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A guide to critical appraisal of evidence

Fineout-Overholt, Ellen PhD, RN, FNAP, FAAN

Ellen Fineout-Overholt is the Mary Coulter Dowdy Distinguished Professor of Nursing at the University of Texas at Tyler School of Nursing, Tyler, Tex.

The author has disclosed no financial relationships related to this article.

Critical appraisal is the assessment of research studies' worth to clinical practice. Critical appraisal—the heart of evidence-based practice—involves four phases: rapid critical appraisal, evaluation, synthesis, and recommendation. This article reviews each phase and provides examples, tips, and caveats to help evidence appraisers successfully determine what is known about a clinical issue. Patient outcomes are improved when clinicians apply a body of evidence to daily practice.

How do nurses assess the quality of clinical research? This article outlines a stepwise approach to critical appraisal of research studies' worth to clinical practice: rapid critical appraisal, evaluation, synthesis, and recommendation. When critical care nurses apply a body of valid, reliable, and applicable evidence to daily practice, patient outcomes are improved.

Critical care nurses can best explain the reasoning for their clinical actions when they understand the worth of the research supporting their practices. In c ritical appraisal , clinicians assess the worth of research studies to clinical practice. Given that achieving improved patient outcomes is the reason patients enter the healthcare system, nurses must be confident their care techniques will reliably achieve best outcomes.

Nurses must verify that the information supporting their clinical care is valid, reliable, and applicable. Validity of research refers to the quality of research methods used, or how good of a job researchers did conducting a study. Reliability of research means similar outcomes can be achieved when the care techniques of a study are replicated by clinicians. Applicability of research means it was conducted in a similar sample to the patients for whom the findings will be applied. These three criteria determine a study's worth in clinical practice.

Appraising the worth of research requires a standardized approach. This approach applies to both quantitative research (research that deals with counting things and comparing those counts) and qualitative research (research that describes experiences and perceptions). The word critique has a negative connotation. In the past, some clinicians were taught that studies with flaws should be discarded. Today, it is important to consider all valid and reliable research informative to what we understand as best practice. Therefore, the author developed the critical appraisal methodology that enables clinicians to determine quickly which evidence is worth keeping and which must be discarded because of poor validity, reliability, or applicability.

Evidence-based practice process

The evidence-based practice (EBP) process is a seven-step problem-solving approach that begins with data gathering (see Seven steps to EBP ). During daily practice, clinicians gather data supporting inquiry into a particular clinical issue (Step 0). The description is then framed as an answerable question (Step 1) using the PICOT question format ( P opulation of interest; I ssue of interest or intervention; C omparison to the intervention; desired O utcome; and T ime for the outcome to be achieved). 1 Consistently using the PICOT format helps ensure that all elements of the clinical issue are covered. Next, clinicians conduct a systematic search to gather data answering the PICOT question (Step 2). Using the PICOT framework, clinicians can systematically search multiple databases to find available studies to help determine the best practice to achieve the desired outcome for their patients. When the systematic search is completed, the work of critical appraisal begins (Step 3). The known group of valid and reliable studies that answers the PICOT question is called the body of evidence and is the foundation for the best practice implementation (Step 4). Next, clinicians evaluate integration of best evidence with clinical expertise and patient preferences and values to determine if the outcomes in the studies are realized in practice (Step 5). Because healthcare is a community of practice, it is important that experiences with evidence implementation be shared, whether the outcome is what was expected or not. This enables critical care nurses concerned with similar care issues to better understand what has been successful and what has not (Step 6).

Critical appraisal of evidence

The first phase of critical appraisal, rapid critical appraisal, begins with determining which studies will be kept in the body of evidence. All valid, reliable, and applicable studies on the topic should be included. This is accomplished using design-specific checklists with key markers of good research. When clinicians determine a study is one they want to keep (a “keeper” study) and that it belongs in the body of evidence, they move on to phase 2, evaluation. 2

In the evaluation phase, the keeper studies are put together in a table so that they can be compared as a body of evidence, rather than individual studies. This phase of critical appraisal helps clinicians identify what is already known about a clinical issue. In the third phase, synthesis, certain data that provide a snapshot of a particular aspect of the clinical issue are pulled out of the evaluation table to showcase what is known. These snapshots of information underpin clinicians' decision-making and lead to phase 4, recommendation. A recommendation is a specific statement based on the body of evidence indicating what should be done—best practice. Critical appraisal is not complete without a specific recommendation. Each of the phases is explained in more detail below.

Phase 1: Rapid critical appraisal . Rapid critical appraisal involves using two tools that help clinicians determine if a research study is worthy of keeping in the body of evidence. The first tool, General Appraisal Overview for All Studies (GAO), covers the basics of all research studies (see Elements of the General Appraisal Overview for All Studies ). Sometimes, clinicians find gaps in knowledge about certain elements of research studies (for example, sampling or statistics) and need to review some content. Conducting an internet search for resources that explain how to read a research paper, such as an instructional video or step-by-step guide, can be helpful. Finding basic definitions of research methods often helps resolve identified gaps.

To accomplish the GAO, it is best to begin with finding out why the study was conducted and how it answers the PICOT question (for example, does it provide information critical care nurses want to know from the literature). If the study purpose helps answer the PICOT question, then the type of study design is evaluated. The study design is compared with the hierarchy of evidence for the type of PICOT question. The higher the design falls within the hierarchy or levels of evidence, the more confidence nurses can have in its finding, if the study was conducted well. 3,4 Next, find out what the researchers wanted to learn from their study. These are called the research questions or hypotheses. Research questions are just what they imply; insufficient information from theories or the literature are available to guide an educated guess, so a question is asked. Hypotheses are reasonable expectations guided by understanding from theory and other research that predicts what will be found when the research is conducted. The research questions or hypotheses provide the purpose of the study.

Next, the sample size is evaluated. Expectations of sample size are present for every study design. As an example, consider as a rule that quantitative study designs operate best when there is a sample size large enough to establish that relationships do not exist by chance. In general, the more participants in a study, the more confidence in the findings. Qualitative designs operate best with fewer people in the sample because these designs represent a deeper dive into the understanding or experience of each person in the study. 5 It is always important to describe the sample, as clinicians need to know if the study sample resembles their patients. It is equally important to identify the major variables in the study and how they are defined because this helps clinicians best understand what the study is about.

The final step in the GAO is to consider the analyses that answer the study research questions or confirm the study hypothesis. This is another opportunity for clinicians to learn, as learning about statistics in healthcare education has traditionally focused on conducting statistical tests as opposed to interpreting statistical tests. Understanding what the statistics indicate about the study findings is an imperative of critical appraisal of quantitative evidence.

The second tool is one of the variety of rapid critical appraisal checklists that speak to validity, reliability, and applicability of specific study designs, which are available at varying locations (see Critical appraisal resources ). When choosing a checklist to implement with a group of critical care nurses, it is important to verify that the checklist is complete and simple to use. Be sure to check that the checklist has answers to three key questions. The first question is: Are the results of the study valid? Related subquestions should help nurses discern if certain markers of good research design are present within the study. For example, identifying that study participants were randomly assigned to study groups is an essential marker of good research for a randomized controlled trial. Checking these essential markers helps clinicians quickly review a study to check off these important requirements. Clinical judgment is required when the study lacks any of the identified quality markers. Clinicians must discern whether the absence of any of the essential markers negates the usefulness of the study findings. 6-9

The second question is: What are the study results? This is answered by reviewing whether the study found what it was expecting to and if those findings were meaningful to clinical practice. Basic knowledge of how to interpret statistics is important for understanding quantitative studies, and basic knowledge of qualitative analysis greatly facilitates understanding those results. 6-9

The third question is: Are the results applicable to my patients? Answering this question involves consideration of the feasibility of implementing the study findings into the clinicians' environment as well as any contraindication within the clinicians' patient populations. Consider issues such as organizational politics, financial feasibility, and patient preferences. 6-9

When these questions have been answered, clinicians must decide about whether to keep the particular study in the body of evidence. Once the final group of keeper studies is identified, clinicians are ready to move into the phase of critical appraisal. 6-9

Phase 2: Evaluation . The goal of evaluation is to determine how studies within the body of evidence agree or disagree by identifying common patterns of information across studies. For example, an evaluator may compare whether the same intervention is used or if the outcomes are measured in the same way across all studies. A useful tool to help clinicians accomplish this is an evaluation table. This table serves two purposes: first, it enables clinicians to extract data from the studies and place the information in one table for easy comparison with other studies; and second, it eliminates the need for further searching through piles of periodicals for the information. (See Bonus Content: Evaluation table headings .) Although the information for each of the columns may not be what clinicians consider as part of their daily work, the information is important for them to understand about the body of evidence so that they can explain the patterns of agreement or disagreement they identify across studies. Further, the in-depth understanding of the body of evidence from the evaluation table helps with discussing the relevant clinical issue to facilitate best practice. Their discussion comes from a place of knowledge and experience, which affords the most confidence. The patterns and in-depth understanding are what lead to the synthesis phase of critical appraisal.

The key to a successful evaluation table is simplicity. Entering data into the table in a simple, consistent manner offers more opportunity for comparing studies. 6-9 For example, using abbreviations versus complete sentences in all columns except the final one allows for ease of comparison. An example might be the dependent variable of depression defined as “feelings of severe despondency and dejection” in one study and as “feeling sad and lonely” in another study. 10 Because these are two different definitions, they need to be different dependent variables. Clinicians must use their clinical judgment to discern that these different dependent variables require different names and abbreviations and how these further their comparison across studies.

Sample and theoretical or conceptual underpinnings are important to understanding how studies compare. Similar samples and settings across studies increase agreement. Several studies with the same conceptual framework increase the likelihood of common independent variables and dependent variables. The findings of a study are dependent on the analyses conducted. That is why an analysis column is dedicated to recording the kind of analysis used (for example, the name of the statistical analyses for quantitative studies). Only statistics that help answer the clinical question belong in this column. The findings column must have a result for each of the analyses listed; however, in the actual results, not in words. For example, a clinician lists a t -test as a statistic in the analysis column, so a t -value should reflect whether the groups are different as well as probability ( P -value or confidence interval) that reflects statistical significance. The explanation for these results would go in the last column that describes worth of the research to practice. This column is much more flexible and contains other information such as the level of evidence, the studies' strengths and limitations, any caveats about the methodology, or other aspects of the study that would be helpful to its use in practice. The final piece of information in this column is a recommendation for how this study would be used in practice. Each of the studies in the body of evidence that addresses the clinical question is placed in one evaluation table to facilitate the ease of comparing across the studies. This comparison sets the stage for synthesis.

Phase 3: Synthesis . In the synthesis phase, clinicians pull out key information from the evaluation table to produce a snapshot of the body of evidence. A table also is used here to feature what is known and help all those viewing the synthesis table to come to the same conclusion. A hypothetical example table included here demonstrates that a music therapy intervention is effective in reducing the outcome of oxygen saturation (SaO 2 ) in six of the eight studies in the body of evidence that evaluated that outcome (see Sample synthesis table: Impact on outcomes ). Simply using arrows to indicate effect offers readers a collective view of the agreement across studies that prompts action. Action may be to change practice, affirm current practice, or conduct research to strengthen the body of evidence by collaborating with nurse scientists.

When synthesizing evidence, there are at least two recommended synthesis tables, including the level-of-evidence table and the impact-on-outcomes table for quantitative questions, such as therapy or relevant themes table for “meaning” questions about human experience. (See Bonus Content: Level of evidence for intervention studies: Synthesis of type .) The sample synthesis table also demonstrates that a final column labeled synthesis indicates agreement across the studies. Of the three outcomes, the most reliable for clinicians to see with music therapy is SaO 2 , with positive results in six out of eight studies. The second most reliable outcome would be reducing increased respiratory rate (RR). Parental engagement has the least support as a reliable outcome, with only two of five studies showing positive results. Synthesis tables make the recommendation clear to all those who are involved in caring for that patient population. Although the two synthesis tables mentioned are a great start, the evidence may require more synthesis tables to adequately explain what is known. These tables are the foundation that supports clinically meaningful recommendations.

Phase 4: Recommendation . Recommendations are definitive statements based on what is known from the body of evidence. For example, with an intervention question, clinicians should be able to discern from the evidence if they will reliably get the desired outcome when they deliver the intervention as it was in the studies. In the sample synthesis table, the recommendation would be to implement the music therapy intervention across all settings with the population, and measure SaO 2 and RR, with the expectation that both would be optimally improved with the intervention. When the synthesis demonstrates that studies consistently verify an outcome occurs as a result of an intervention, however that intervention is not currently practiced, care is not best practice. Therefore, a firm recommendation to deliver the intervention and measure the appropriate outcomes must be made, which concludes critical appraisal of the evidence.

