [ 23 ], staff retention [ 24 ] and ultimately, building a more sustainable workforce.

As efforts to standardise and develop the ACP role continue, ACPs are becoming more widespread within the NHS. The proliferation of ACPs brings a need for a better understanding of all aspects of ACP training, both during and after qualification. We sought to explore the training experiences of ACPs with the aim of informing future models of education and support.

Theoretical framework

The theoretical framework of this study is based on the theories of Bourdieu, particularly his concept of Habitus [ 25 ], as it offers a valuable lens for examining the multifaceted identities, roles, and positionalities of ACPs. Habitus, ingrained dispositions and cultural knowledge shaped by social experiences, acts as a bridge between individual practitioners and the complex healthcare field they navigate. It influences how ACPs perceive and enact their roles, shaped by their educational background, professional training, and prior clinical experiences. Furthermore, Habitus interacts with the “field,” the social space within which ACPs operate, characterized by power dynamics, established hierarchies, and competing ideologies. This interaction influences the capital, both symbolic and material, that ACPs possess and wield within the field. Through this lens, we can understand how ACPs negotiate complex power dynamics within the healthcare system, navigate tensions between professional autonomy and institutional constraints, and ultimately construct their own sense of meaning and purpose within their evolving roles. By analyzing these interactions between Habitus, field, and capital, Bourdieu’s framework offers a rich and nuanced understanding of the experiences and challenges faced by ACPs, paving the way for further research and dialogue on optimizing their practice and impact.

We sought to explore the training experiences of ACPs as well as their perceptions on role identity, gaining clinical competency and future development of the role.

This exploratory study used a qualitative design to conduct focus groups with a purposive sample of ACPs currently working in South Yorkshire and Bassetlaw in the North of England. In 2022 there were 585 trainee ACPs and approximately 1200 qualified ACPs working in this region.

Participants

Qualified ACPs or trainee ACPs that have completed at least 1 year’s full time equivalent of Advanced Care Practitioners clinical training, and currently work in this role within either Mental Health, Community or Secondary Care within the South Yorkshire and Bassetlaw region. It was felt 12-month minimum training experience would ensure trainees were sufficiently embedded in the clinical and educational programmes.

Recruitment

The NHS England Regional Faculty for Advancing Practice– North East and Yorkshire (FACP-NEY) acted as gatekeepers for the recruitment, contacting all qualified and trainee Advanced Care Practitioners working in the region with an invitation to participate by email. The email included a brief outline of the study, dates and times of the focus groups, details of an incentive payment of £30 for participation, a participant information sheet and, a web link to a short online questionnaire and contact details form. Additionally, the study was also advertised on social media platforms (Twitter, Facebook), with those who expressed an interest sent the same study invitation email, documentation and web link. Recruitment was open between February and May 2021, with one reminder email sent from the FACP-NEY during this time.

ACPs that wished to participate in the study were required to complete the short online questionnaire built using the survey tool, Qualtrics ( www.qualtrics.com ). After confirming eligibility, basic details were recorded about the participant and their ACP training including name, contact details, gender, age group, ethnicity, length of experience in the ACP role, supervision routine, portfolio status and supernumerary time. A variety of dates and times (morning, afternoon and evening) were provided for the focus groups to maximise recruitment, and participants were asked to indicate their preference. A total of 14 participants took part across five focus groups.

Data collection

Focus groups took place online using the Google Meets platform, with a maximum of 3 participants per group. To ensure participants were confident in using the Google Meets platform, the focus group began with an overview of the main functions and how to use them, for example clicking the ‘hand-up’ icon to indicate a wish to speak and chat facility. A focus group schedule was designed and used to guide the discussion similar to that used by Macnaghten and Jacobs (1997) [ 26 ] with an emphasis on each topic followed by discussion amongst the participants. The topics covered included experiences of undertaking ACP training (including gaining competence), role identity and career progression. Data collection was discontinued once it was felt there was no new contributions to the analysis, and there had been full investigation of the developed themes.

Participants provided written informed consent prior to attending the focus group, and consent was also acquired verbally at the start of each focus group. Each focus group was facilitated by one of the two authors (SA and MK), both of whom are experienced qualitative researchers with no clinical background or experience. Google Meets was used to video and audio-record the focus groups. The focus groups were transcribed verbatim by a third party, and quality checked against the recordings for accuracy. The duration of the focus groups was 2 h with a 15-minute comfort break. On completion of the focus groups, participants were sent a £30 shopping voucher to compensate them for their time.

Data analysis

The data was thematically analysed by three researchers (MK, SA and JSK) following the six-phrase process of Braun and Clarke, commencing with familiarisation of the data and then line by line coding to identify preliminary categories [ 27 , 28 ]. The data was then ordered and synthesised, combining similar categories and exploring the relationships between them [ 29 ]. This process was repeated for three of the five transcripts at which point the main themes and sub-themes were identified forming a test model, this was then applied to the final two transcripts. Following discussion amongst the research team, the main themes and sub-themes were agreed. NVIVO Release 1.3 (QSR International) [ 30 ] was used to help organise the data. The Standards for Reporting Qualitative Research (SRQR) checklist was used to report the findings (see Additional file 1).

The focus groups highlighted significant variability in the training experience of ACPs, dependent on their role and place of work. Table  1 provides an overview of the participant characteristics of each of the focus groups, and an overview of the overarching themes and sub-themes that were developed are displayed in Table  2 .

Overarching themes

A number of overarching themes were identified in our analysis that appeared to be strongly linked to role identity. We found the experiences of the ACP training were influenced by internal and external perceptions of the ACP role, often acting as barriers, with structural aspects being significant contributory factors. These findings were revealed in four key themes - lack of structure and support in the clinical training, existing experience and knowledge as enablers and inhibitors to progress with implications for confidence, the poorly understood nature of the ACP role and associated responsibilities, and a need for change to provide security to the ACP role in the future.

Clinical training lacked structure and support

The data revealed a stark contrast between the academic and clinical training, with clinical training found to be lacking in structure and support. Experiences of the clinical training were often expressed negatively due to the lack of structure which was heavily reliant on supervision and placements. As a result, ACPs often had to take the lead on their training and having to identify their own supervisor(s) and/ or placements was felt to be challenging. Consequently, some ACPs reported they had no dedicated medical supervisor at all. Where supervisors were in place, the quality of supervision varied, from being ad hoc (p41) and chaotic (p52) to great ( p53). Some of the supervision issues raised by the ACPs included lack of supervisor knowledge in relation to the ACP training and their required responsibilities, accessibility of supervisor (available time) and little direct clinical oversight. ACPs felt they needed an experienced medical professional as their supervisor, providing similar support and advice to that received by junior doctors.

We have nursing supervision from the lead community matron who is our line manager, but we do miss that sort of medical supervision (p22, Trainee ACP– Primary care) . I’m line managed by a nurse who is the operational lead for the service. He is the right person, but I don’t go to him for clinical support. It would be nice to have a medical supervisor (p. 41, Trainee ACP– Community care) .

Good supportive supervision appeared to enhance the ACP training, conversely poor, unsuitable or no supervision was perceived to have a serious negative impact on training and well-being, with suggestions that ACPs had left during training because of it.

I’ve had free reign over my own training, and planned everything myself, and that’s a positive for me (p41, Trainee ACP– Community care) . So the positives, um, I think the academic and educational supervision’s been, err, accessible and supportive. So we have, um, supervision from [regional] ACP lead,…and then there’s, um, the course unit lead, which she’s there and she’s supportive. So yeah, the academic, err, supervision is good (p52, Trainee ACP– Secondary care) . I think, um, something that I haven’t touched upon is, which I realised, so I’ve got a, um, clinical supervisor, she’s a consultant *****, and…the module I’ve just done which is minor illness, you had to do like a learning log, so they had to see you do….a load of things. And it made me laugh cos they turned around and said, look, I haven’t assessed anybody’s abdomen in ten years…. (p53, Trainee ACP– Secondary care)

Similar to supervision, clinical placements were highly valued by the ACPs and recognised as an important part of the training to achieve competence and consolidate their academic learning. All of the ACPs reported obstacles in organising and undertaking such placements, with those working in the community or mental health facing particular difficulties due to placements needing to be in a different clinical setting to where they worked. Competition with other trainees, the need to ‘ beg ’ (p7) and insufficient time from trainers were highlighted as ongoing problems. Conflict with junior doctors was also described as a competition for training opportunities.