A recommendation that is off limits is conducting more research, as this is not the focus of clinicians' critical appraisal. In the case of insufficient evidence to make a recommendation for practice change, the recommendation would be to continue current practice and monitor outcomes and processes until there are more reliable studies to be added to the body of evidence. Researchers who use the critical appraisal process may indeed identify gaps in knowledge, research methods, or analyses, for example, that they then recommend studies that would fill in the identified gaps. In this way, clinicians and nurse scientists work together to build relevant, efficient bodies of evidence that guide clinical practice.

Evidence into action

Critical appraisal helps clinicians understand the literature so they can implement it. Critical care nurses have a professional and ethical responsibility to make sure their care is based on a solid foundation of available evidence that is carefully appraised using the phases outlined here. Critical appraisal allows for decision-making based on evidence that demonstrates reliable outcomes. Any other approach to the literature is likely haphazard and may lead to misguided care and unreliable outcomes. 11 Evidence translated into practice should have the desired outcomes and their measurement defined from the body of evidence. It is also imperative that all critical care nurses carefully monitor care delivery outcomes to establish that best outcomes are sustained. With the EBP paradigm as the basis for decision-making and the EBP process as the basis for addressing clinical issues, critical care nurses can improve patient, provider, and system outcomes by providing best care.

Seven steps to EBP

Step 0–A spirit of inquiry to notice internal data that indicate an opportunity for positive change.

Step 1– Ask a clinical question using the PICOT question format.

Step 2–Conduct a systematic search to find out what is already known about a clinical issue.

Step 3–Conduct a critical appraisal (rapid critical appraisal, evaluation, synthesis, and recommendation).

Step 4–Implement best practices by blending external evidence with clinician expertise and patient preferences and values.

Step 5–Evaluate evidence implementation to see if study outcomes happened in practice and if the implementation went well.

Step 6–Share project results, good or bad, with others in healthcare.

Adapted from: Steps of the evidence-based practice (EBP) process leading to high-quality healthcare and best patient outcomes. © Melnyk & Fineout-Overholt, 2017. Used with permission.

Critical appraisal resources

• The Joanna Briggs Institute http://joannabriggs.org/research/critical-appraisal-tools.html
• Critical Appraisal Skills Programme (CASP) www.casp-uk.net/casp-tools-checklists
• Center for Evidence-Based Medicine www.cebm.net/critical-appraisal
• Melnyk BM, Fineout-Overholt E. Evidence-Based Practice in Nursing and Healthcare: A Guide to Best Practice . 3rd ed. Philadelphia, PA: Wolters Kluwer; 2015.

A full set of critical appraisal checklists are available in the appendices.

Bonus content!

This article includes supplementary online-exclusive material. Visit the online version of this article at www.nursingcriticalcare.com to access this content.

critical appraisal; decision-making; evaluation of research; evidence-based practice; synthesis

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Academic writing: using literature to demonstrate critical analysis, kathleen duffy senior lecturer, school of nursing, midwifery and community health, glasgow caledonian university, glasgow, elizabeth hastie senior lecturer, school of nursing, midwifery and community health, glasgow caledonian university, glasgow, jacqueline mccallum senior lecturer, school of nursing, midwifery and community health, glasgow caledonian university, glasgow, valerie ness lecturer, school of nursing, midwifery and community health, glasgow caledonian university, glasgow, lesley price lecturer, school of nursing, midwifery and community health, glasgow caledonian university, glasgow.

When writing at degree level, nurses need to demonstrate an understanding of evidence by summarising its key elements and comparing and contrasting authors’ views. Critical analysis is an important nursing skill in writing and in practice. With the advent of an all-degree profession, understanding how to develop this skill is crucial. This article examines how students can develop critical analysis skills to write at undergraduate degree level. It highlights some of the common errors when writing at this academic level and provides advice on how to avoid such mistakes.

Nursing Standard . 23, 47, 35-40. doi: 10.7748/ns2009.07.23.47.35.c7201

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This article has been subject to double blind peer review

Critical appraisal - Education: methods - Literature and writing - Student nurses - Study skills

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• Volume 21, Issue 1
• What is a case study?
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• Roberta Heale 1 ,
• Alison Twycross 2
• 1 School of Nursing , Laurentian University , Sudbury , Ontario , Canada
• 2 School of Health and Social Care , London South Bank University , London , UK
• Correspondence to Dr Roberta Heale, School of Nursing, Laurentian University, Sudbury, ON P3E2C6, Canada; rheale{at}laurentian.ca

https://doi.org/10.1136/eb-2017-102845

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What is it?

Case study is a research methodology, typically seen in social and life sciences. There is no one definition of case study research. 1 However, very simply… ‘a case study can be defined as an intensive study about a person, a group of people or a unit, which is aimed to generalize over several units’. 1 A case study has also been described as an intensive, systematic investigation of a single individual, group, community or some other unit in which the researcher examines in-depth data relating to several variables. 2

Often there are several similar cases to consider such as educational or social service programmes that are delivered from a number of locations. Although similar, they are complex and have unique features. In these circumstances, the evaluation of several, similar cases will provide a better answer to a research question than if only one case is examined, hence the multiple-case study. Stake asserts that the cases are grouped and viewed as one entity, called the quintain . 6  ‘We study what is similar and different about the cases to understand the quintain better’. 6

The steps when using case study methodology are the same as for other types of research. 6 The first step is defining the single case or identifying a group of similar cases that can then be incorporated into a multiple-case study. A search to determine what is known about the case(s) is typically conducted. This may include a review of the literature, grey literature, media, reports and more, which serves to establish a basic understanding of the cases and informs the development of research questions. Data in case studies are often, but not exclusively, qualitative in nature. In multiple-case studies, analysis within cases and across cases is conducted. Themes arise from the analyses and assertions about the cases as a whole, or the quintain, emerge. 6

Benefits and limitations of case studies

If a researcher wants to study a specific phenomenon arising from a particular entity, then a single-case study is warranted and will allow for a in-depth understanding of the single phenomenon and, as discussed above, would involve collecting several different types of data. This is illustrated in example 1 below.

Using a multiple-case research study allows for a more in-depth understanding of the cases as a unit, through comparison of similarities and differences of the individual cases embedded within the quintain. Evidence arising from multiple-case studies is often stronger and more reliable than from single-case research. Multiple-case studies allow for more comprehensive exploration of research questions and theory development. 6

Despite the advantages of case studies, there are limitations. The sheer volume of data is difficult to organise and data analysis and integration strategies need to be carefully thought through. There is also sometimes a temptation to veer away from the research focus. 2 Reporting of findings from multiple-case research studies is also challenging at times, 1 particularly in relation to the word limits for some journal papers.

Examples of case studies

Example 1: nurses’ paediatric pain management practices.

One of the authors of this paper (AT) has used a case study approach to explore nurses’ paediatric pain management practices. This involved collecting several datasets:

Observational data to gain a picture about actual pain management practices.

Questionnaire data about nurses’ knowledge about paediatric pain management practices and how well they felt they managed pain in children.

Questionnaire data about how critical nurses perceived pain management tasks to be.

These datasets were analysed separately and then compared 7–9 and demonstrated that nurses’ level of theoretical did not impact on the quality of their pain management practices. 7 Nor did individual nurse’s perceptions of how critical a task was effect the likelihood of them carrying out this task in practice. 8 There was also a difference in self-reported and observed practices 9 ; actual (observed) practices did not confirm to best practice guidelines, whereas self-reported practices tended to.

Example 2: quality of care for complex patients at Nurse Practitioner-Led Clinics (NPLCs)

The other author of this paper (RH) has conducted a multiple-case study to determine the quality of care for patients with complex clinical presentations in NPLCs in Ontario, Canada. 10 Five NPLCs served as individual cases that, together, represented the quatrain. Three types of data were collected including:

Review of documentation related to the NPLC model (media, annual reports, research articles, grey literature and regulatory legislation).

Interviews with nurse practitioners (NPs) practising at the five NPLCs to determine their perceptions of the impact of the NPLC model on the quality of care provided to patients with multimorbidity.

Chart audits conducted at the five NPLCs to determine the extent to which evidence-based guidelines were followed for patients with diabetes and at least one other chronic condition.

The three sources of data collected from the five NPLCs were analysed and themes arose related to the quality of care for complex patients at NPLCs. The multiple-case study confirmed that nurse practitioners are the primary care providers at the NPLCs, and this positively impacts the quality of care for patients with multimorbidity. Healthcare policy, such as lack of an increase in salary for NPs for 10 years, has resulted in issues in recruitment and retention of NPs at NPLCs. This, along with insufficient resources in the communities where NPLCs are located and high patient vulnerability at NPLCs, have a negative impact on the quality of care. 10

These examples illustrate how collecting data about a single case or multiple cases helps us to better understand the phenomenon in question. Case study methodology serves to provide a framework for evaluation and analysis of complex issues. It shines a light on the holistic nature of nursing practice and offers a perspective that informs improved patient care.

• Gustafsson J
• Calanzaro M
• Sandelowski M

Competing interests None declared.

Provenance and peer review Commissioned; internally peer reviewed.

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The impact of applying unfolding case-study learning on critical care nursing students' knowledge, critical thinking, and self-efficacy; a quasi-experimental study

Affiliations.

• 1 Faculty of Nursing, Arab American University/ Palestine (AAUP), Palestine. Electronic address: [email protected].
• 2 Faculty of Nursing, The University of Jordan-Aqaba Campus, Jordan. Electronic address: [email protected].
• 3 Faculty of Nursing, Arab American University/ Palestine (AAUP), Palestine. Electronic address: [email protected].
• 4 Faculty of Nursing, Zarqa University, Jordan. Electronic address: [email protected].
• PMID: 38852273
• DOI: 10.1016/j.nepr.2024.104015

Background: The unfolding case-study learning approach is a growing modernized learning strategy implemented in different health disciplines. However, there is a lack of existing research that examines the effects of unfolding case studies in advanced nursing courses.

Aim: To examine the impact of applying an unfolding case-study learning approach on critical care nursing students' knowledge, critical thinking, and self-efficacy.

Methods: This posttest-only, quasi-experimental study was conducted at XXX University in Palestine. A single-stage cluster sampling was used to assign nursing students enrolled in the critical care nursing course into experiment and conventional groups. The intervention group (n= 91) underwent unfolding case-study learning for selected cardiovascular topics, whereas the conventional group (n= 78) was taught using the traditional teaching methods. The posttest assessment was conducted using Knowledge Acquisition tests, Yoon`s Critical Thinking Disposition Instrument (YCTD), and the Self-Efficacy for Learning and Performance instruments. The Social Constructivist Theoretical Framework was integrated into the study.

Results: Homogeneity was achieved between both groups concerning Age, Gender, and GPA. The experiment group scored significantly higher than the conventional group regarding the posttest knowledge acquisition tests (7.12 vs. 5.49, respectively, t=-12.7, P<0.001, CI: -1.89 to -1.38), critical thinking (4.32 vs. 3.63 respectively, t=17.390, p<0.001, CI: -77 to -61) and self-efficacy (6.12 vs. 4.4 respectively, t=-30.897, p<0.001, CI: -1.82 to -1.60). Multivariate analysis revealed that 69 % of the variations of posttest scores were influenced by critical thinking scores (Adjusted R Squared=0.690, F=3.47, P=0002, η2=0.969). Similarly, self-efficacy has been shown to contribute by 74 % to the variations of scores after conducting the study program (Adjusted R Squared=0.743, F=4.21, P=0001, η2=0.974). However, the variations of both critical thinking and self-efficacy scores were not significantly influenced by the contribution of knowledge acquisition (p=0.772 and 0.857, respectively) and students' GPA (p=0.305 and 0.956, respectively).

Conclusions: Irrespective of knowledge level and GPA, the unfolding case-study learning approach can enhance the critical thinking and self-efficacy of students enrolling in advanced nursing courses.

Keywords: Critical thinking; Knowledge; Nursing students; Self-efficacy; Unfolding case-study.

Copyright © 2024 Elsevier Ltd. All rights reserved.

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Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

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Flemish critical care nurses’ experiences regarding the influence of work-related demands on their health: a descriptive interpretive qualitative study

• Lukas Billiau   ORCID: orcid.org/0009-0009-9563-0999 1 ,
• Larissa Bolliger 2 ,
• Els clays 2 ,
• Kristof Eeckloo 1 , 2 &
• Margo Ketels 2  

BMC Nursing volume  23 , Article number:  387 ( 2024 ) Cite this article

134 Accesses

Metrics details

Critical care nurses (CCNs) around the globe face other health challenges compared to their peers in general hospital nursing. Moreover, the nursing workforce grapples with persistent staffing shortages. In light of these circumstances, developing a sustainable work environment is imperative to retain the current nursing workforce. Consequently, this study aimed to gain insight into the recalled experiences of CCNs in dealing with the physical and psychosocial influences of work-related demands on their health while examining the environments in which they operate. The second aim was to explore the complex social and psychological processes through which CCNs navigate these work-related demands across various CCN wards.

A qualitative study following Thorne’s interpretive descriptive approach was conducted. From October 2022 to April 2023, six focus groups were organised. Data from a diverse sample of 27 Flemish CCNs engaged in physically demanding roles from three CCN wards were collected. The Qualitative Analysis Guide of Leuven was applied to support the constant comparison process.

Participants reported being exposed to occupational physical activity, emotional, quantitative, and cognitive work-related demands, adverse patient behaviour, and poor working time quality. Exposure to these work-related demands was perceived as harmful, potentially resulting in physical, mental, and psychosomatic strain, as well as an increased turnover intention. In response to these demands, participants employed various strategies for mitigation, including seeking social support, exerting control over their work, utilising appropriate equipment, recognising rewards, and engaging in leisure-time physical activity.

Conclusions

CCNs’ health is challenged by work-related demands that are not entirely covered by the traditional quantitative frameworks used in research on psychologically healthy work. Therefore, future studies should focus on improving such frameworks by exploring the role of psychosocial and organisational factors in more detail. This study has important implications for workplace health promotion with a view on preventing work absenteeism and drop-out in the long run, as it offers strong arguments to promote sufficient risk management strategies, schedule flexibility, uninterrupted off-job recovery time, and positive management, which can prolong the well-being and sustainable careers of the CCN workforce.

Peer Review reports

Globally, the nursing profession is a strenuous occupation with high levels of work-related demands, leading to adverse health outcomes for nurses [ 1 ], reduced marital and life satisfaction [ 2 ], absenteeism, and high costs for society [ 3 ]. In addition, the nursing workforce has to address staffing shortages due to the reduced number of individuals entering the nursing profession [ 4 ], the ageing working population [ 5 ], and the increased number of nurses in premature retirement [ 6 , 7 ].

Especially critical care nurses (CCNs), who specialise in managing life-threatening diseases across all age groups, work in an exceptionally demanding environment [ 8 ]. Increasing evidence suggests that CCNs’ health is mainly challenged by five work-related demands, namely, occupational physical activity (OPA) [ 1 ], shiftwork [ 9 ], and quantitative [ 10 ], cognitive [ 11 ], and emotional work-related demands [ 12 ]. Among CCNs, OPA involves various physically demanding tasks, such as forward bending and isometric neck postures, heavy lifting, prolonged standing, and long-distance walking [ 1 , 9 ]. With continued exposure to OPA, musculoskeletal disorders can arise in terms of pain-related complaints of the wrists, back, thigh, knees, and feet [ 1 ]. However, many studies have reported that engaging in regular leisure-time physical activity has a beneficial influence on health, while OPA may have no beneficial, or even adverse, influence on health [ 13 ]. These conflicting health influences are indicated as the “physical activity health paradox” [ 13 ] and might be explained by differences in duration, intensity, recovery opportunities, and physiological responses [ 14 , 15 ].

In addition to OPA is shift work, which is the amount of time an individual works outside the typical nine AM to five PM schedule, known to impact CCNs’ health through circadian rhythm disruption, fatigue, and social isolation [ 16 , 17 , 18 ]. First, circadian rhythm disruption induces the proliferation of dysfunctional immune cells and is likely to cause cancer [ 19 ], coronary heart disease [ 20 ], diabetes mellitus [ 21 ], and gastrointestinal disorders [ 18 , 22 ]. Second, fatigue may contribute to the development of cancer [ 16 ], coronary heart disease, diabetes mellitus, gastrointestinal disorders [ 23 ], and psychological stress [ 18 , 24 ]. Finally, CCNs report experiencing social isolation because shift work makes it difficult for them to participate in leisure-time activities or family time, which can lead to depression [ 25 , 26 ].

Furthermore, CCNs face quantitative work-related demands regarding high workload, time pressure, and workflow interruptions [ 10 , 27 ]. These demands impair CCNs’ mental focus and increase the likelihood of developing prolonged fatigue and stress [ 10 ]. In addition, CCNs need to deal with high levels of cognitive work-related demands, which can be defined as: “burdens placed on the brain processes involved in information processing” [ 28 , p.1574]. These cognitive work-related demands above the acceptable threshold contribute to attention narrowing, psychological stress, and burnout [ 29 , 30 , 31 ]. Moreover, CCNs are exposed to emotional work-related demands that require them to exert effort to deal with the desired emotional responses [ 28 ]. These demands involve workplace violence and end-of-life care issues and can cause anxiety, fatigue, and depression [ 12 , 32 ].

Given the number of studies having postulated the adverse health effects of work-related demands, there is an increasing need for developing mitigating strategies to guarantee extended healthy working lives [ 33 ]. From a theoretical perspective, the Job Demand-Control-Support model [ 34 ] hypothesises job control and workplace social support as psychosocial moderators to mitigate the strenuous impact of work-related demands on health [ 35 ]. In particular, job control refers to: “a working individual’s potential control over his task and his conduct during the working day” [ 36 , pp. 289–290]. It has been argued that job control can reduce the physiological impact of work-related demands on employees’ health by allowing them to take a break if necessary [ 35 ]. Likewise, workplace social support can be considered as interpersonal relationships at work to cope with stressful situations by putting them into another perspective, thereby leading to less psychological stress [ 37 ]. Additionally, the Effort-Reward Imbalance model [ 38 ] considers the prevention of adverse health outcomes by providing sufficient rewards in line with the performed efforts at work [ 39 ].

Numerous correlational studies are available which research the impact of work-related demands on nurses’ health [ 40 , 41 , 42 ]. To our knowledge, no qualitative studies have comprehensively investigated how exposure to multiple work-related demands influences CCNs’ health, or the complex social and psychological processes through which CCNs navigate these work-related demands across various CCN wards. However, it is essential to identify new factors in the research of CCNs’ work-related health and to create a policy that prevents health complaints and their associated costs.

The aims and design of the study

This qualitative study was based on Thorne’s interpretive descriptive approach [ 43 ] and was part of the Flemish Employees’ Physical Activity study [ 44 ]. Thorne’s interpretive descriptive approach embraces the concept that reality is shaped by social constructs, acknowledging the existence of diverse constructed realities [ 43 ]. Thus, this approach was appropriate to gain insight into the recalled experiences of CCNs in dealing with the physical and psychological influence of work-related demands on their health, while also examining the environments in which they operate [ 43 ]. In addition, this approach was well suited to explore the complex social and psychological processes through which CCNs navigate these work-related hazards across various CCN wards [ 43 ].

Setting and participants

This study was conducted in a local hospital in Flanders (Belgium) with a capacity of 1046 beds. First, 18 CCNs were recruited between October 2022 and January 2023 by means of convenience sampling to ensure a wide range of experiences by posting recruitment flyers in the CCNs’ lockers and placing posters in the CCN wards. Moreover, an invitation mail with informed consent was sent to the head nurses, who then delivered this mail to their CCNs. However, the CCNs could also participate by directly expressing their willingness to engage by email to the research team. Eligibility criteria required CCNs to be employed for more than 50% in the emergency department (ED), intensive care unit (ICU), stroke unit, or the critical care mobile nursing team and to be Dutch speaking. Nurses of the critical care mobile nursing team were employed simultaneously in the ED, ICU, and stroke unit. CCNs in management positions were not included due to their potential impact on the reporting of their subordinates’ experiences [ 45 ].

According to the insights that emerged after the intermediate analysis of the first four focus groups, nine CCNs were purposively selected between January 2023 and April 2023 via a snowball sampling technique to deepen the understanding of the discussed topics from earlier focus groups [ 46 ]. For example, CCNs reported the detrimental influence of prehospital physician-staffed emergency care interventions on their health. Therefore, CCNs with similar and diverse experiences in prehospital physician-staffed emergency care interventions were recruited.

Data collection

Data collection methods.

Thorne’s interpretive descriptive approach was applied by conducting focus groups, which refer to a guided discussion with several people to explore ideas and perceptions about a specific topic from a multiplicity of views [ 47 ]. Conducting focus groups has several benefits, such as stimulating group dynamics, revealing deeper expressions of genuine feelings and beliefs, and enabling the acquisition of rich information in a cost-effective manner. Furthermore, the multiplicity of views during focus groups is useful to deepen the understanding of the complex social and psychological processes through which CCNs navigate their work-related demands, as these views could generate new ideas and perspectives that yield unexpected insights into the recalled experiences.

The research team consisting of experts in occupational health (EC, MK, and LBo), emergency nursing (LBi), and qualitative research (LBo) developed a semi-structured focus group guide (Table  1 ). This guide sought to explore the recalled experiences of CCNs in dealing with the physical and psychological influence of their work-related demands on their health and to identify strategies in which CCNs could mitigate this influence. The focus group guide used a deductive approach because of the preliminary exploration of the Job Demand-Control-Support model [ 34 ], the Effort-Reward Imbalance model [ 38 ], and the Sixth European Working Conditions Survey (EWCS) [ 48 ]. However, the focus groups were conducted with an open mind to identify new topics and to stimulate further questions that could contribute to the in-depth understanding of the CCNs’ recalled experiences [ 43 ]. As a result, the focus group guide became more focused when the transcripts were coded and preliminary ideas of the research team emerged [ 49 ].

Data collection procedure

Between October 2022 and April 2023, six focus groups were held in a comfortable meeting room after lunchtime at the local hospital in Flanders (Belgium). Each focus group consisted of four to five CCNs from the same CCN ward and lasted uninterrupted for a maximum of 90 minutes, with an average duration of 68.75 minutes. The first 60 minutes were during working time, and the rest could be accounted as overtime. All focus groups were conducted by one master’s student in nursing science (LBi). The data collection process was supervised by an experienced qualitative researcher in occupational health (LBo) who provided feedback on the interview style. The master’s student was known superficially at the ED in the local hospital due to his previous nursing student work, which helped in understanding and contextualising the complexities and subtleties of the CCNs’ experiences. The interviewer wore clothes from the hospital to reduce the risk of interviewer bias. No observer was present during the focus groups. Because the participants were encouraged to share their experiences freely, the focus group guide was only implemented when the participants discussed topics irrelevant to this study, when a participant was too dominant, or when the discussion needed stimulation [ 45 ]. The interviewer sought to obtain input from all participating CCNs by asking open-ended and probing questions to introvert participants to elicit in-depth views. All focus groups were audiotaped with a smartphone and tablet.

Data analysis

The audiotapes were transcribed verbatim and deleted afterwards. The data analysis process was based on the Qualitative Analysis Guide of Leuven, which guaranteed a cyclic process between data collection and data analysis to propose a conceptual framework [ 50 ]. The Qualitative Analysis Guide of Leuven consists of two crucial phases, namely, the preparation of the coding process by paper and pencil work and the actual coding process by using qualitative software [ 50 ].

First, two members of the research team (LBi and LBo) read the transcripts several times to obtain an in-depth understanding of the intricate details [ 18 ]. Second, both researchers wrote down memos and then developed a narrative focus group report for each focus group [ 50 ]. Third, concepts were drawn up to replace tangible or concrete experiences, which allowed the development of a conceptual scheme for each focus group. During this process, the same two researchers discussed and cross-checked the identified analytical and contextual concepts and sought to obtain a detailed understanding of the data [ 50 ]. This constant comparison process through inductive and interpretative reasoning allowed a within-case and across-case analysis to compare new concepts with earlier coded data so that similarities and differences in data could be identified and analysed [ 51 , 52 , 53 ]. Subsequently, the concepts were linked to relevant focus group fragments by using the QSR NVivo 12 software program. During this phase, data were further coded by combining concepts into groups of concepts based on emerging ideas and comparable meanings. These groups of concepts resulted in certain categories and were then divided into subcategories and main categories. The main categories were tested in the existing literature and rooted in the practical and theoretical knowledge of the research team after several intermediate meetings. Finally, the main categories were outlined in a conceptual framework, which represented the essential structure of the results. Data saturation was reached when no new dimensions or relationships emerged during the analysis, which was confirmed by conducting an additional focus group [ 52 ].