Completely unsupported by the Trust because they just weren’t set up for it, there was no one leading on it, there were no one for us to contact really to talk. And then, like you said, I got my placements from begging on a, on a forum on Facebook and a nurse set me up (p16, Trainee ACP– Secondary care) . To kind of fulfil the module requirements, it was pretty much, for minor illness basically phoning up GP surgeries, practice nurses, beg stealing and borrowing, you know, begging people can you help me out, to try and get the amount of hours that you needed (p7, Trainee ACP– Secondary care) . But sometimes, it’s a little bit of a fight to get to what you need when you need because there’s so many junior doctors that also need that same training. So, there are occasions where you have to sort of step up and say we are training the same as these guys, we also need to be able to have these opportunities and you kind of have to have a little bit of a voice to say, we’re here (p17, Trainee ACP– Secondary care) .

In contrast to the clinical training, the academic learning followed a traditional format of taught lessons which ACPs felt covered a wide breadth of knowledge. There was some feeling that modules might have been more useful if they had been tailored towards individuals’ specialisms such as mental health or physiotherapy, however on the whole it was described as a positive learning experience with good supportive academic supervision.

I found the dissection labs quite alien but they have really helped to develop my practice (p24, Qualified ACP– Secondary care) . It feels a lot like there’s university, which is one day a week, and you do that, and it’s really supportive, and I’ve made some really good friends there, and everybody supports each other. But then at work, it’s a bit of a try and find your own way (p53, Trainee ACP– Secondary care) .

ACPs did describe the two learning environments (clinical and academic) as disconnected, separate and discrete, even though the ACP training is a combination of academic and clinical learning.

From the course point of view it’s pretty straightforward but it’s marrying that up with the expectations of the employer. Willingness of the employer to be able to give you the time you need to do what you need to do (p. 38, Qualified ACP– Secondary care) . They’d learn something at University (e.g. Cardiology) but there was no way this could be built on within the Trust. They just don’t deal with the physical health side of things (p. 7, Trainee ACP– Community mental health) .

Existing knowledge and experience appeared to act as both an enabler and inhibitor for ACPs, with implications for confidence

As existing experienced clinical practitioners, ACPs felt they were able to recognise their knowledge gaps and work quickly towards filling them, however the training approach also led to declines in confidence when deficiencies in knowledge and skills were highlighted. ACPs reported learning ‘backwards’ compared to junior doctors, using pattern recognition rather than pathology as a starting point, for example, being able to identify the treatment based on a diagnosis, but not necessarily knowing how the diagnosis was made originally. Not being able to adequately answer questions sufficiently on such subjects when tested by clinicians, and as experienced clinical practitioners, ACPs perceived themselves as lacking competence with a subsequent drop in confidence.

ACPs are trained ‘bottom-up’– we learn pattern recognition and then work our way back, whereas doctors know the diseases better (p41, Trainee ACP– Community care) . I think about cases backwards compared to doctors– as they think about pathology first and then build on that (p9, Trainee ACP– Primary care) .

A comparison between the clinical training processes of junior doctors and ACPs was a common discussion between ACPs with suggestions that it would be more beneficial if ACPs were recognised in a similar manner to junior doctors. For example, ACPs felt they should not be ‘counted in the nursing numbers’ when working on a ward, and as a consequence should not be expected to undertake a dual role of managing a nursing shift and practicing as an advanced practitioner:-

So say for example, you’re sat with somebody talking about their prescription and trying, you know, looking to see if there needs to be a change made, and then you’ve got other people banging on the door saying, I want to go out on leave, and I need this and I need that, and you’re the nurse in charge and need to be doing that. The people that usually do those jobs, so say for example the doctors in the week, when they’re having those sorts of consultations with people, they’ve not got that stress, the pressure, the disruption and the responsibility of running a nursing shift or a completely other shift. So, us as novices, it just doesn’t make sense to me (p. 52, Trainee ACP– Secondary care)

ACPs spoke of being unsure of when they had reached clinical competency, and how they would maintain this. They worried that if they were not given sufficient time to practise the new clinical skills, their confidence would decline and that they would ultimately feel unsafe in their clinical practice. ACPs emphasised the importance of having sufficient time to practice new skills and consolidate knowledge, enabling autonomy and confidence building. It was also felt this provided essential opportunities for colleagues to observe progress.

I’ve got most of my competencies but I still wouldn’t see myself as an expert practitioner (p41, Trainee ACP– Community care) .

The ACP role and associated responsibilities are poorly understood by ACPs and the wider medical profession

Exploring the experiences of training and the process of developing clinical competence with ACPs revealed there was a lack of clarity regarding the job role depending on where the ACP worked, and this applied to the ACPs themselves as well as their colleagues. This uncertainty impacted the responsibilities the ACP undertook within the clinical environment, and the expectations on them from the staff that they worked with.

ACPs that worked within the Emergency Department reported that colleagues understood the ACP role and utilised the advanced skillset the ACPs gained as the training progressed. They described feeling fully immersed within the department as an advanced practitioner, yet they were also recognised as being in a transitional stage with appropriately allocated time to undertake the necessary training.

ACPs working in other areas of healthcare such as acute wards, outpatients, mental health and community care discussed a general lack of awareness about the advanced practitioner role by both healthcare staff and patients. It was felt this led to a lack of utilisation of the advanced skills of the ACPs and expectations that the ACP should fulfil multiple job roles, creating feelings of intense pressure and demoralisation. ACPs reported hearing discouraging comments from colleagues about their abilities and felt a need to justify their role. Some ACPs described struggling with how to introduce themselves to both staff and patients, with their uniform described as an important part of their identity and how they were perceived by others. Adding to these external perceptions, ACPs revealed their job description was not necessarily updated to reflect their ACP role and where it was, the job description could be vague further undermining their role identity and leading to feelings of conflict between their original healthcare professional role (e.g., nurse) and working at an advanced level.

There’s been a lot of ambiguity around the job description for ACPs and trainee ACPs, so that’s left wriggle room for everybody making their own assumptions about what you’re supposed to do and what you should be doing, and therefore you’re pulled into all different things that don’t tie in to on paper in terms of national, regional frameworks……. there’s just pressure on the role being categorised as an extension of the nursing team, and taking on classic nursing tasks, it’s what people are familiar with, it’s what they assume (p52, Trainee ACP– Secondary care) . The challenge is with our role, is the ACP is tagged on to the end of our existing job. So, we have all of our normal nursing duties, we’re bed managers, we triage nurse, we run the hospital. And then you’ve got ACP tagged on the end. (p25, Qualified ACP– Secondary care)

Inconsistencies in awareness of the role, experience, training and clinical practice were felt to be a reflection of the different professions undertaking ACP training, a lack of standardised job role and unclear expectations. The variation in financial remuneration within and across different organisations for ACPs was also felt to be a contributing factor to these identity issues.

The ACP role is important, but changes are required to provide security to the role in the future

There was consensus that the combination of experience and advanced skills made the ACP a unique and valued role in the NHS, fulfilling an important gap in patient care. ACPs reported uncertainty about their future in the role, and the need for change structurally to ensure the ACP role has a future. Accreditation was felt to be necessary as this would legitimise the ACP role and apply some professional control in respect to the role title. ACPs viewed this as an existing issue with ‘advanced’ used by a multitude of health professions that have not undertaken the accredited training.

I kind of feel that, certainly as an ACP title, it should be some sort of standardised title, and then people would probably understand it a little bit more. I think our colleagues would understand it, and I think you won’t get so much resistance, from some medical colleagues, maybe, if people were sort, if it were a bit more regulated. I mean, if there were talking about credentialing and looking at a directory for ACPs anyway, it should be a registered regulated title (p54, Qualified ACP– Primary care) . I think everybody should be under the same governing body and there should be a bit of standardised, training placement (p41, Trainee ACP– Community care) .

As well as increased knowledge and skills, ACPs discussed the additional benefits of the training including the broad range of opportunities offered both during and after the training, and the potential boost in future prospects. A key attraction to the ACP training route that was repeatedly highlighted was the fact that it offers career progression whilst maintaining clinical responsibilities, progressing through more traditional routes into a managerial role appears to involve considerably less clinical duties and contact with patients. However, there was also some feelings of insecurity regarding the future of the ACP role because of the general lack of awareness of how ACPs fitted and could contribute to the NHS. It was felt that the deficiency in formal structure for the ACP role contributed to this; ensuring job descriptions existed and reflected the responsibilities of the role, and there was a structure for career progression was proposed as a good starting point to improve understanding amongst staff.

In terms of where I see myself in five to ten years’ time, I’m not sure, it depends how that organisation I work for pans out, because…. I won’t be sat here in five years’ time saying the same stuff. If it’s still the same I won’t be there, I will have gone somewhere else cos there are places that fulfil the role (p52, Trainee ACP– Secondary care) . I don’t see much career progression within ACPs other than to become a lead ACP and there is nothing to define progression within that role from a banding point of view (p1, Trainee ACP– Secondary care) .

On the whole, the ACPs felt the role had great future potential but this was often caveated, that changes were needed in formalisation of the training and particularly, wider recognition of the role and its responsibilities. Without these changes, a number of ACPs felt they would not be in the ACP role in 5 years’ time.

The one thing that I do know is that I love the job, I love the role (p38, Qualified ACP– Secondary care) .

This qualitative study collected the perspectives of 14 ACPs from different specialties and at different stages of their career. The findings suggest that ACPs continue to face significant barriers, undermining their development, transition and integration into the healthcare workforce.

ACPs described a number of challenges experienced in their training within the clinical environment, notably with placements and supervision. Both of these elements appeared to suffer from a lack of formal structure; where some ACPs experienced a supportive clinical environment making their training experience ‘phenomenal’, others reported unsuitable supervision and having to identify their own supervisors and/ or placements. This lack of support was felt to have a serious negative impact on ACP training and well-being, which has been reported nationally and internationally [ 17 , 31 , 32 ]. It is recognised that a supportive environment is a healthy environment, aiding not only ACPs in their competency, role transition and job satisfaction but also helping to optimise quality patient care, recruitment and retention [ 13 , 24 ]. Additionally, a disconnect between academic and clinical training was highlighted. This lack of ‘joined-up’ working between educators, healthcare staff and managers has been described previously with suggestions that it can impede the development of ACPs and their fulfilment of the role [ 22 , 33 ].

The knowledge and experience already held by ACPs from their original professional training was perceived as both a strength and weakness. Whilst the ACPs felt they could provide improved holistic patient care and identify gaps in their own training, it influenced their approach to learning which was described as ‘bottom-up’ and ‘backwards’ compared to how junior doctors learnt. This had implications for confidence as ACPs often felt they could not adequately answer questions posed during training. Furthermore, if they were not given sufficient time to consolidate their new knowledge, this led to an additional drop in confidence and doubts about their competence. This was reported by MacLellan, Higgins and Levett-Jones (2017) [ 34 ] and has been referred to as Imposter Syndrome [ 35 ]. It links closely with role transition and identity which has been widely researched within the advanced practitioner community [ 12 , 13 , 14 ]. Increasing autonomy and responsibility is part of the transition for ACPs and whilst some of the ACPs in this study found this experience exciting, the majority conveyed mixed emotions including feeling stressed, pressured and uncertain. This was more prominent for those ACPs in areas where the role appeared to be less established and a lack of awareness among healthcare staff of the ACP role. For a smooth and successful transition, Barnes (2015) [ 12 ] identified a number of defining attributes including a shift from provider of care to prescriber of care, straddling two identities and mixed emotions. The experiences of our ACPs covered all of these attributes and suggest they have not experienced a smooth transitional journey.

Inconsistencies in the ACP training and lack of structure in relation to the clinical job role were discussed as contributing factors to role identity issues, which impacted their daily working lives. It appears the ACPs in our study are still experiencing the consequences of a role which was introduced without clear definition, standardisation, skills and scope [ 20 ], even though there has been significant development in recent years within advanced practice [ 5 ] of the ACP training. As a role introduced to work alongside doctors, nurses, pharmacists, and other healthcare professionals to deliver comprehensive and patient-centred care, ACPs play a pivotal role in fostering interprofessional collaboration within healthcare teams. However, with blurred definitions regarding the ACP role and responsibilities, it is unsurprising our ACPs reported a lack of understanding of their expertise and respect from their colleagues. Such barriers to interprofessional collaboration not only prevents ACPs from working to the full extent of their education and training [ 36 ] but impacts patients, on their outcomes and access to specialist care [ 21 , 37 , 38 ]. A review of 64 studies undertaken by Schot, Tummers and Noordegraaf (2020) of interprofessional collaboration among healthcare professionals described this as being multifaceted, and that for change to occur, individuals needs to work daily on tasks such as bridging gaps, negotiating overlaps and creating spaces [ 39 ].

There was agreement between the ACPs that accreditation of the role would help address some of the issues around role identity. The use of ‘advanced practice’ is widely applied within healthcare with little relationship to education level, often leading to confusion [ 18 ]. Accreditation would help protect the role by providing professional identity as well as providing more clarity to ACPs and those in the wider healthcare setting about the role and scope of practice [ 6 , 17 , 18 ]. It may also alieve fears of insecurity which were raised by the ACPs in relation to the future of the role. Improving and promoting knowledge brokering at both the individual and collective (system) levels would improve the transition process [ 40 ], whilst also encouraging change in an environment that is traditionally intransigent.

Although the ACPs reported challenges in their training and felt changes were necessary to ensure wider recognition of the ACP role, there was consensus among the ACPS that participated in this study that the training ‘boosted’ opportunities and allowed career progression whilst maintaining clinical responsibilities, an important factor to many of the ACPs in this study. Surprisingly, there was little discussion regarding the impact of the COVID-19 pandemic on ACP training, even though the focus groups took place during the pandemic. When it was discussed, it was generally in the context of placements and how they had been further limited.

This qualitative insight into the training experience of ACPs has highlighted that there are many challenges still to be overcome to ensure ACPs feel supported through their role transition journey and are recognised appropriately for their skills and experience in the healthcare workforce. These findings are not new [ 13 , 14 , 20 , 22 ] but after the release of the 2017 HEE multi-professional framework for advanced clinical practice [ 5 ], it would be expected that there would have been more clarity and structure in the ACP training and role, benefitting ACPs, wider healthcare professionals and employers. Progress may improve as a result of the NMC review on regulation of advanced nursing practice that is due in the next 12 months [ 9 ], however, at the time of this study, the ACPs appeared to feel progress was slow and more work was needed.

Strengths and limitations

The opinions and experiences provided in this study were from a group of ACPs, either during (> 1 year FTE) or post training, working in the South Yorkshire and Bassetlaw region. It is reasonable to suggest therefore that the results are not generalisable to other populations. Qualified and trainee ACPs were contacted about the study by email through the regional FACP-NEY who acted as gate keepers, as well as the study being advertised on social media platforms. It is assumed that this broad recruitment strategy helped to reach a wider population, although most respondents appeared to be as a result of the direct email. This approach may have introduced some bias but using a purposive sampling approach, participants from different specialties, professions and career stages were included. Information about the local ACP workforce such as size and individual characteristics was requested from the regional FACP-NEY but this was not provided thus an exact response rate cannot be calculated nor can any inferences be made regarding how representative the sample of ACPs were that participated in the study. The number of males that registered an interest in the study was low (three) and only one male participated in the focus groups; this is a limitation as there may be different perspectives and experiences of ACP training related to gender. Due to the COVID-19 pandemic focus groups had to be undertaken online. Adaptions were made to accommodate for this such as reducing the number of participants per focus group and creating time to build rapport [ 41 ]. One participant did experience technical issues, however using a digital approach did not appear to impede the participant-researcher interaction and compared favourably with traditional face to face focus groups [ 41 , 42 ]. There is a risk that views from participants were oversimplified due to the limited number of ACPs involved in the focus groups but findings from this study appear to align with previously published literature [ 6 , 17 , 19 , 21 ] providing some confidence in the results.

Future work

This was a small exploratory study in a rapidly evolving field, providing insights on ACP training, role identity and competence at one point in time. ACPs did report differences in their experiences due to their specialty thus a much larger study would provide an opportunity to explore this further and allow for more in-depth comparisons. The multi-professional framework was relatively new when this study was undertaken and since its publication, there has been much development in the guidance and practice of ACPs including the Royal College of Emergency Care ACP training [ 43 ] and the merger of Health Education England with NHS England. It would be useful to explore what impact, if any, these developments may have had on ACPs and if similar issues around role identity and competence still exist.

The ACP role is now integrated across many specialties both nationally and internationally, however challenges continue to persist in training, impacting on transition into the role. At a collective level, there remains a lack of structure and clarity around the ACP role, and individually ACPs appear to experience issues with supervision and support. This study has highlighted that the journey to advanced level practice is often turbulent, and changes are required to further embed the ACP training and role into the workplace. Ensuring ACPs have appropriate continuous support, allocated sufficient time to learn and practice, and wider recognition of the ACP role through accreditation would aid the training experience and a successful role transition.

Data availability

The datasets generated and analysed during the current study are not publicly available due to the participants privacy being compromised but are available from the corresponding author on reasonable request.

Abbreviations

Advanced Clinical Practitioner

Faculty for Advanced Clinical Practice

Health Education England

National Health Service

Imison C, Castle-Clarke S, Watson R. Reshaping the workforce to deliver the care patients need. Research report 2016, Nuffield Trust: London.