Trustworthiness

The confirmability of the data was improved by applying different strategies. During the iterative process, the interview style and the questions arising from the focus group guide that could contribute to the in-depth understanding of the CCNs’ recalled experiences were peer-reviewed by the research team. Next, investigator triangulation was applied by two researchers with prior experience in the nursing profession (LBi and LBo) who analysed the transcripts independently and discussed the inductive code tree continuously. These transcripts and inductive code tree were then peer-reviewed by the entire research team at several intermediate meetings.

In addition, an audit trail with detailed information about the decisions made by the research team throughout the research process was documented to enhance the dependability and confirmability of the study [ 45 ]. This audit trail included descriptive interview notes, reflexive notes, methodological notes, and analytical notes. The development of reflexive notes was encouraged by sustaining transparent communication with the research team, which was stimulated because one research member was not familiar with occupational health, two research members were not a nurse, and one research member only had experience in the nursing profession in Switzerland [ 52 ]. Furthermore, the interviewer with experience in emergency nursing reflected on his personal values, opinions, and experiences, which cultivated awareness [ 43 ]. The audit trail also included a thick description of the setting, sample, and observations, supporting the transferability of the results. The Standards for Reporting Qualitative Research were implemented to enhance the quality of the reported data [ 54 ].

Participants

The sample consisted of 37 CCNs, of which 27 CCNs participated in one of the six focus groups and ten CCNs could not participate due to organisational difficulties. Of those 27 CCNs, six were male and 21 were female, with a mean age of 36.07 years. Most CCNs worked in the ED (55.55%), with 77.78% of all included CCNs working full-time. Further sociodemographic characteristics of the CCNs are shown in Table  2 .

The interrelated categories

During iterative development, the influence of work-related demands on the participants’ health and mitigating strategies were identified. While being employed at a CCN ward, participants were continuously exposed to OPA, emotional, cognitive, and quantitative work-related demands, adverse patient behaviour, and poor working time quality. Exposure to such work-related demands was perceived as harmful and could lead to physical, mental, and psychosomatic complaints and increased turnover intention. Participants sought to mitigate the influence of work-related demands on their health by relying upon social support, job control, work equipment, rewards, and leisure-time physical activity. The results are outlined in the conceptual framework (Fig.  1 ). The central hexagon symbolises the consequences on CCNs’ health by surrounding work-related demands. The outer circle illustrates the applied strategies to mitigate adverse health outcomes.

Conceptual framework inspired by the Job Demand-Control-Support model [ 34 ], Effort-Reward Imbalance model [ 38 ], and EWCS [ 48 ]

The structuring of the results was inspired by the Job Demand-Control-Support model [ 34 ], the Effort-Reward Imbalance model [ 38 ], and the EWCS [ 48 ], and supported with exemplar citations referring to the specific participants along with the focus groups they belonged to (FG-P) [ 46 ].

• Work-related demands

Participants experienced continuous exposure to OPA inside the hospital and during prehospital physician-staffed emergency care interventions. The included ED nurses were exposed to less OPA during the morning shift than ICU and stroke unit nurses. The most reported types of OPA were forward bending and isometric neck postures, prolonged standing, and long-distance walking. Forward bending and isometric neck postures were frequently required in various tasks performed, such as resuscitating, plastering, carrying heavy emergency coffers, tilling heavy patients in ambulance stretchers, and caring for intubated patients:

For example applying a plaster, holding up a leg with one arm and your back being curved, I have already had instances where the day after I thought: ‘I had to hold up a leg of 50 kilos which made my arm hurt the day after’. (FG3-P3)

Emotional work-related demands

Participants indicated the resuscitation of a child or family member, severe trauma victims, the announcement of cancer diagnosis to patients, and the high mortality rate as emotionally demanding:

I have seen things during the COVID that I never want to see again. I found that terrible… Yes (…), that feeling of powerlessness. You had to go through it. How many people died alone? I held their hands, but I stood there alone in my alien outfit. Then you have to call the family and tell them that you didn’t leave them alone. Those family members started to cry and I cried with them. I have apologised for that… I found that a very heavy period, those first two months of COVID. In addition, those older persons who arrived and said: ‘You do not have to give the oxygen to us, give it to the younger persons’, and after two hours they were dead. (FG4-P4)

In addition, the quality of management by supervisors was identified as a significant work-related demand among participants, as they reported feeling undervalued and unsupported, as well as experiencing a lack of empathy of their supervisors. Multiple CCNs claimed that the high number of telephone calls from their supervisors to provide shift coverage during off-job time contributed to this perceived poor management quality. FG1 and FG2 participants added that they felt the sense of being controlled by their supervisors via electronic patient records or checklists. The need for resilience, the changing work environment, and the lack of decision authority were further mentioned as significant demands in their role:

They ask for your opinion when it has already been determined. That is something that often happens to us. They already decided on something and then asked us for the show like: ‘How do you think about it?’, but our opinion does not matter anymore. (FG3-P3)

Furthermore, the adverse social behaviour from colleagues was cited as emotionally demanding by several participants. In particular, participating CCNs reported that interpersonal conflicts, such as working with nursing students, inexperienced colleagues or colleagues with whom the participants had a less good connection, contributed to an increased interdependency and the need to control the delivered care:

You have colleagues you get completely stressed out by… Yes, because the way of working is completely different, that you cannot relate to them, that you cannot do anything right for them, whereas you have other colleagues where you feel each other. (FG4-P1)

Finally, participants experienced a demand to perform without the ability to schedule a break and to be present at work during an illness because of their loyalty to colleagues:

Recently, a colleague arrived with a kidney stone. She sat in the kitchen with an infusion of analgesics and started to work an hour and a half later. (FG1-P4)

Cognitive work-related demands

Participants reported feeling highly vigilant throughout their shifts, especially when attending to unplanned care for critically ill patients. This required hypervigilance, combined with a lower presence of physicians, increasing their sense of responsibility. In addition, FG3 participants expressed being overwhelmed by the high amount of auditory stimulation they were exposed to:

In the ICU, I do have more stress because of the responsibility in comparison with the ED. In the ED, the emergency physicians will do many things by themselves, whereas in the ICU, I am expected to do it by myself. In the ICU, you also have a lot more critical patients than in the ED, because in the ED, sometimes you have a lot of geriatrics, but there is nothing critical about it. Whereas in the ICU, if you have an unstable patient, you have to think and reason continuously. Then, again, that is tougher, the psychological aspect. (FG4-2)

Quantitative work-related demands

Participants perceived the high work pace combined with telephone-related workflow interruptions, caused by managing the chaotic CCN ward and processing the high amount of medical orders, as harmful to their health. Furthermore, participating CCNs considered the need to carry out double work and inefficient work as significant demands in their role. As a consequence, multiple CCNs stated that more OPA was performed due to a lack of instrumental social support from colleagues:

Sometimes you feel like you are behind the times. You have to do this and that and that and that. You have continuously, you are faced with something that is not feasible of care as you have been taught. In practice, that is not feasible. This is then shifted on a maximum of pressure (…). (FG4-P3)

Adverse patient behaviour

Participants reported experiencing feelings of incongruence and dissatisfaction while providing care to self-referred non-urgent, dissatisfied, disrespectful, or aggressive patients:

I sometimes feel unsafe, yes. Especially in the ED, very unsafe… Yes, I am roused and stressed. I put it away. I do not show it externally because I do not want the patient to realise this. Internally, this is something that eats you up. I feel I am tachycardic then. (FG4-P2)

Poor working time quality

Participants highlighted the atypical working times as demanding due to working full-time in rotating shifts, on holidays, and during weekends:

Those mixed evening shifts, morning shifts, night shifts, and day shifts… Yes, I stopped working full-time here because I could no longer cope with it. (FG4-P3)

Furthermore, the highly commanded flexibility and poor working time arrangements were mentioned as significant work-related demands due to keeping up with all the refresher courses during off-job time, assisting in other nursing wards, dealing with unpredictable work schedules, and providing shift coverage when colleagues call in sick:

I got a call an hour later from my nursing supervisor asking if I could work another night shift. However, I said: ‘It is my non-working weekend and again it is during my non-working weekend that I have to do a night shift’. Again, I was justifying myself and I thought: ‘Why am I doing that?’. They know my weaknesses and you gave in to one [supervisor], but the other one [supervisor] is also trying because maybe you will also give in to him. (FG5-P1)

Consequences of work-related demands

Physical complaints.

Participants reported experiencing musculoskeletal disorders, particularly after increased exposure to OPA during busy shifts. Multiple CCNs mentioned the most intense pain in the lower and upper back, neck, shoulders, knees, hips, or bilateral wrists. FG2 and FG3 participants also experienced inflammation in their feet, lateral epicondylitis, and restless legs at a young age:

I have never, in the beginning, I did not suffer so much from that, but recently, I started having such restless legs from time to time <<< laughs>>>. In addition, then I think: ‘Oh so embarrassing because you are only 25 or 26 years old’. (FG3-P4)

However, several participants suggested that they had developed musculoskeletal disorders more easily due to OPA compared to leisure-time physical activity. This distinction was attributed to the fact that OPA involves prolonged exposure to less intense physical activity and leisure-time physical activity involves shorter exposure to more intense physical activity:

The physical work is more chronic (…), walking (…), or your arms or your back being strained… Whereas when you exercise that is very intense (…), your arms or your legs that you are training. (FG2-P3)

Furthermore, FG4 participants experienced an increased risk of developing urinary disorders in terms of urinary tract infections and kidney stones. This increased risk was attributed to the lack of opportunities to drink while working and unhealthy toileting behaviours, such as delayed voiding while facing a high work pace. Moreover, participants stated that their rotating shift work and atypical working times led to irregular and unhealthy eating patterns, resulting in unintentional weight gain:

I eat chips with a mandarin and a sandwich with chocolate, and minced meat. (FG3-P4)

Last, participants reported that they had developed impaired sleep quantity in terms of insomnia, shortened or prolonged sleep duration, and increased sleep disturbances, which were probably caused by circadian rhythm disruption due to shift work:

Yeah, especially if I had to switch from night to day rhythm. I was nauseous, intolerant, restless, rushed, unable to sleep, lying awake, not finding rest, being hungry when not being hungry. (FG4-P3) .

Mental complaints

Participants mentioned experiencing challenges in detaching mentally from patient-related stressful situations, particularly when children or family members were involved. Further difficulties in detaching from work were attributed to the high number of consecutive working days, the changing work environment, the challenging weekend schedule/shift, and the considerable level of flexibility required of CCNs. Participating CCNs expressed that this lack of detachment contributed to their impaired sleep health, emotional exhaustion, concentration disorders, work-family interference, and alcohol consumption:

I often need something like alcohol to just, truly, detach for a while <<< sighs>>>. My partner shares in the blows, but you are so overwhelmed at work and you come home with nine emails, a message from that one and a message from that one. On your day off again those emails, again those telephone calls, again… (FG5-P2)

In addition, participants reported that they experienced work-related stress and more intense perceptions of OPA due to poor management quality, adverse social behaviour from colleagues, and working with nursing students. Multiple CCNs added that the refresher courses during off-job time, adverse patient behaviour, and the reported shortcomings in providing the best possible care to patients contributed to their perceived work-related stress, likely resulting in personal dissatisfaction, moral distress, carry over into their personal lives, and increased turnover intention:

That satisfaction is completely overshadowed by the workload and the unsafe atmosphere at the ED. A stroke patient is located in the hallway and a person with epilepsy is located in the hallway, I am not satisfied when I come home. I just think: ‘No one died because of me in my care zone’. (FG5-P2)

Furthermore, participants tended to experience feelings of agitation during exclusion from the multidisciplinary decision-making processes and due to the lack of social support from physicians and the confrontation with dissatisfied patients:

We also do not understand why nurses were never involved in the development of patient rooms. I was part of the project group and when I measured everything and said it would not work for that, I got the reply: ‘Sorry, but it is too late, the rooms are already made and you cannot change that anymore’. (FG6-P4)

In addition, participants perceived emotional exhaustion, which could lead to personality changes and reduced marital and life satisfaction:

I do not know what all of you think about that, but everyone is sad at work. I feel that about myself too. (FG6-P2)

Moreover, participants reported experiencing work-family interference and attributed this to the considerable level of flexibility required, the nature of shift work, and the presence of patient-related stressors. Because of this continuous interference, the included CCNs were not able to take care of their children, perform tasks at home, and spend time with family. This work-family interference caused work-related stress, emotional exhaustion, concentration disorders, impaired marital satisfaction, and a reduced perceived work ability among participants:

So I also stopped working night shifts because of the work-life imbalance. From the moment I had my third child, I said: ‘This is no longer possible’. This caused tension in all possible areas, and then you have to make a choice and say that your private life comes first. It is almost not feasible to work full-time at the pace we work and in the circumstances we work. It is almost not feasible. (FG3-P1)