Mann C, et al. Exploring the role of advanced clinical practitioners (ACPs) and their contribution to health services in England: a qualitative exploratory study. Nurse Educ Pract. 2023;67:103546.

Article   PubMed   PubMed Central   Google Scholar  

Evans C, et al. Characterising the outcomes, impacts and implementation challenges of advanced clinical practice roles in the UK: a scoping review. BMJ Open. 2021;11(8):e048171.

Stewart-Lord A, et al. The role and Development of Advanced Clinical Practice within Allied Health Professions: a mixed method study. J Multidisciplinary Healthc. 2020;13:1705–15.

Article   Google Scholar  

Health Education England. Multi-professional framework for advanced clinical practice in England . 2017.

Evans CR, et al. Characterising the evidence base for advanced clinical practice in the UK: a scoping review protocol. BMJ Open. 2020;10(5):e036192.

Health Education England: The Centre for Advancing Practice. Programme accreditation. 2023; Available from: https://advanced-practice.hee.nhs.uk/our-work/programme-accreditation/ .

Health Education England. The Centre for advancing Practice., workplace supervision for Advanced Clinical Practice: an integrated multi-professional approach for practitioner development . Health Education England; 2020.

Nursing and Midwifery Council (NMC). Regulate, support, influence: strategy 2020–2025. London: NMC; 2020.

Google Scholar  

Palmer W, Julian S, Vaughan L. Independent report on the regulation of advanced practice in nursing and midwifery. Research report. London: Nuffield Trust; 2023.

BritainThinks. Advanced Practice qualitative research . 2023, BritainThinks: London.

Barnes H. Nurse practitioner role transition: a Concept Analysis. Nurs Forum. 2015;50(3):137–46.

Article   PubMed   Google Scholar  

Moran G, Nairn S. How does role transition affect the experience of trainee Advanced Clinical practitioners: qualitative evidence synthesis. J Adv Nurs. 2018;74(2):251–62.

Fitzpatrick S, Gripshover J. Expert nurse to novice nurse practitioner: the Journey and how to improve the process. J Nurse Practitioners. 2016;12(10):e419–21.

Timmons S, et al. The Advanced Clinical Practitioner (ACP) in UK healthcare: dichotomies in a new ‘multi-professional’ profession. SSM - Qualitative Res Health. 2023;3:100211.

Reynolds J, Mortimore G. Transitioning to an ACP: a challenging journey with tribulations and rewards. Br J Nurs. 2021;30(3):166.

Fothergill L, et al. Nationwide evaluation of the advanced clinical practitioner role in England: a cross-sectional survey. BMJ Open. 2022;12(1):e055475.

Leary A, et al. Variation in job titles within the nursing workforce. J Clin Nurs. 2017;26(23–24):4945–50.

Lawler J, Maclaine K, Leary A. Workforce experience of the implementation of an advanced clinical practice framework in England: a mixed methods evaluation. Volume 18. Human Resources for Health; 2020. 1.

Nadaf C. Perspectives: reflections on a debate: when does Advanced Clinical Practice stop being nursing? J Res Nurs. 2018;23(1):91–7.

Evans C, et al. Advanced Clinical practitioners in Primary Care in the UK: a qualitative study of Workforce Transformation. Int J Environ Res Public Health. 2020;17(12):4500.

Jones A, et al. Realising their potential? Exploring interprofessional perceptions and potential of the advanced practitioner role: a qualitative analysis. BMJ Open. 2015;5(12):e009740.

Wood E, et al. Sources of satisfaction, dissatisfaction and well-being for UK advanced practice nurses: a qualitative study. J Nurs Manag. 2021;29(5):1073–80.

Price S, Reichert C. The importance of Continuing Professional Development to Career satisfaction and patient care: meeting the needs of novice to Mid- to late-Career nurses throughout their Career Span. Administrative Sci. 2017;7(2):17.

Bourdieu P. The logic of practice. Translated by R. Nice . 1990, London, UK: Polity Press.

Macnaghten P, Jacobs M. Public identification with sustainable development: investigating cultural barriers to participation. Glob Environ Change, 1997: p. 5–24.

Braun V, Clarke V. Using thematic analysis in psychology. Qualitative Res Psychol. 2006;3(2):77–101.

Braun V, Clarke V. Successful qualitative research: a practical guide for beginners. Thousand Oaks, California: Sage; 2013.

Strauss A, Corbin JM. Basics of qualitative research: grounded theory procedures and techniques. California: Sage Publications Inc; 1990.

QSR International Pty Ltd. NVivo qualitative data analysis software . 2020.

Cusson R, Strange S. Neonatal nurse practitioner role transition: the process of reattaining expert status. J Perinat Neonatal Nurs. 2008;22(4):329–37.

Duke C. The lived experience of nurse practitioner graduates’ transition to hospital-based practice , in nursing . East Carolina University: US; 2010. p. 138.

Townsend A. Developing a portfolio for advanced practice. Nurs Times. 2015;111:23–6.

MacLellan L, Higgins I, Levett-Jones T. An exploration of the factors that influence nurse practitioner transition in Australia: a story of turmoil, tenacity, and triumph. J Am Assoc Nurse Pract. 2017;29(3):149–56.

Redfern-Jones J. Unmask your talent. Nurs Stand. 2009;23(38):64.

Moss E, Seifert CP, O’Sullivan A. Registered nurses as Interprofessional Collaborative Partners: creating Value-based outcomes. Online J Issues Nurs, 2016. 21(3).

Goldsberry JW. Advanced practice nurses leading the way: interprofessional collaboration. Nurse Educ Today. 2018;65:1–3.

Hardy M. Health and Care Professions Council. Advanced practice: research report . 2021.

Schot E, Tummers L, Noordegraaf M. Working on working together. A systematic review on how healthcare professionals contribute to interprofessional collaboration. J Interprof Care. 2020;34(3):332–42.

Putri AF, Tocher J, Chandler C. Emergency department nurses’ role transition towards emergency nurse practitioner: a realist-informed review. Int Emerg Nurs. 2022;60:101081.

Keen S, Lomeli-Rodriguez M, Joffe H. From challenge to opportunity: virtual qualitative research during COVID-19 and Beyond. Int J Qual Methods. 2022;21:16094069221105075.

Murray B. Online tools for qualitative research during the Covid-19 pandemic. Nurs Times [online]. 2022;118(6):1–3.

Royal College of Emergency Medicine. Emergency Medicine– Advanced Clinical Practitioner (EM-ACP). 2024; Available from: https://rcem.ac.uk/emergency-care-advanced-clinical-practitioners/ .

Download references

Acknowledgements

The authors would like to thank the Sheffield Emergency Care Forum (SECF) PPI group ( https://secf.org.uk/ ) for their helpful feedback on the recruitment materials (email invitation, information sheet and consent form) developed for this study to ensure they were suitable for a lay audience. For helping with the recruitment, we would also like to thank the Faculty of Advanced Practice, particularly Fran Mead. Lastly, we would like to thank our participants for giving up their valuable free time to share with us their experiences of developing clinical competence as an Advanced Clinical Practitioner, and for their opinions on role identity.

This manuscript is independent research funded by the National Institute for Health and Care Research, Yorkshire and Humber Applied Research Collaborations (NIHR200166). The views expressed in this publication are those of the author(s) and not necessarily those of the NHS, the National Institute for Health and Care Research or the Department of Health and Social Care.

Author information

Authors and affiliations.

Centre for Urgent and Emergency Care Research (CURE), Sheffield Centre for Health and Related Research (ScHARR), The University of Sheffield, S1 4DA, Sheffield, UK

Maxine Kuczawski, Suzanne Ablard, Fiona Sampson, Susan Croft, Joanna Sutton-Klein & Suzanne Mason

Emergency Department, Northern General Hospital, S5 7AU, Sheffield, UK

Susan Croft

Manchester Royal Infirmary, Oxford Rd, M13 9WL, Manchester, UK

Joanna Sutton-Klein

You can also search for this author in PubMed   Google Scholar

Contributions

Made substantial contributions to conception and design, or acquisition of data: MK, SA and JSK; Analysis and interpretation of data: MK, SA, SC and JSK; Manuscript draft: MK, SA and JSK; Manuscript critical revisions: MK; SA; SC; JSK; FS; SM. All authors approved the final version of the manuscript.

Corresponding author

Correspondence to Maxine Kuczawski .

Ethics declarations

Ethics approval and consent to participate.

Ethical approval for the conduct of the research was obtained from the University of Sheffield Research Ethics Committee (REC reference. 032462). Written informed consent was obtained from all participants prior to the focus group, and all methods were performed in accordance with the relevant guidelines and regulations.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Additional information

Publisher’s note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary Material 1

Rights and permissions.

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Cite this article.

Kuczawski, M., Ablard, S., Sampson, F. et al. Exploring advanced clinical practitioner perspectives on training, role identity and competence: a qualitative study. BMC Nurs 23 , 185 (2024). https://doi.org/10.1186/s12912-024-01843-x

Download citation

Received : 20 September 2023

Accepted : 04 March 2024

Published : 18 March 2024

DOI : https://doi.org/10.1186/s12912-024-01843-x

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Advanced clinical practitioner
• Qualitative
• Role identity

BMC Nursing

ISSN: 1472-6955

• General enquiries: [email protected]

Stanton Foundation grant to fund canine mitral valve diagnosis research at veterinary college

• Kevin Myatt

21 Mar 2024

• Share on Facebook
• Share on Twitter
• Copy address link to clipboard

Mitral valve degeneration is common among small dogs as they age. It’s often asymptomatic and not always lethal, but it can lead to heart enlargement and heart failure. Medications can reduce the effects and delay the onset of heart failure.

A $141,000 grant from the Stanton Foundation will fund research at the Virginia-Maryland College of Veterinary Medicine to determine if primary care veterinarians using only a stethoscope and chest X-rays can be effective in identifying dogs that would benefit from medical treatment for myxomatous mitral valve disease before symptoms have occurred.

Spectrum of care

The research supports the Stanton Foundation’s focus on “spectrum of care,” a concept also embraced by the veterinary college, its Veterinary Teaching Hospital , and its  Small Animal Community Practice  veterinary clinic. Clinicians provide a variety of care options and work with the client to decide together which approach best meets the needs of the pet and its family. This approach provides affordable and readily available options for those who cannot afford or don’t have access to more expensive or specialized procedures for their dogs.

“The foundation’s mission in canine health is to ensure that dogs who belong to families of modest economic means enjoy the best possible health throughout their lives,” according to the Stanton Foundation website. “It supports clinical research on preventive care and alternatives to ‘gold standard’ veterinary medicine with wider experiential learning in veterinary training.”

In this case, research will determine the accuracy of less costly and readily available diagnostic testing for identifying dogs for mitral valve disease that would benefit from treatment without the use of an echocardiogram

“Clients have a variety of ability, both from an access standpoint - whether there's a specialist in their area - and a cost standpoint - what their budget can allow for – in pursuing gold standard veterinary care,” said Sunshine Lahmers , clinical associate professor of cardiology and principal investigator for the Stanton-supported research. “The spectrum of care concept from the Stanton Foundation is for all clients to feel like they can provide their pets quality care, even if they can't pursue the gold standard testing. We want to develop evidence-based approaches for a primary care practitioner to provide a client a variety of options when they hear a murmur in a patient’s heart.”

Heart murmurs

Jenny Marin , clinical assistant professor in community practice, said cases of heart murmurs in dogs, often related to mitral valve disease, are very common.

“We see it all the time in general practice,” said Marin, who was a veterinarian in a North Carolina private clinic before joining the Veterinary Teaching Hospital. “The struggle I was having a lot before I came here, where I have cardiologists down the hall, was getting these dogs in to see a cardiologist at an early stage of their heart disease. We were having to make a lot of decisions just based on things we could do.

“The goal is to see if those techniques work well and have some evidence-based procedures to help general practitioners, like me, be able to make those decisions when we can’t send those dogs to a cardiologist.”

Two stages of research

The research funded by the Stanton Foundation at veterinary college will have two stages.

The first stage is a retrospective study, in which 150 radiographs of asymptomatic dogs with murmurs evaluated at the teaching hospital over the past decade will be reviewed. Kurt Zimmerman , professor of pathology and informatics, will use a computer model to create a decision tree designed to help clinicians predict the cases of asymptomatic mitral valve disease that would benefit from treatment.

The second stage will involve 30 dogs in a case recruitment pilot study to test the performance of the model, which will gauge how accurate primary care clinicians can be, without an echocardiogram, in identifying the dogs with a murmur that can have the onset of heart failure delayed with medical treatment.

Andrew Mann

540-231-9005

• Biomedical and Veterinary Sciences
• Blacksburg, Va.
• Good Health and Well-Being
• Graduate Education
• Industry, Innovation, and Infrastructure
• Partnerships for the Goals
• Reduce Inequalities
• Small Animal Clinical Sciences
• Small Animal Community Practice
• Veterinary Teaching Hospital
• Virginia-Maryland College of Veterinary Medicine

Related Content

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

• Advanced Search
• Journal List
• Front Psychol

Methods of increasing cultural competence in nurses working in clinical practice: A scoping review of literature 2011–2021

Training for the development of cultural competence is often not part of the professional training of nurses within the European Economic Area. Demographic changes in society and the cultural diversity of patients require nurses and other medical staff to provide the highest quality healthcare to patients from different cultural backgrounds. Therefore, nurses must acquire the necessary cultural knowledge, skills, and attitudes as part of their training and professional development to provide culturally competent care to achieve this objective.

This review aims to summarize existing methods of developing cultural competence in nurses working in clinical practice.

A scoping review of the literature.

The following databases were used: PubMed, ScienceDirect, ERIH Plus, and Web of Science using keywords; study dates were from 2011 to 2021.

The analysis included six studies that met the selection criteria. The studies were categorized as face-to-face, simulations, and online education learning methods.

Educational training for cultural competence is necessary for today’s nursing. The training content should include real examples from practice, additional time for self-study using modules, and an assessment of personal attitudes toward cultural differences.

Introduction

Current demographic changes mean that nurses need to provide quality nursing care for patients from different cultural backgrounds. Horvat et al. (2014) report that health workers will increasingly be obliged to provide healthcare to patients from different cultural groups. Eurostat (2019) states that 4.2 million people from other countries migrated to the European Union in 2019. Germany (88,630), France (29,910), Spain (29,620), and Romania (23,370) reported the largest number of immigrants. Cruz et al. (2017a) draw attention to the fact that every population group has unique norms, values, and practices that determine the group’s perception of health, which is why it is important to implement the principles of culturally specific healthcare.

Cultural competence in nursing

Cultural competence ( Ahn, 2017 ) in nursing care is essential for providing quality care for patients from different cultural backgrounds. It is a specific concept related to transcultural nursing and contains a wealth of skills and knowledge regarding cultural values, health beliefs, religion, and human philosophy. It is a concept linked to culturally specific nursing care ( Leininger and McFarland, 2002 ). Cultural competence in nursing has been defined as a set of knowledge, skills, and attitudes applied in the clinical practice of nursing in an intercultural context ( Cerezo et al., 2014 ; Paric et al., 2021 ).

Development of cultural competence of nurses

According to Horvat et al. (2014) , the development of cultural competencies is a crucial component for addressing health disparities and strategies to improve culturally competent care, and many experts agree ( Harkess and Kaddoura, 2016 ; Mariño et al., 2018 ; Curtis et al., 2019 ; Červený et al., 2020 ; Swihart et al., 2021 ). Faber (2021) adds that the education of health professionals is also a method of addressing racial and ethnic discrimination resulting from structural inequality. According to Carey (2011) , nursing schools should provide adequate opportunities to develop cultural competence. Cruz et al. (2017b) recommend that nursing schools include international standards for culturally competent nursing care.

Moreover, teaching standards should be adapted to local cultural diversity within each country. This ensures that nurses have a proper cultural context that can promote the development of cultural sensitivity, cultural adaptability, and cultural motivation. This type of education is demanding for teachers, who need to have the most up-to-date information from professional literature, constantly evaluate self-esteem, and modify educational methods to develop cultural competence ( Prosen and Bošković, 2020 ). However, according to Faber (2021) , there is a wealth of evidence in literature where researchers present the effectiveness of cultural competence training in individual health professions to be more linguistically and culturally aware. Farber also states that there are no coherent sector-wide standards for defining cultural competence, educational practice, evaluation measures, or target results.

Why is a literature review essential?

Accelerating globalization and demographic changes in society, the incidence of patients from different cultural backgrounds, language barriers, discrimination, racism, prejudice, and stereotypes are all factors that affect the quality of nursing care ( Červený et al., in press ; Shepherd et al., 2019 ; Williams et al., 2019 ; Joo and Liu, 2020 ). Prosen (2018) states that providing culturally competent nursing care for patients from different cultural backgrounds should not be seen as a privilege but as a human right. In order to eliminate barriers to quality care, it is necessary to find the best possible methods for developing cultural competence in nurses in clinical practice.

Research question

• What methods are effective at increasing the level of cultural competence?
• What factors can improve existing methods of increasing the level of cultural competence?