Finally, participants expressed being subject to social isolation as a result of their demanded flexibility, shift work, and unpredictable work schedules:

Yes, for example, I can no longer take dance classes because it is at a particular hour, and due to irregular shifts, I cannot guarantee that I can follow the class every week. So yes, too bad, but I cannot do my hobby anymore that I love to do. (FG3-P2)

Psychosomatic complaints

Participants stated that the experienced emotional exhaustion and work-related stress led to unintentional weight loss, increased muscle tension, and migraine:

I notice from myself that due to the emotional burden at work, I am starting to have physical complaints. For example, migraine, um yes, always being so tired, extremely losing weight, not being able to gain weight. (FG5-P1)

Moreover, multiple participants expressed the physical effort of OPA and leisure-time physical activity as comparable, but the lack of decision authority and satisfaction that comes with OPA increased their risk of developing prolonged fatigue and emotional exhaustion, contributing to physical exhaustion:

I can spend a whole day in my garden doing heavy work, then I come in [inside home] and I feel so energetic, fulfilled, and relaxed. However, when I come home from work, I feel so empty and drained of energy… The mindset here is already different. It [gardening] is also not an obligation. The work in the ED is an obligation… I can also feel that [physical activity during gardening] in my back and muscles, but still, I am not tired. (FG4-P3)

Furthermore, repetitive exposure to work-related stress was seen by the participants as a main factor in developing heart palpitations and tachycardia:

The moment I had tachycardia at triage due to enormous stress, no one cared from the physicians, except my two colleagues who then did take care of me. (FG5-P1)

Additionally, participants experienced reduced sleep quality, which was attributed to work-related stress, emotional exhaustion, and lack of detachment. In particular, the participating CCNs faced excessive daytime sleepiness and nightmares:

I went for a blood draw last week because my girlfriend said: ‘You should go for a blood draw because you are always tired, you always sleep around the clock and you would take another afternoon nap’. However, yes, everything was normal so the cause is probably my work. (FG5-P2)

Last, participants reported that they had developed concentration disorders likely caused by work-related stress, prolonged fatigue, emotional exhaustion, and lack of detachment, increasing their risk of traffic accidents:

I also nearly drove through a red light once. I had three to four prehospital physician-staffed emergency care interventions during one night and I was thinking of (…), anyways, I had to hit my brakes suddenly. (FG1-P1)

Turnover intention

Participants stated that they tended to leave their CCN ward due to the high work pace, unsafe working conditions, work-family interference, and lack of social support from their supervisors:

I have been in it [CCN profession] for more than 20 years now and I always said: ‘If it works out, I will stay in it until my retirement’… That you can stay employed until your retirement, I do not think that is possible anymore because of the current workload. (FG5-P5)

Mitigating strategies

Social support.

Participants reported instrumental social support from colleagues as a strategy to prevent the physical burden when dealing with OPA and to alleviate cognitive overload when coordinating a chaotic CCN ward:

If I know it is a severely affected patient or someone who is somewhat corpulent and obese, I usually do go and ask the colleague: ‘Do you want to help me with turning this patient so I can wash his back?’. (FG2-P4)

Moreover, the included CCNs indicated that emotional social support from supervisors and colleagues reduced their work-related stress by putting work-related demands into another perspective. As a result, participants carried less emotional and cognitive work-related demands over into their personal life, improving their mental well-being and marital satisfaction. Multiple CCNs added that ventilating to a self-employed psychologist or a family member who also works in healthcare helped them prevent emotional exhaustion and burnout:

Listening, giving advice, helping you, cheering you up, coming to help you unasked (…). Just asking if they can do something, for instance. Often they cannot do anything, but just the question they ask does wonders. (FG4-P1)

Job control

Participants emphasised a high amount of skill discretion due to accommodative access to refresher courses, which contributed to their sense of safety and resulted in less work-related stress and more job satisfaction. Concerning decision authority, multiple CCNs considered the perceived amount of control to schedule their holidays and take up overtime as an important motivator to cope with work-related demands. Additionally, participants stated that the authority to schedule a break at work was needed to recover mentally and physically during periods of high work pace:

It feels good if you can recuperate for once. If you now say like, for example, in certain night shifts, you have finished your patient care, and at midnight or 1 AM, you say: ‘Come, let us drink a coffee’. That you can <<< blows out>>>. This is just for 15 minutes because you still have to do… (FG1-P5)

Work equipment

Participants expressed that work equipment to transfer patients, such as the HoverMatt®, sliding sails, and patient lifts, alleviated the physical burden of OPA. Nevertheless, several CCNs reported shortcomings in ergonomic work equipment to address OPA during prehospital physician-staffed emergency care interventions. In addition to these shortcomings, work equipment to transfer patients was not used to its full potential while facing a high work pace. Furthermore, participants disclosed that adjustable hospital stretchers, ergonomic shoes, and chairs with adaptability for taking blood samples were beneficial in preventing physical complaints. Participants in FG1 and FG3 added the benefits of compression stockings, analgesics, and magnesium to avoid restless legs:

And especially if you work night shifts, the restless legs that you have when you get into your bed. Now, I no longer have that <<< looks at compression stockings>>>. (FG1-P4)

Participants perceived the patients’ gratitude, wages, job security, equal social benefits, career prospects, and off-job time as helpful to cope with the required efforts at work:

That you have been able to do your job the way you want and if you build up a good relationship with your patient who you feel you have been able to help him both physically and mentally through the difficult period, then this does give you satisfaction, uhm. (FG2-P3)

Leisure-time physical activity

Participants indicated leisure-time physical activity as a strategy to detach mentally from work:

I exercise every day and that just helps me more, I am more relaxed compared to when I do not exercise. (FG1-P2)

Participants were exposed to OPA, emotional, cognitive, and quantitative work-related demands, adverse patient behaviour, and poor working time quality. In response to these work-related demands, participants employed various strategies for mitigation, including seeking social support, exerting control over their work, utilising appropriate equipment, recognising rewards, and engaging in leisure-time physical activity. Throughout the following discussion, the results were compared with traditional quantitative frameworks used in research on psychologically healthy work to investigate if these frameworks still comprise all essential factors influencing CCNs’ work-related health.

A key finding of this study was the continuous exposure to a high amount of OPA. However, contrary to Aleid et al. [ 55 ], this study sample identified differences in exposure to OPA between the different participating CCN occupations. This result could be attributed to two organisational factors of the local hospital. First, the hospital’s patient occupancy rate is normally lower during the morning at the ED compared to the ICU and stroke unit. Second, the participating ICU and stroke unit nurses had their work equipment to deal with OPA more closely available in the patient room, while ED nurses did not [ 9 ]. In contrast to Clays et al. [ 56 ], however, this study also emphasised the psychosocial work environment as an influencer of exposure to OPA. This result could be explained by the participating CCNs experiencing adverse social behaviour from colleagues with whom they had a less good connection, resulting in them receiving less instrumental social support and having to perform more OPA alone. Another possible explanation could be that these CCNs were subject to more OPA due to the lack of authority to question medical orders given by physicians. This may be attributed to the experienced patriarchal physician-nurse relationship and the financial incentive of diagnostic tests for physicians due to the fee-for-service payment system in Belgium. Because of the exposure to OPA, the CCNs in this study reported experiencing musculoskeletal disorders, which corroborates the results of previous studies among CCNs [ 1 , 57 ]. Despite several risk management strategies across the nursing profession to reduce the risk of developing musculoskeletal disorders, exposure to side-bending postures during prehospital physician-staffed emergency care interventions is not decreasing [ 58 , 59 ]. From a theoretical perspective, OPA is widely covered by the physical job demands subscale of the Job Demand-Control-Support model [ 34 ], the effort subscale of the Effort-Reward Imbalance model [ 38 ], and the physical environment index of the EWCS [ 48 ].

Exposure to emotional work-related demands related to exclusion from multidisciplinary decision-making processes and providing inappropriate care to patients and their relatives resulted among the participants in moral distress and emotional exhaustion. Consistent with Azoulay et al. [ 40 ], this mental burden can be considered an important factor in developing burnout. As a consequence, participants tended to experience unintentional weight loss, migraines, personality changes, job dissatisfaction, and increased turnover intention. Concerning personality changes, previous research has noted that 38.6% of South Korean ICU nurses were characterised by a Type D personality in terms of anxiety, depression, and inappropriate worrying [ 60 ]. However, CCNs in this study also experienced less empathy towards their patients, and remarkably less empathy towards their partners and friends. Despite the major influence of emotional work-related demands on CCN’s health, these demands are solely covered by the EWCS [ 48 ].

Our results indicate that exposure to cognitive work-related demands during employment at a CCN ward is essential to consider when evaluating CCNs’ health. Previous research has indicated that the continuous solving of unforeseen problems can contribute to self-development at work [ 48 ]. However, consistent with Bolliger et al. [ 46 ], the included CCNs perceived this continuous problem-solving as stress-inducing. An increasing amount of evidence suggests that the required cognitive hypervigilance of CCNs can increase the risk of concentration disorders and may lead to medical errors [ 10 , 11 ]. This increased risk of medical errors was not demonstrated by this study, which could be due to socially desirable answers during the focus groups. Cognitive work-related demands are part of the effort subscale of the Effort-Reward Imbalance model [ 38 ] and the skills and discretion index of the EWCS [ 48 ].

Participants underscored that exposure to quantitative work-related demands in terms of high work pace, workflow interruptions, and inefficient work reduced their attention and sleep health due to work-related stress, which is well supported by evidence [ 10 ]. Multiple participating CCNs experienced reduced subjective sleep quality, disrupted sleep duration, and increased sleep disturbances, which were associated with an increased risk of traffic accidents, and are in line with Smyth’s [ 61 ] Pittsburgh Sleep Quality Index. According to the theoretical models, quantitative work-related demands are covered by the demands subscale of the Job Demand-Control-Support model [ 34 ], the effort subscale of the Effort-Reward Imbalance model [ 38 ], and the work intensity index of the EWCS [ 48 ].

Consideration is required concerning the influence of working time quality on CCNs’ health. Regarding the working time quality index of the EWCS [ 48 ], the combination of atypical working times and family role demands was perceived by participants as detrimental to their health and marital life. A possible explanation for this might be that most participating CCNs were aged between 25 and 35 years, which is seen as the most interesting period for career development, marriage, and raising children [ 31 , 62 , 63 ]. Furthermore, in line with the EWCS [ 48 ], participants who were informed at short notice of adaptations in their work schedule tended to experience a lack of detachment, work-family interference, and social isolation. However, previous research has shown that male workers are more likely to develop low back pain due to work-related demands when they experience work-family interference [ 64 ]. Given these results, nursing supervisors should give more consideration to the risk factors for work-family interference in risk management strategies to prevent the development of musculoskeletal disorders. The dimensions of the working time quality index are not considered by the Job Demand-Control-Support model [ 34 ] or by the Effort-Reward Imbalance model [ 38 ].

This study identified workplace social support as a psychosocial moderator of the development of emotional exhaustion due to stress-inducing work-related demands. In line with Sampei et al. [ 65 ], participants reported that they had developed emotional exhaustion when they faced high exposure to work-related demands with low levels of social support. In contrast to Clays et al. [ 35 ], however, no evidence of the buffering potential of social support on the development of coronary heart diseases due to OPA was detected. From a theoretical perspective, workplace social support is widely mentioned in the Job Demand-Control-Support model [ 34 ], the Effort-Reward Imbalance model [ 38 ], and the EWCS [ 48 ].

Concerning skill discretion, access to training opportunities among the European workforce improved by 12% in 2015 compared to 2005 [ 48 ]. This finding is consistent with this study, in which accommodative access to refresher courses contributed to the participants’ sense of safety at work. However, the amount of flexibility required to be present in the refresher courses during off-job time was likely to induce work-related stress and work-family interference. Regarding decision authority, participants experienced exclusion from multidisciplinary decision-making processes and had fewer opportunities to schedule a break at work. This result is consistent with the EWCS [ 48 ] stating that only a scarce 33% of European subordinates were involved by their supervisors in decision-making processes influencing their work [ 46 ]. Surprisingly, the Job Demand-Control-Support model [ 34 ] was found to measure job control solely on positively perceived decision authority [ 46 ].

The included CCNs expressed the mitigating influence of wages, career prospects, and job security in regard to coping with work-related demands. According to the earnings index of the EWCS [ 48 ], 39% of the European workforce agreed that their employment offers prospects that are beneficial for career advancement. This is in line with this study, in which participants perceived that being employed at a CCN ward contributed to their professional development. From a theoretical perspective, the Effort-Reward Imbalance model [ 38 ] includes the rewards subscale in terms of money, esteem, and security/career opportunities.