Aim of literature overview

The main objective of the review was to summarize the existing methods of developing cultural competence in nurses working in clinical practice.

• Determine which educational methods effectively increase cultural competence in clinical practice.
• Identify the impact of education on cultural competence.
• Identify potential opportunities to improve the development of cultural competence.

Materials and methods

This study is based on a qualitative scoping review using the Preferred Reporting Items for Systematic Reviews and a Meta-Analyses Extension for Scoping review ([PRISMA-ScR], Tricco et al., 2018 ; Page et al., 2021 ; Figure 1 ) and the Participants, Interventions, Comparison, and Outcomes (PICO) listed in Table 1 .

PRISMA flow diagram of the scoping review.

Inclusion and Exclusion criteria for the scoping review.

Methods of searching the literature

The analyzed publications were collected from the PubMed, ScienceDirect, ERIH Plus, and Web of Science databases using keywords and Booleans operatives: (“transcultural education”) OR (“training”) AND (“culturally competence”) AND (“nurses”) AND (“clinical practice”). All sources were academic publications that went through the peer-review process. The focus of this review was on the following elements:

• Population: Clinical practice nurses
• Intervention: Education to increase cultural competences
• Related: Clinical practice nurses
• Outcome: Increasing cultural competencies in clinical practice nurses through education (training)

The criteria for the selection of resources are presented in Table 1 . We searched for resources dated from 01.12.2011 to 31.12.2021.

Data charting, extraction, and quality evaluation

We used a 3-step screening process that was evaluated in MS Excel. In the first step, we searched the article’s title and abstract. In the second step, we identified and sorted articles that met the outline ranking criteria and assessed their quality. To evaluate the articles’ quality, two co-authors independently used the Critical Appraisal Skills Programe (2018) . This general tool evaluates any qualitative methodology. It has 10 questions asking the researcher to assess whether appropriate research methods were used and whether the findings were presented meaningfully ( Červený et al., 2020 ; Long et al., 2020 ). The results of the quality assessment are presented in Table 2 . In the third step, the data were extracted.

Results of critical appraisal checklist results.

Questions of quality, author(s), year, country

Y, Yes; N, No; CT, Cannot tell; ROK, Republic of South Korea; ISR, Israel; SWE, Sweden; AUS, Australia; NDL, Netherlands (the); FIN, Finland.

A total of 548 articles were identified based on database searches, and two other articles were added to the analysis because they met the criteria for selecting articles. After removing duplicates, we approached the analysis of titles and abstracts of individual articles. Based on the analyses of abstracts, we discarded 500 articles. Forty-two articles were selected for full-text analysis, but we discarded another 36 articles after analysis. The articles included in the scoping review were re-analyzed a week after the first reading to avoid erroneous conclusions. The data were sorted, encoded, and categorized into three themes: (1) Methods of increasing cultural competence, (2) The impact of education on the cultural competence of participants, and (3) Possibilities for developing educational programs in the field of cultural competence.

Characteristics of articles

The articles included in the analysis were published from 2011 to 2021. The articles came from 6 countries: South Korea ( Ahn, 2017 ), Israel ( Slobodin et al., 2021 ), Sweden ( McDonald et al., 2021 ), Australia ( Perry et al., 2015 ), the Netherlands ( Celik et al., 2012 ), and Finland ( Kaihlanen et al., 2019 ). Three articles used a mixed-method method ( Celik et al., 2012 ; Perry et al., 2015 ; McDonald et al., 2021 ). One article was based on a cross-sectional study ( Ahn, 2017 ), and one article used an online education intervention study ( Slobodin et al., 2021 ). Only one article utilized a qualitative study ( Kaihlanen et al., 2019 ).

In terms of study participants, in the study by Celik et al. (2012) , there were 31 paramedics, two psychiatric hospital nurses, six hospital nurses, and four nursing home nurses. Kaihlanen et al. (2019) included 20 nurses in their training program. Nurses were explicitly included in all analyzed articles, except for the study by Slobodin et al. (2021) , in which participants were described as healthcare professionals, but no further details were provided. Table 3 provides an overview of the studies included in this scoping review.

Characteristics of included studies.

Theme 1: Methods of increasing cultural competence

Methods for developing cultural competencies in nurses are presented in Table 3 .

An online educational program was used in the study by Perry et al. (2015) and Slobodin et al. (2021) . Slobodin et al. (2021) divided their training sessions into eight modules lasting about 30 min. Their training was linked to the pandemic situation; therefore, the online training course included a historical review of the pandemic and its impact on the social fabric of society. The study by Perry et al. (2015) included modules lasting about 60 min that focused on understanding the importance of language in the healthcare environment, using interpreters in clinical practice, and addressing linguistic and cultural issues during patient discharge from the hospital. Celik et al. (2012) used a modified six-phase Deming cycle during four training sessions. As the authors stated, the first phase was an attention-free phase (Unawareness), where health professionals were unaware of diversity factors in healthcare and thought these factors or questions were irrelevant to clinical practice. The second phase was the phase of ‘limited” awareness, where healthcare workers realize that diversity factors exist but do not implement them in clinical practice. The first two phases, which the authors added, were followed by the usual phases of the Deming cycle (Plan, Do, Study or Check, and Act). The (Plan) in their study means: deliberately paying attention to diversity in clinical practice, the (Do) means to implement knowledge into clinical practice, the (Study or Check) means evaluating the results after implementation of culturally diverse care, and the (Act) means the implementation of modified nursing care based on that process.

McDonald et al. (2021) used Comprehensive Cross-Cultural Training (CCCT), developed in 2016, in response to a health crisis. The authors carried out 12 all-day training and two half-day interventions in this study. In the Kaihlanen et al. (2019) study, training included 16 h of full-time teaching, divided into four, 4-h modules, which ran once a week for 4 weeks. The training timing encouraged trainees to implement the acquired knowledge into practice quickly. The first training focused on the issue of culture (What is culture), the second training involved awareness of one’s own culture (Culture in me), the third training covered communication, and the last training focused on understanding attitudes (Meaning of conviction). The teaching method was “storytelling,” where the lecturer used real-life experiences from practice and images to demonstrate the cultural aspects of diversity. The image presentation was intended to make participants realize that people with different cultural backgrounds perceive the same image differently. After each module, there was a discussion to assess cultural features and understand why it is essential to apply culturally specific facts to the care of patients. Participants were given access to a Web-based learning platform where they could anonymously share their thoughts with others.

Theme 2: Impact of cultural competence education on participants

Kaihlanen et al. (2019) used three semi-structural small-group interviews, which focused on the general usefulness of training, personal usefulness, usefulness for patients, quality of training, and suggestions for improvement. The participants in the training welcomed the fact that the training was not entirely focused only on cultural competence in healthcare. The lecturer was not a healthcare professional and integrated new ideas and insights into actual clinical practice in the hospital. A positive impact can be seen as a general and open debate on cultural issues, which are often not part of the general working culture. Small training groups also facilitated participant involvement in the discussion. After completing the training, participants felt more open-minded and focused on caring for patients with different cultural backgrounds. The training also drew the attention of participants to inappropriate communication skills. The training also benefited patients since participants exited the training with better attitudes, awareness, and ability to recognize and respect the cultural background of the patient without imposing stereotypes and prejudices. After completing the training, most participants stated that they no longer had to use checklists or guidance for treating patients from different cultural backgrounds; however, they continued to express uncertainty regarding religious issues.

Celik et al. (2012) , McDonald et al. (2021) , and Slobodin et al. (2021) used pre and post-tests to determine the effect of individual training on cultural competence. Perry et al. (2015) used only post-testing. The post-test used by McDonald et al. (2021) statistically confirmed that participants who had experience with patients from different cultural backgrounds had higher cultural assessments than participants who did not. A similar relationship was seen regarding the use of interpreting services. The study Focus-Group showed that CCCT training significantly contributed to a better understanding of cultural competence, cultural viewpoints, and cultural phrases in patients from different cultural backgrounds.

The trainees received important information about migration and being an immigrant and understood that they needed to act to benefit the patient ( McDonald et al., 2021 ). The use of eSimulations also significantly impacted the cultural awareness of graduates ( Perry et al., 2015 ). After completing eSimulation training, post-survey questionnaires reported better communication and a better understanding of language and culture in the context of healthcare, as well as the benefits of using an interpreter when talking to patients from different cultural backgrounds. Participants also expressed new awareness of their assumptions about patients and the dangers of hasty conclusions involving cultural issues in patient care and planning. An online training study by Slobodin et al. (2021) found that only two independent variables had a statistically significant impact on cultural competence (1) the pre-intervention level of self-reported cultural competence ( p  = 0.005) and (2) exposure to previous cultural competence training as part of their overall educational framework. After completing training, the most significant gains were seen relative to culturally competent attitudes, meetings, and skills, and the smallest gains were seen in overall knowledge.

Celik et al. (2012) reported that the degree of cultural awareness improved significantly in mental health workers ( p  = 0.026) and hospital workers ( p  < 0.005). Improvements for those working in nursing homes were not statistically significant ( p  = 0.749). Participants said they became more critical of a neutral approach to diversity and had not previously considered diversity relevant to healthcare, although they reported that they better perceived each patient as unique, with each having specific health needs.

Theme 3: Opportunities for the development of cultural competence education

The research by Ahn (2017) used a questionnaire investigation to verify the hypothetical model of cultural competence in nurses. The following measuring tools were used: Multicultural Experiences Questionnaire, a Generalized Ethnocentrism Scale, a Cultural Competence Assessment Instrument, the Low and High Context Measure of Attributional Confidence Scale, the Intergroup Anxiety Scale, the Cybernetic Coping Scale, and the Cultural Competence Scale for Clinical Nurses. The authors found that multicultural experience, ethnocentric attitudes, organizational competence support, intercultural anxiety, and coping strategies have statistically significant direct and indirect impacts on cultural competence.

Coping strategies were seen to have a direct impact on cultural competence. Kaihlanen et al. (2019) examined methods for developing cultural competence training. They suggested using real examples, open discussion, and the lecturer’s expertise. However, training participants noted that trainers with other cultural backgrounds should also be included. Trainees suggested that (1) materials should be available online, (2) training should take less time, and (3) each training should be followed by a one-week break (participants said they felt time pressure to complete the assigned tasks). Additionally, more time between training would allow time for reflection on training content. Participants in the study by Celik et al. (2012) also suggested that there be more time between training sessions, again to provide more time to reflect on the concepts of cultural diversity.

This scoping review summarizes the available resources on developing cultural competence in nurses in clinical practice. Using the analyzed studies, we identified that attendance and distance training methods could impact the development of cultural competencies in nurses. Participants were offered several methods, such as face-to-face training, simulation training, eSimulation methods, and web-based learning.

The findings of this scoping review suggest that appropriate educational training can increase the cultural competence of nurses. These findings are supported by Cicolini et al. (2015) , Yilmaz et al. (2017) , Červený et al. (2020) , and Antón-Solanas et al. (2021) . Marja and Suvi (2021) report that simulations allow the integration of cultural elements into different vocational training and deepen the overall understanding of patient-centered cultural practices among simulation participants.

Workshops aimed at shaping culturally sensitive and competent attitudes, intensive and in-depth interactions with patients from different cultures, increasing knowledge of cultural issues, and intercultural communication training also strengthen the levels of cultural competence. There is a need to create smaller groups and increase practical hours to develop cultural competence ( Majda et al., 2021 ).

Changing demographics make it necessary to prepare nurses to better meet the healthcare needs of patients from different cultural backgrounds. Cultural diversity in healthcare requires healthcare professionals to be aware of cultural needs and provide culturally appropriate healthcare ( Turale et al., 2020 ). Cultural competence is essential in nursing since nurses spend more time in direct patient care than other medical staff ( Gallagher and Polanin, 2015 ). Young and Guo (2016) report that cultural competencies develop through internal reflection and awareness over time. Findings of this review have shown that coping strategies are also an appropriate means of developing cultural competence.

According to Berlin et al. (2010) , educational training should also include information on the cultural challenges and concerns of nurses and patients in the context of healthcare. Addressing these problems could improve daily clinical practice. Cultural competence in healthcare professionals improves patient satisfaction ( Govere and Govere, 2016 ; Watt et al., 2016 ). Tosun (2021) add that integrating cultural education as an optional subject is insufficient because if nursing students did not choose the subject, they would not get the necessary information and skills to improve their culturally competent care.

This scoping review also shows the importance of overcoming language barriers and the role of interpreters in clinical practice. A systematic review by Govere and Govere (2016) recommends that training aimed at developing cultural competence includes the following topics or focuses: race, religion, sexual orientation, gender, and disability; vocal tones and nonverbal communication; and Latina Cultural Competence, Cultural Sensitivity program, Medical Spanish course, and Cultural Competencemodule.

Cai et al. (2021) draw attention to the need for practical cultural training. They note the need to identify and examine the factors that determine cultural competence. When offering training for cultural competence, there is often a risk of stereotyping since the training content often emphasizes minority groups and draws attention to the differences between minorities and the majority population. Such an approach should include a “do and do not” approach that defines how a nurse should treat a patient from each cultural background ( Dogra, 2010 ).

Limits of literary overview

This scoping review has several limits. The small number of studies analyzed is the main limitation of the study. Additionally, only studies available in English were included in the analysis. Moreover, studies from the “Grey literature” were not included, which may have led to the omission of some relevant studies.

The increasing cultural diversity within global societies has created the need for cultural competence education in clinical practice nurses. The results of this scoping review point to possible methods for increasing cultural competencies among nurses. We report on several methods that can positively impact the development of cultural competence. Furthermore, the rapidly changing cultural demographics mean that societies need to constantly reassess the content of cultural diversity training so that participants are always prepared to provide culturally competent care. Cultural competence training greatly benefits nurses since it improves nurse–patient communication; however, it also benefits patients from different cultural backgrounds via improved healthcare and feelings of greater acceptance in society.

Author contributions

MČ and VT: conception and design. MČ: data analysis and interpretation and manuscript draft. IK and VH: critical revision of the manuscript. MČ, IK, VH, and VT: final approval of the manuscript. All authors contributed to the article and approved the submitted version.

This paper relates to the grant project 046/2021/S, supported by the Grant Agency of the University of South Bohemia in České Budějovice.

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher’s note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