In light of the discussed theoretical models, some show additional shortcomings. Although the participants’ health was influenced by patient-related stressful situations, poor management quality, and the experienced demand to perform, these emotional work-related demands are not considered by the Job Demand-Control-Support model [ 34 ] or by the Effort-Reward Imbalance model [ 38 ]. In addition, the Job Demand-Control-Support model [ 34 ] does not pay attention to the work-family interference concept caused by the considerable level of required flexibility, the nature of shift work, and the presence of patient-related stressors. However, the Effort-Reward Imbalance model partially conceptualises work-family interference as overcommitment [ 46 , 48 ]. Finally, the Job Demand-Control-Support model [ 34 ] does not include the rewards subscale in terms of patients’ gratitude, wages, job security, equal social perks, career prospects, or off-job time. Thus, solely the EWCS [ 48 ] covers a wide range of work-related demands that are perceived as harmful according to this study sample.

Limitations

The inclusion of only one hospital may have provoked selection bias and might hinder the transferability of the results to other CCNs employed in similar work environments. Furthermore, the scheduled focus groups with the ICU nurses were frequently cancelled at short notice due to seasonal epidemics and changing work schedules. In addition, the stroke unit’s nursing team is characterised by a limited number of nurses, and therefore, it was only possible to organise one focus group. As a consequence, the subgroup of ICU and stroke unit nurses was small, and data saturation concerning sampling remains debatable. Another limitation is the possible occurrence of healthy worker effect bias [ 66 ], as nurses on sick leave may have felt impeded from participating. During each focus group, essential observations could have been missed due to the absence of an observer. Additionally, interviewer bias may have occurred due to the moderator’s pre-existing superficial relationship with the ED nurses. However, the research team is convinced that the CCNs employed in the local hospital were not hampered from engaging and that this relationship stimulated them to share their deep-rooted feelings and perceptions.

Implications for practice

The results of this study include several recommendations for practice, structured by the developed conceptual framework. In particular, the identified and assessed physical and psychosocial risk factors can be integrated into the current risk management strategies. This is crucial as existing risk management strategies often overlook the consideration of multiple risk factors. Concerning OPA, more ergonomic emergency coffers could be provided to prevent side-bending postures during prehospital physician-staffed emergency care interventions. To tackle emotional work-related demands, nursing supervisors should provide vertical trust, job security, transparent communication, decision authority, and social support to their employees, thereby mitigating the perceived influence of work-related demands [ 46 ]. Addressing job security, the meta-analysis of Kim and von dem Knesebeck [ 67 ] demonstrated that employees without job security had 29% more risk of developing depressive symptoms compared to employees with job security. Moreover, Mazzetti et al. [ 68 ] underscored the need for organisations to provide a leadership programme in which supervisors learn appropriate coaching strategies, enhancing proximal factors such as job satisfaction and commitment. In reference to cognitive and quantitative work-related demands, greater efforts are needed to ensure a sufficient and uninterrupted recovery time between shifts, to provide breaks without interruptions and to reduce the demand to perform [ 69 ]. With respect to adverse patient behaviour, the risk of mental complaints and work-related stress can be reduced by assigning a psychologist who educates CCNs on how to cope with patient-related stressful situations. Furthermore, nursing supervisors can improve poor working time quality by implementing forward and rapidly rotating work schedules to impede the development of circadian rhythm disruption [ 25 ]. In addition, schedule flexibility should be guaranteed by introducing the principles of self-scheduling to provide more control over working time, prevent work-family interference, and reduce the risk of circadian rhythm disruption [ 25 ].

Implications for research

Considerably more work will need to be done to determine the long-term moderating effects of psychosocial job resources by implementing longitudinal research designs. Additionally, further studies need to be carried out to establish the modernisation of traditional quantitative frameworks used in research on psychologically healthy work, in which they explore the role of psychosocial and organisational factors in more detail. Concerning the modernisation of these frameworks, the influence of individual work-related demands on CCNs’ health is well-known according to recent evidence. However, research on the influence of multiple intertwined work-related demands on the health of CCNs remains scarce. As increasing research employs latent profile analyses, the interdependence of job factors becomes evident. Therefore, future research should investigate how multiple work-related demands interact or manifest in certain combinations on CCNs’ health.

This qualitative study identified that the participants’ health was challenged by work-related demands that are not entirely covered by the traditional quantitative frameworks used in research on psychologically healthy work. In particular, CCNs included in this study were exposed to OPA, emotional, cognitive, and quantitative work-related demands, adverse patient behaviour, and poor working time quality. In response to these demands, these CCNs employed various strategies for mitigation, including seeking social support, exerting control over their work, utilising appropriate equipment, recognising rewards, and engaging in leisure-time physical activity. Therefore, future studies should explore the role of psychosocial and organisational factors in more detail. In conclusion, this study recommends the development of an employee-centric work environment by providing sufficient risk management strategies, schedule flexibility, uninterrupted off-job recovery time, and positive management to guarantee extended healthy working lives among the CCN workforce.

Data availability

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

Abbreviations

Critical Care Nurses

European Working Conditions Surveys

Emergency Department

Intensive Care Unit

Occupational Physical Activity

Qualitative Analysis Guide of Leuven

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LBi, MK, EC, KE, and LBo contributed to the conceptualisation and design of the study. LBi acquired the data, while LBi and LBo undertook the formal analysis of the data. Data curation was taken up by LBi. Resources were provided by EC and KE. LBi developed the original draft preparation, while MK, EC, LBo, and KE critically reviewed and edited the manuscript. Supervision was ensured by MK, EC, KE, and LBo. KE and EC performed the funding acquisition. All authors have read the final draft and agreed to publish this version.

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Billiau, L., Bolliger, L., clays, E. et al. Flemish critical care nurses’ experiences regarding the influence of work-related demands on their health: a descriptive interpretive qualitative study. BMC Nurs 23 , 387 (2024). https://doi.org/10.1186/s12912-024-02032-6

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Clinical Spectrum of SARS-CoV-2 Infection

Last Updated: February 29, 2024

Patients with SARS-CoV-2 infection can experience a range of clinical manifestations, from no symptoms to critical illness. In general, adults with SARS-CoV-2 infection can be grouped into the following severity of illness categories; however, the criteria for each category may overlap or vary across clinical guidelines and clinical trials, and a patient’s clinical status may change over time.

• Asymptomatic or presymptomatic infection: Individuals who test positive for SARS-CoV-2 using a virologic test (i.e., a nucleic acid amplification test [NAAT] or an antigen test) but have no symptoms consistent with COVID-19.
• Mild illness: Individuals who have any of the various signs and symptoms of COVID-19 (e.g., fever, cough, sore throat, malaise, headache, muscle pain, nausea, vomiting, diarrhea, loss of taste and smell) but do not have shortness of breath, dyspnea, or abnormal chest imaging.
• Moderate illness: Individuals who show evidence of lower respiratory disease during clinical assessment or imaging and who have an oxygen saturation measured by pulse oximetry (SpO 2 ) ≥94% on room air at sea level.
• Severe illness: Individuals who have an SpO 2 <94% on room air at sea level, a ratio of arterial partial pressure of oxygen to fraction of inspired oxygen (PaO 2 /FiO 2 ) <300 mm Hg, a respiratory rate >30 breaths/min, or lung infiltrates >50%.
• Critical illness: Individuals who have respiratory failure, septic shock, or multiple organ dysfunction.

SpO 2 is a key parameter for defining the illness categories listed above. However, pulse oximetry has important limitations (discussed in more detail below). Clinicians who use SpO 2 when assessing a patient must be aware of those limitations and conduct the assessment in the context of that patient’s clinical status.

The risk of progressing to severe disease increases with age and the number of underlying conditions. Patients aged ≥50 years, especially those aged ≥65 years, and patients who are immunosuppressed, unvaccinated, or not up to date with COVID-19 vaccinations are at a higher risk of progressing to severe COVID-19. 1,2 Certain underlying conditions are also associated with a higher risk of severe COVID-19, including cancer, cardiovascular disease, chronic kidney disease, chronic liver disease, chronic lung disease, diabetes, advanced or untreated HIV infection, obesity, pregnancy, cigarette smoking, and being a recipient of immunosuppressive therapy or a transplant. 3 Health care providers should closely monitor patients who have COVID-19 and any of these conditions until clinical recovery is achieved.

The initial evaluation for patients may include chest imaging (e.g., X-ray, ultrasound or computed tomography scan) and an electrocardiogram, if indicated. Laboratory testing should include a complete blood count with differential and a metabolic profile, including liver and renal function tests. Although inflammatory markers such as C-reactive protein (CRP), D-dimer, and ferritin are not routinely measured as part of standard care, results from such measurements may have prognostic value. 4-7

The definitions for the severity of illness categories also apply to pregnant patients. However, the threshold for certain interventions is different for pregnant and nonpregnant patients. For example, oxygen supplementation for pregnant patients is generally used when SpO 2 falls below 95% on room air at sea level to accommodate the physiologic changes in oxygen demand during pregnancy and to ensure adequate oxygen delivery to the fetus. 8  

If laboratory parameters are used for monitoring pregnant patients and making decisions about interventions, clinicians should be aware that normal physiologic changes during pregnancy can alter several laboratory values. In general, leukocyte cell count increases throughout gestation and delivery and peaks during the immediate postpartum period. This increase is mainly due to neutrophilia. 9 D-dimer and CRP levels also increase during pregnancy and are often higher in pregnant patients than in nonpregnant patients. 10 Detailed information on treating COVID-19 in pregnant patients can be found in Special Considerations During Pregnancy and After Delivery and in the pregnancy considerations subsections in the Guidelines. 

In children with COVID-19, radiographic abnormalities are common and, for the most part, should not be the only criteria used to determine the severity of illness. The normal values for respiratory rate also vary with age in children. Therefore, hypoxemia should be the primary criterion used to define severe COVID-19, especially in younger children. In a small subset of children and young adults, SARS-CoV-2 infection may be followed by the severe inflammatory condition multisystem inflammatory syndrome in children (MIS-C). 11,12 This syndrome is discussed in detail in Special Considerations in Children .

Clinical Considerations for the Use of Pulse Oximetry

During the COVID-19 pandemic, the use of pulse oximetry to assess and monitor patients’ oxygenation status increased in hospital, outpatient health care facility, and home settings. Although pulse oximetry is useful for estimating blood oxygen levels, pulse oximeters may not accurately detect hypoxemia under certain circumstances. To avoid delays in recognizing hypoxemia, clinicians who use pulse oximetry to assist with clinical decisions should keep these limitations in mind.

Pulse oximetry results can be affected by skin pigmentation, thickness, or temperature. Poor blood circulation or the use of tobacco or fingernail polish also may affect results. The Food and Drug Administration (FDA) advises clinicians to refer to the label or manufacturer website of a pulse oximeter or sensor to ascertain its accuracy. 13 The FDA also advises using pulse oximetry only as an estimate of blood oxygen saturation, because an SpO 2 reading represents a range of arterial oxygen saturation (SaO 2 ). For example, an SpO 2 reading of 90% may represent a range of SaO 2 from 86% to 94%. Studies that compared SpO 2 and SaO 2 levels measured before the pandemic found that pulse oximeters overestimated oxygen saturation in people who were classified as having darker skin pigmentation and in people whose race or ethnic origin was reported as non-Hispanic Black, Black, or African American. 14,15

Several published reports have compared SpO 2 and SaO 2 measurements in patients with COVID-19, including children. 14,16-18 The studies demonstrated that occult hypoxemia (defined as an SaO 2 <88% despite an SpO 2 >92%) was more common in patients with darker skin pigmentation, which may result in adverse consequences. The likelihood of error was greater in the lower ranges of SpO 2 . In 1 of these studies, occult hypoxemia was associated with more organ dysfunction and hospital mortality. 17 These studies did not specify the specific devices used to assess SpO 2 levels. The FDA has recognized the need for better real-world evidence to address ongoing concerns about the accuracy of pulse oximeters when they are used to measure oxygen saturation in people with darker skin pigmentation. 19

A 5-hospital registry study of patients evaluated in the emergency department or hospitalized for COVID-19 found that 24% were not identified as eligible for treatment due to overestimation of SaO 2 . 20 The majority of patients (55%) who were not identified as eligible were Black. The study also examined the amount of time delay patients experienced before being identified as eligible for treatment. The median delay for patients who were Black was 1 hour longer than the delay for patients who were White. 