• Ahn J. W. (2017). Structural equation modeling of cultural competence of nurses caring for foreign patients . Asian Nurs. Res. 11 , 65–73. doi: 10.1016/j.anr.2017.03.001, PMID: [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Antón-Solanas I., Tambo-Lizalde E., Hamam-Alcober N., Vanceulebroeck V., Dehaes S., Kalkan I., et al.. (2021). Nursing students’experience of learning cultural competence . PLoS One 16 :e0259802. doi: 10.1371/journal.pone.0259802, PMID: [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Berlin A., Nilsson G., Törnkvist L. (2010). Cultural competence among Swedish child health nurses after specific training: A randomized trial . Nurs Health Sci. 12 , 381–391. doi: 10.1111/j.1442-2018.2010.00542.x [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Cai D., He W., Klug D. (2021). Cultural competence among nurses and its influencing factors: A cross-sectional study . Nurs Health Sci. 23 , 411–418. doi: 10.1111/nhs.12821 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Carey R. E. (2011). Cultural competence assessment of baccalaureate nursing students: An integrative review of the literature . Int. J. Humanit. Soc. Sci. 1 , 258–266. [ Google Scholar ]
• Celik H., Abma T. A., Klinge I., Widdershoven G. A. (2012). Process evaluation of a diversity training program: the value of a mixed method strategy . Eval. Program Plann. 35 , 54–65. doi: 10.1016/j.evalprogplan.2011.07.001, PMID: [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Cerezo G. P., Galceran M. S., Soriano M. G., Camps L. M., Moral J. M. L.. (2014). Design and evaluation of an educational course in cultural competence of nursing . Procedia Soc. Behav. Sci. 132 , 262–268. doi: 10.1016/j.sbspro.2014.04.308 [ CrossRef ] [ Google Scholar ]
• Červený M., Dimunová L., Della Pelle C., Papp K., Siaki L. L. A., Kilíková M., et al.. (2020). Self-reported cultural competence of nurses providing nursing care in Slovakia . J. Nurs. Scholarsh. 52 , 705–712. doi: 10.1111/jnu.12601, PMID: [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Červený M., Siaki L., Prosen M., Nagórska M. (in press). Challenges experienced by nurses caring for patients from different cultures: A scoping review of the literature 2010-2020 . Cent. Eur. J. Nurs. Midwifery [ Google Scholar ]
• Cicolini G., Della Pelle C., Comparcini D., Tomietto M., Cerratti F., Schim S. M., et al.. (2015). Cultural competence among Italian nurses: A multicentric survey . J. Nurs. Scholarsh. 47 , 536–543. doi: 10.1111/jnu.12165, PMID: [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Critical Appraisal Skills Programme (2018). CASP Checklist. Available at: https://casp-uk.net/wp-content/uploads/2018/01/CASP-Qualitative-Checklist-2018.pdf (Accessed April 10, 2022).
• Cruz J. P., Alquwez N., Cruz C. P., Felicilda-Reynaldo R. F. D., Vitorino L. M., Islam S. M. S. (2017a). Cultural competence among nursing students in Saudi Arabia: a cross-sectional study . Int. Nurs. Rev. 64 , 215–223. doi: 10.1111/inr.12370, PMID: [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Cruz J. P., Aguinaldo A. N., Estacio J. C., Alotaibi A., Arguvanli S., Cayaban A. R. R., et al.. (2017b). A multicountry perspective on cultural competence among baccalaureate nursing students . J. Nurs. Scholarsh. 50 , 92–101. doi: 10.1111/jnu.12350, PMID: [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Curtis E., Jones R., Tipene-Leach D., Walker C., Loring B., Paine S. J., et al.. (2019). Why cultural safety rather than cultural competency is required to achieve health equity: a literature review and recommended definition . Int. J. Equity Health 18 , 174. doi: 10.1186/s12939-019-1082-3, PMID: [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Dogra N. (2010). Ethnicity and culture and their relationship to health care . InnovAiT 3 , 366–372. doi: 10.1093/innovait/inp158 [ CrossRef ] [ Google Scholar ]
• Eurostat (2019). Migration and Migrant Population Statistics. Available at: https://ec.europa.eu/eurostat/statistics-explained/index.php?title=Migration_and_migrant_population_statistics#Migration_flows:_Immigration_to_the_EU_from_non-member_countries_was_2.7_million_in_2019 (Accessed April 20, 2019).
• Faber W. L. (2021). Cultural competence education for health professionals: summary of a Cochrane review . Exp. Dermatol. 17 , 383–384. doi: 10.1016/j.explore.2021.04.011, PMID: [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Gallagher R. W., Polanin J. R. (2015). A meta-analysis of educational interventions designed to enhance cultural competence in professional nurses and nursing students . Nurs Educ. Today 35 , 333–340. doi: 10.1016/j.nedt.2014.10.021, PMID: [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Govere L., Govere E. M. (2016). How effective is cultural competence training of healthcare providers on improving patient satisfaction of minority groups? A systematic review of literature . Worldviews Evid.-Based Nurs. 13 , 402–410. doi: 10.1111/wvn.12176, PMID: [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Harkess L., Kaddoura M. (2016). Culture and cultural competence in nursing education and practice: The state of the art . Nurs. Forum 51 , 211–222. doi: 10.1111/nuf.12140, PMID: [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Horvat L., Horey D., Romios P., Kis-Rigo J. (2014). Cultural competence education for health professionals . Cochrane Database Syst. Rev. 5 :CD009405. doi: 10.1002/14651858.CD009405.pub2, PMID: [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Joo J. Y., Liu M. F. (2020). Nurses’ barriers to Care of Ethnic Minorities: A qualitative systematic review . West. J. Nurs. Res. 42 , 760–771. doi: 10.1177/0193945919883395, PMID: [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Kaihlanen A. M., Hietapakka L., Heponiemi T. (2019). Increasing cultural awareness: qualitative study of nurses’ perceptions about cultural competence training . BMC Nurs. 18 , 38. doi: 10.1186/s12912-019-0363-x, PMID: [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Leininger M., McFarland R. M. (eds.) (2002). Transcultural Nursing: Concepts, Theories, Research & Practice . New York: McGraw-Hill. [ Google Scholar ]
• Long A. H., French P. D., Brooks M. J. (2020). Optimising the value of the critical appraisal skills programme (CASP) tool for quality appraisal in qualitative evidence synthesis . Res. Methods Med. Health Sci. 1 , 31–42. doi: 10.1177/2632084320947559 [ CrossRef ] [ Google Scholar ]
• Majda A., Zalewska-Puchała J., Bodys-Cupak I., Kurowska A., Barzykowski K. (2021). Evaluating the effectiveness of cultural education training: cultural competence and cultural intelligence development among nursing students . Int. J. Environ. Res. Public Health 18 :4002. doi: 10.3390/ijerph18084002, PMID: [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Mariño R. J., Ghanim A., Barrow S. L., Morgan M. V. (2018). Cultural competence skills in a dental curriculum: A review . Eur. J. Dent. Educ. 22 , e94–e100. doi: 10.1111/eje.12263, PMID: [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Marja S. L., Suvi A. (2021). Cultural competence learning of the health care students using simulation pedagogy: An integrative review . Nurse Educ. Pract. 52 :103044. doi: 10.1016/j.nepr.2021.103044, PMID: [ PubMed ] [ CrossRef ] [ Google Scholar ]
• McDonald J. T., Dahlin M., Bäärnhielm S. (2021). Cross-cultural training program on mental health care for refugees - a mixed method evaluation . BMC Med. Educ. 21 :533. doi: 10.1186/s12909-021-02965-5, PMID: [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Page M. J., McKenzie J. E., Bossuyt P. M., Boutron I., Hoffmann T. C., Mulrow C. D., et al.. (2021). The PRISMA 2020 statement: An updated guideline for reporting systematic reviews . J Clin Epi. 134 , 178–189. doi: 10.1016/j.jclinepi.2021.03.001 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Paric M., Kaihlanen A. M., Heponiemi T., Czabanowska K. (2021). Nurse teacher’s perceptions on teaching cultural competence to students in Finland: a descriptive qualitative study . Nurs. Educ. Today 99 :104787. doi: 10.1016/j.nedt.2021.104787, PMID: [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Perry A., Woodland L., Brunero S. (2015). eSimulation: A novel approach to enhancing cultural competence within a health care organisation . Nurs. Educ. Pract. 15 , 218–224. doi: 10.1016/j.nepr.2014.11.013, PMID: [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Prosen M. (2018). Developing cross-cultural competences: for ensuring health and healthcare equality and equity . Slov. Nurs. Rev. 52 , 76–80. doi: 10.14528/snr.2018.52.2.262 [ CrossRef ] [ Google Scholar ]
• Prosen M., Bošković S. (2020). The need for cultural competence education in nursing degree programmes: comparative perspectives . Kontakt. 22 , 139–145. doi: 10.32725/kont.2020.022 [ CrossRef ] [ Google Scholar ]
• Shepherd S. M., Willis-Esqueda C., Newton D., Sivasubramaniam D., Paradies Y. (2019). The challenge of cultural competence in the workplace: perspectives of healthcare providers . BMC Health Serv. Res. 19 , 135. doi: 10.1186/s12913-019-3959-7, PMID: [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Slobodin O., Kula Y., Clempert N., Cohen O. (2021). Building capacity in times of crisis: increasing cultural competence of healthcare professionals in the context of the COVID-19 . J. Clin. Nurs. doi: 10.1111/jocn.15897 [Epub ahead of print]., PMID: [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Swihart D. L., Yarrarapu S., Martin R. L. (2021). Cultural Religious Competence in Clinical Practice . Treasure Island: StatPearls Publishing. [ PubMed ] [ Google Scholar ]
• Tosun B. (2021). Addressing the effects of transcultural nursing education on nursing students’ cultural competence: A systematic review . Nurse Educ. Pract. 55 :103171. doi: 10.1016/j.nepr.2021.103171, PMID: [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Tricco A. C., Lillie E., Zarin W., O’Brien K. K., Colquhoun H., Levac D., et al.. (2018). PRISMA extension for scoping reviews (PRISMA ScR): checklist and explanation . Ann. Intern. Med. 169 , 467–473. doi: 10.7326/M18-0850, PMID: [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Turale S., Kunaviktikul W., Mesukko J. (2020). Giving undergraduate nursing students international experiences: Issues and strategies . Nurs Health Sci. 22 , 830–836. doi: 10.1111/nhs.12722, PMID: [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Watt K., Abbott P., Reath J. (2016). Developing cultural competence in general practitioners: an integrative review of the literature . BMC Fam. Pract. 17 , 158. doi: 10.1186/s12875-016-0560-6, PMID: [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Williams D. R., Lawrence J. A., Davis B. A. (2019). Racism and health: evidence and needed research . Annu. Rev. Public Health 40 , 105–125. doi: 10.1146/annurev-publhealth-040218-043750, PMID: [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Yilmaz M., Toksoy S., Direk Z. D., Bezirgan S., Boylu M. (2017). Cultural sensitivity among clinical nurses: A descriptive study . J. Nurs. Scholarsh. 49 , 153–161. doi: 10.1111/jnu.12276 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Young S., Guo K. L. (2016). Cultural diversity training: The necessity of cultural competence for health care providers and in nursing practice . Health Care Manag. 35 , 94–102. doi: 10.1097/HCM.0000000000000100 [ PubMed ] [ CrossRef ] [ Google Scholar ]