In pulse oximetry, skin tone is an important variable, but accurately measuring oxygen saturation is a complex process. One observational study in adults was unable to identify a consistently predictable difference between SaO 2 and SpO 2 over time for individual patients. 16 Factors other than skin pigmentation (e.g., peripheral perfusion, pulse oximeter sensor placement) are likely involved.

Despite the limitations of pulse oximetry, an FDA-cleared pulse oximeter for home use can contribute to an assessment of a patient’s overall clinical status. Practitioners should advise patients to follow the manufacturer’s instructions for use, place the oximeter on the index or ring finger, and ensure the hand is warm, relaxed, and held below the level of the heart. Fingernail polish should be removed before testing. Patients should be at rest, indoors, and breathing quietly without talking for several minutes before testing. Rather than accepting the first reading, patients or caretakers should observe the readings on the pulse oximeter for ≥30 seconds until a steady number is displayed and inform their health care provider if the reading is repeatedly below a previously specified value (generally 95% on room air at sea level). 13,21 Pulse oximetry has been widely adopted as a remote patient monitoring tool, but when the use of pulse oximeters is compared with close monitoring of clinical progress via video consultation, telephone calls, text messaging, or home visits, there is insufficient evidence that it improves clinical outcomes. 22,23

Not all commercially available pulse oximeters have been cleared by the FDA. SpO 2 readings obtained through devices not cleared by the FDA, such as over-the-counter sports oximeters or mobile phone applications, lack sufficient accuracy for clinical use. Abnormal readings on these devices should be confirmed with an FDA-cleared device or an arterial blood gas analysis. 24,25

Regardless of the setting, SpO 2 should always be interpreted within the context of a patient’s entire clinical presentation. Regardless of a pulse oximeter reading, a patient’s signs and symptoms (e.g., dyspnea, tachypnea, chest pain, changes in cognition or attentional state, cyanosis) should be evaluated. 

Asymptomatic or Presymptomatic Infection

Asymptomatic SARS-CoV-2 infection can occur, although the percentage of patients who remain truly asymptomatic throughout the course of infection is variable and incompletely defined. The percentage of individuals who present with asymptomatic infection and progress to clinical disease is unclear. Some asymptomatic individuals have been reported to have objective radiographic findings consistent with COVID-19 pneumonia. 26,27  

Mild Illness

Patients with mild illness may exhibit a variety of signs and symptoms (e.g., fever, cough, sore throat, malaise, headache, muscle pain, nausea, vomiting, diarrhea, loss of taste and smell). They do not have shortness of breath, dyspnea on exertion, or abnormal imaging. Most patients who are mildly ill can be managed in an ambulatory setting or at home. No imaging or specific laboratory evaluations are routinely indicated in otherwise healthy patients with mild COVID-19. Patients aged ≥50 years, especially those aged ≥65 years, patients with certain underlying comorbidities, and patients who are immunosuppressed, unvaccinated, or not up to date with COVID-19 vaccinations are at higher risk of disease progression and are candidates for antiviral therapy. 1,2 See Therapeutic Management of Nonhospitalized Adults With COVID-19 for recommendations regarding anti-SARS-CoV-2 therapies. 

Moderate Illness

Moderate illness is defined as evidence of lower respiratory disease during clinical assessment or imaging, with an SpO 2 ≥94% on room air at sea level. Given that pulmonary disease can progress rapidly in patients with COVID-19, patients with moderate disease should be closely monitored. See Therapeutic Management of Nonhospitalized Adults With COVID-19 for recommendations regarding anti-SARS-CoV-2 therapies in patients at high risk of progression to severe disease. 

Severe Illness 

Patients with COVID-19 are considered to have severe illness if they have an SpO 2 <94% on room air at sea level, PaO 2 /FiO 2 <300 mm Hg, a respiratory rate >30 breaths/min, or lung infiltrates >50%. These patients may experience rapid clinical deterioration and should be given oxygen therapy and hospitalized. See Therapeutic Management of Hospitalized Adults With COVID-19 for treatment recommendations. 

Critical Illness 

SARS-CoV-2 infection can cause acute respiratory distress syndrome, virus-induced distributive (septic) shock, cardiac shock, an exaggerated inflammatory response, thrombotic disease, and exacerbation of underlying comorbidities.

The clinical management of patients with COVID-19 who are in the intensive care unit should include treatment with immunomodulators and, in some cases, the addition of remdesivir. These patients should also receive treatment for any comorbid conditions and nosocomial complications. For more information, see Critical Care for Adults and Therapeutic Management of Hospitalized Adults With COVID-19 .

Infectious Complications in Patients With COVID-19

Some patients with COVID-19 may have additional infections when they present for care or that develop during the course of treatment. These coinfections may complicate treatment and recovery. Older patients or those with certain comorbidities or immunocompromising conditions may be at higher risk for these infections. The use of immunomodulators such as dexamethasone, Janus kinase inhibitors (e.g., baricitinib, tofacitinib), interleukin-6 inhibitors (e.g., tocilizumab, sarilumab), tumor necrosis factor inhibitors (e.g., infliximab), or abatacept to treat COVID-19 may also increase the risk of infectious complications. However, when these therapies are used appropriately, the benefits outweigh the risks. 

Infectious complications in patients with COVID-19 can be categorized as follows:

• Coinfections at presentation: Although most individuals present with only SARS-CoV-2 infection, concomitant viral infections, including influenza and other respiratory viruses, have been reported. 28-30 Community-acquired bacterial pneumonia has also been reported, but it is uncommon. 28,31,32 Antibacterial therapy is generally not recommended unless additional evidence for bacterial pneumonia is present (e.g., leukocytosis, the presence of a focal infiltrate on imaging).
• Reactivation of latent infections: There are case reports of underlying chronic hepatitis B virus and latent tuberculosis infections reactivating in patients with COVID-19 who receive immunomodulators as treatment, although the data are currently limited. 33-35 Reactivation of herpes simplex virus and varicella zoster virus infections have also been reported. 36 Cases of severe and disseminated strongyloidiasis have been reported in patients with COVID-19 during treatment with tocilizumab and corticosteroids. 37,38 Many clinicians would initiate empiric treatment (e.g., with the antiparasitic drug ivermectin), with or without serologic testing, in patients who require immunomodulators for the treatment of COVID-19 and have come from areas where Strongyloides is endemic (i.e., tropical, subtropical, or warm temperate areas). 39,40
• Nosocomial infections: Hospitalized patients with COVID-19 may acquire common nosocomial infections, such as hospital-acquired pneumonia (including ventilator-associated pneumonia), line-related bacteremia or fungemia, catheter-associated urinary tract infection, and diarrhea associated with Clostridioides difficile . 41,42 Early diagnosis and treatment of these infections are important for improving outcomes in these patients.
• Opportunistic fungal infections: Invasive fungal infections, including aspergillosis and mucormycosis, have been reported in hospitalized patients with COVID-19. 43-46 Although these infections are relatively rare, they can be fatal, and they may be seen more commonly in patients who are immunocompromised or receiving mechanical ventilation. The majority of mucormycosis cases have been reported in India and are associated with diabetes mellitus or the use of corticosteroids. 47,48 The approach for managing these fungal infections should be the same as the approach for managing invasive fungal infections in other settings. 

SARS-CoV-2 Reinfection and Breakthrough Infection

As seen with other respiratory viral infections, reinfection after recovery from prior infection has been reported for SARS-CoV-2. 49 Reinfection may occur as initial immune responses to the primary infection wane over time. Data regarding the prevalence, risk factors, timing, and severity of reinfection are evolving and vary depending on the circulating variants. Breakthrough SARS-CoV-2 infections (i.e., infection in people who are up to date with COVID-19 vaccinations) also occur. 50 When compared with infection in people who are unvaccinated, breakthrough infections in vaccinated individuals appear less likely to lead to severe illness or symptoms that persist ≥28 days. 50-53 The time to breakthrough infection has been reported to be shorter for patients with immunocompromising conditions (i.e., solid organ or bone marrow transplant recipients or people with HIV) than for those with no immunocompromising conditions. 50

Although data are limited, no evidence suggests that the treatment of suspected or documented SARS-CoV-2 reinfection or breakthrough infection should be different from the treatment used during the initial infection, as outlined in Therapeutic Management of Nonhospitalized Adults With COVID-19 and Therapeutic Management of Hospitalized Adults With COVID-19 . 

Prolonged Viral Shedding, Persistent Symptoms, and Other Conditions After SARS-CoV-2 Infection

Symptomatic SARS-CoV-2 infection is typically associated with a decline in viral shedding and resolution of COVID-19 symptoms over days to weeks. However, in some cases, reduced viral shedding and symptom resolution are followed by viral or symptom rebound. People who are immunocompromised may experience viral shedding for many weeks. Some people experience symptoms that develop or persist for more than 4 weeks after the initial COVID-19 diagnosis. 

Viral or Symptom Rebound Soon After COVID-19

Observational studies and results from clinical trials of therapeutic agents have described SARS-CoV-2 viral or COVID-19 symptom rebound in patients who have completed treatment for COVID-19. 54-56 Viral and symptom rebounds have also occurred when anti-SARS-CoV-2 therapies were not used. 56,57 Typically, this phenomenon has not been associated with progression to severe COVID-19.

Prolonged Viral Shedding in Patients Who Are Immunocompromised

Patients who are immunocompromised may experience prolonged shedding of SARS-CoV-2 with or without COVID-19 symptoms. 58,59 Prolonged viral shedding may affect SARS-CoV-2 testing strategies and isolation duration for these patients. In some cases, the prolonged shedding may be associated with persistent COVID-19 symptoms. See Special Considerations in People Who Are Immunocompromised for more information on the clinical management of people who are immunocompromised. 

Persistent, New, or Recurrent Symptoms More Than 4 Weeks After SARS-CoV-2 Infection 

Some patients report persistent, new, or recurrent symptoms and conditions (e.g., cardiopulmonary injury, neurocognitive impairment, new-onset diabetes, gastrointestinal and dermatologic manifestations) more than 4 weeks after the initial COVID-19 diagnosis. 60 The nomenclature for this phenomenon is evolving; no clinical terminology has been established. The terminology used includes long COVID, post-COVID condition, post–COVID-19 syndrome, and post-acute sequelae of SARS-CoV-2. Patients who have these symptoms or conditions have been called “long haulers.” 

Data on the incidence, natural history, and etiology of these symptoms are emerging. However, reports on these syndromes have several limitations, such as differing case definitions, a lack of comparator groups, and overlap between the reported symptoms and the symptoms of post-intensive care syndrome that have been described in patients without COVID-19. In addition, many reports only included patients who attended post-COVID clinics. Details on the pathogenesis, clinical presentation, and treatment for these conditions are beyond the scope of these Guidelines. The Centers for Disease Control and Prevention provides information about the timeframes, presentation of symptoms, and management strategies for post-COVID conditions. Research on the prevalence, characteristics, and pathophysiology of persistent symptoms and conditions after COVID-19 is ongoing, including research through the National Institutes of Health’s RECOVER Initiative , which aims to inform potential therapeutic strategies.

MIS-C and multisystem inflammatory syndrome in adults (MIS-A) are serious postinfectious complications of SARS-CoV-2 infection. For more information on these syndromes, see Therapeutic Management of Hospitalized Children With MIS-C, Plus a Discussion on MIS-A .

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• v.29(3); 2021 Oct

Nursing Students’ Views and Suggestions About Case-Based Learning Integrated Into the Nursing Process: A Qualitative Study

Rukiye burucu.

1 Department of Nursing, Necmettin Erbakan University, Seydişehir Faculty of Health Science, Konya, Turkey

Selda Arslan

2 Department of Nursing, Necmettin Erbakan University, Faculty of Nursing, Konya, Turkey

This study aimed to evaluate students’ views and suggestions about case-based learning.

: The research was planned by using qualitative method of phenomenological type. Case-based learning was integrated into the nursing process and implemented in four sessions, and then, students’ views and suggestions were collected. In the interview, a semi-structured interview form was used, in-depth interviews were made, and the data were evaluated by qualitative data analysis. Phenomelogical approach of Colazzi was used in the analyzes and Huberman method was applied. The COREQ was used to analyze and report the qualitative data. The sample consisted of second-year students in the nursing department of a public university in Anatolia in the academic year 2017-2018. Participants attended the case-based learning program. A focus group interview was conducted with 10 of the participants.

Participants are 10 students with a mean age of 19.86 ± 0.78 years. A total of 65 opinions and suggestions were presented during the focus group meeting. These were grouped under two main and seven sub-themes. Participants had positive views on the program and gave practical suggestions.

Case-based learning integrated into the nursing process is a practical nursing method that helps students learn and understand the nursing process better and approach patients from a holistic perspective.

Introduction

The goal of nursing education is to encourage students to develop personal and professional skills (Sharif & Masoumi, 2005). Using nursing students’ teaching methods of choice promotes learning, ensures learning retention, and improves academic performance (Vizeshfar & Torabizadeh, 2018). Different methods should be used for high-quality nursing education ( Azizi et al. , 2018 ; Holland et al. , 2017 ). One of these methods is case-based learning (CBL) ( Aluisio et al. , 2016 ; Hong & Yu, 2017 ), which allows students to acquire academic knowledge (Yoo & Park, 2015), develop critical thinking ( Chan et al. , 2016 ; Hong & Yu, 2017 ) and problem-solving skills (Yoo & Park, 2015), and improve professional self-efficacy ( Kim, 2018 ). Cases can be taught through brainstorming, group discussions, concept maps (Laver & Croxon, 2015), role play ( Kim, 2018 ; Tucker et al. , 2015 ), simulation and software ( Tucker et al. , 2015 ), and demonstration ( MacDonnell et al. , 2010 ).

CBL is a method of learning through analysis of a situation that has been or is likely to be experienced ( Kırımsoy et al. , 2013 ). It is a student-centered method that involves the teaching of a topic through a scenario, resulting in improved learning outcomes and decision-making skills (Kanbay & Okanli, 2017), and in permanent and in-depth learning ( Aluisio et al. , 2016 ). CBL promotes active engagement and self-assessment and decision-making, allowing students to gain insight into how they should react in real life situations (Oermann & Kuzu Kurban, 2015). Nurse education should be based on theoretical and practical training to provide students with the opportunity to put their knowledge to use. However, not all students get the chance to encounter all cases in clinical settings. To overcome this problem, nursing education should incorporate the CBL ( Altınbaş & Derya İster, 2020 ), which, however, has not been sufficiently studied so far ( Majeed, 2014 ). It is recommended that researchers provide the CBL to nursing students and then find out about their views and recommendations on it ( Altınbaş & Derya İster, 2020 ). Collecting and analyzing qualitative data is a recommended method of evaluating views and recommendations ( Chan et al. , 2016 ). Qualitative methods are used to collect data on the environment, processes, and perceptions ( Karataş, 2015 ), and can also be applied to data on teaching methods. Students’ views can provide important information about the effectiveness of a method and help create a framework to overcome its shortcomings ( Chan et al. , 2016 ; Kermansaravi et al. , 2015 ; Raymond et al. , 2018 b; van Hooft et al. , 2018 ). Investigating students’ opinions about a teaching method causes them to feel stressed, but also encourages them to improve themselves ( Gholami et al. , 2017 ). This study aimed to determine what nursing students thought about the CBL and what kind of suggestions they would offer to improve it.

Research Questions

• What kind of method do nursing students think the CBL is?
• What do nursing students suggest about the CBL?

Study Design

This was a qualitative study that employed phenomenology.

Nursing education varies across countries. Nursing programs in Turkey offer a 4-year undergraduate education. The sample for this study consisted of second-year nursing students from a public university in Turkey. Purposive sampling does not set a limit on the sample size, but it is believed that too large a sample can make interpretation challenging ( Baltacı, 2018 ). Therefore, this study was completed with 10 volunteers after the CBL intervention.

Data Collection

Prior to the CBL intervention, a detailed lesson plan was developed (Appendix 1) and integrated into the nursing process. Each CBL session lasted 100 minutes. An expert was consulted for the cases in the CBL program (Appendix 2). The integration of the cases into the CBL program was based on the Nursing Interventions Classification, Nursing Outcomes Classification, and NANDA-International (NANDA-I) ( Bulechek et al. , 2017 ; Carpenito-Moyet, 2012). The sample was divided into two for the CBL program, which was applied in classrooms between February and May 2018. One week after the CBL program, a focus-group interview (120 minutes) was conducted with 10 of the 37 participants. The focus-group interview was held using a semi-structured interview form (Appendix 3), for which an expert was consulted (Appendix 2). The interview was audio-recorded. Notes were taken during the interview. One of the researchers acted as a director, while the other acted as a reporter during the interview. Data were collected by the focus-group interview method. It is impossible to prevent respondents from interacting in the focus-group interviews. To minimize this, the researchers asked the interview questions and received answers in order. There were two focus groups of five respondents each. Data collection was terminated when no more data adding new information or insight was forthcoming (data saturation) (Yağar & Dökme, 2018). The interviews were held at the participants’ convenience, so that they would feel comfortable answering the questions. A semi-structured interview form was used during the interviews for consistency. An interview flow template was used for flow and order. Whenever the researchers were in doubt, they consulted with an academic specialized in qualitative research.

In this research, a semi-structured interview form was used to collect the data. There are four questions in this form;

• Can I learn your positive and negative feelings and thoughts about the “case-based teaching method?”
• Have you been taught such a lesson before?
• Compare the “case-based teaching method” with your current courses. What are the differences between the two courses?
• What are your suggestions for this method?

For confirmation, results should be corroborated by those of other studies (Creswell, 2017). Therefore, the researchers discussed the results in line with the related literature.

Reliability

Interrater reliability was calculated for both the semi-structured interview form and the themes using the formula [Reliability = (number of agreements)/(number of agreements + number of disagreements) × 100] (Arastaman et al., 2018; Guba, 1981 ; Ocak & Kutlu Kalender, 2017 ). The interrater reliability was higher than 80, indicating acceptable reliability. Both researchers analyzed the data independently and then combined it based on the order specified by encoders ( Table 1 ). The researchers consulted with an academic specialized in qualitative research to reach a consensus on the parts on which they had disagreed during coding. Bias was reduced using Colaizzi’s phenomenological methodology, which consists of seven steps: (1) recording data, (2) determining significant statements, (3) making sense of the statements, (4) classifying themes into groups, (5) improving the groups, (6) stating the phenomenon clearly, and (7) constructing a fundamental structure ( Onat Kocabıyık, 2016 ).

Colaizzi’s Method of Data Analysis

Statistical Analysis

Themes were developed and categorized. Data were analyzed using conventional qualitative data analysis ( Sönmez & Alacapınar, 2014 ). In the qualitative data analysis, Colaizzi’s phenomenological methodology was used to disclose the meaning attributed by respondents to the intervention in question ( Demir et al. , 2017 ). Colaizzi’s phenomenological methodology is used to reveal the meaning attributed by people to an event/phenomenon ( Onat Kocabıyık, 2016 ). The Consolidated Criteria for Reporting Qualitative Research, which is a 32-item checklist, was used to analyze and report the qualitative data ( Tong et al. , 2007 ).

Ethical Consideration

The study was approved by the Non-Clinical Research Ethics Committee of the Faculty of Health Sciences of Selçuk University (2017/58). Written permission was obtained from the department of nursing. Written informed consent was obtained from participants. The researchers kept the names of the respondents anonymous during data report and kept the audio-recordings and transcripts in encrypted files on their computers.

The focus-group interview was conducted with 10 participants (2 men and 8 women) with a mean age of 19.86 ± 0.78 years. In the focus-group interview, the respondents presented 65 views and recommendations, categorized into two main themes; “Opinions” and “Suggestions.” The theme “opinions” consisted of four subthemes; “The CBL program helped me acquire more academic knowledge and learn the nursing process better”; “The CBL program increased my motivation and appealed to me”; “It was good that the CBL classes were not crowded”; and “The question–answer (Q&A) during the CBL class was helpful.” Theme “suggestions” consisted of three subthemes; “The CBL should be integrated into the current curriculum”; “Nurses and instructors should be role models for students”; and “The CBL nursing education should be offered to other students as well.” The respondents stated that they had never had a case-based course before. Respondents 5 and 7 did not answer question 3, while respondent 8 did not answer question 4. Table 1 shows the distribution of the responses and themes.

Theme 1 Opinions

Subtheme: The CBL program helped me acquire more academic knowledge and learn the nursing process better: All respondents stated that the CBL program made them more aware and knowledgeable about academic content, nursing process, and care planning. The following are direct quotations from three respondents:

• Respondent 1: “...I‘ve learned to approach patients from a holistic perspective and to tackle not only complications but also psychological and social problems, and now I can combine parts and see things as a whole...”
• Respondent 2: “….I didn’t know how to use the nursing process when planning care, but the CBL is helping me manage care now, it‘s also increased my knowledge on medication and helped me understand what nursing diagnosis is…”
• Respondent 10: “…I can plan care more easily and distinguish between descriptive and related factors. I got to see what I’d been (doing wrong during care planning. I used to get bored planning care, but the CBL program helped me better understand the nursing process. The nursing diagnosis book is too general and confusing. It is too broad, but now I understand that I can go beyond that knowledge and that it is practically possible…”

Subtheme: The CBL program increased my motivation and appealed to me : The respondents noted that they felt more confident when they saw that they could easily reach the teacher and ask him/her questions to plan care without fear of being graded. The following are direct quotations from three respondents:

• Respondent 3: “…I was more efficient because I had no fear of being graded, I was more comfortable during the internship than usual ... The CBL classes were more active than others, I was more motivated and engaged because I had no fear of being graded…”
• Respondent 4: “… It was a privilege for me to participate in this training. No one had the chance to do as thorough an examination as the students attending this training, which was an advantage. …”
• Respondent 6: “…I liked it when I saw that I could plan care, it motivates me now…”

Subtheme: It was good that the CBL classes were not crowded: The respondents saw it as a great advantage that they had all their questions answered because the CBL classes were not crowded. The following are direct quotations from three respondents:

• Respondent 2: “…In other classes, we would ask our questions in haste and get some answers because the classes were too crowded, but in the CBL class we could ask our questions in detail.…”
• Respondent 6: “… the CBL class was less crowded than others, and so it was more like a Q&A type of class, so they were more efficient. Besides, the group of 37 was divided into two, which was very good for the CBL class.…”
• Respondent 10: “…we all asked and answered questions, everybody got to talk, which is not possible in other classes because they are too crowded…”

Subtheme: The Q&A during the CBL class was helpful: The respondents remarked that Q&A in the CBL class was better for them because all their questions were answered, which promoted their learning. The following are direct quotations from three respondents:

• Respondent 6: “…theoretical classes were very intense, and the instructors would think that we knew about theory, and so, they sometimes wouldn’t answer our questions, and those classes offered nothing much when it comes to practice, but in the CBL class we examined what was taught in theory, and I thought that I could put it into practice…”
• Respondent 7: “…we always had time constraints in other classes, but in the CBL class we got to ask all our questions one by one and got answers, I mean we kind of had to ask questions, but in the end, we learned…”
• Respondent 10: “…we had Q&A throughout the CBL class, which was very productive, I got to ask all the questions I had in mind and got answers to all of them …”

Theme 2 Suggestions

Subtheme: the CBL should be integrated into the existing curriculum: All but respondents 1 and 8 recommended that the CBL should be integrated into clinical practice or offered by the current curriculum as an elective course. The following are direct quotations from three respondents.

• Respondent 2: “…the CBL should be integrated into the curriculum, there is no need to make extra time for it, I mean, I had to come to school for the CBL class apart from the courses I already have, so it was kind of a hurdle for me…”
• Respondent 5: “… the CBL should be offered as an elective course, and students could be split into groups of 30 and work on cases …”
• Respondent 7: “…In the first week of clinical practice, the instructor should bring a case and present it to her students, just like what we have in the CBL, and tell them that she expects the same from them …”

Subtheme: Nurses and instructors should be role models for students: Respondents 1, 6, 7, and 10 stated that clinical nurses and instructors should adopt a common language and serve as role models for the nursing process and care planning. The following are direct quotations from three respondents:

• Respondent 1: “…nurses should be role models for this…”
• Respondent 6: “… instructors should use a common language and be role models when it comes to planning care.”
• Respondent 7: “… we plan care, but each instructor says something different about it and has different styles... We don‘t even know which one is right and which one is wrong, but they are supposed to serve as models…”

Subtheme: the CBL nursing education should be offered to other students as well: Respondents 4, 7, 9, and 10 highlighted that the CBL program should be offered to all students because they all have difficulty in learning the nursing process and planning care. The following are direct quotations from three respondents:

• Respondent 4: “…we now know it and can put it into practice, but we couldn‘t do it at all in our first year, so nursing students of all grades should attend the CBL program...”
• Respondent 7: “… I believe that other students should also learn these things because no one had taught them to us before, and we didn‘t get to learn them in other classes. There should be a case group or something like that could discuss cases with younger students once a week…”
• Respondent 9: “…care planning is hard for all students, so older students should help younger students with it, so peer education could be helpful …”

The discussion is based on the summarized data in Table 2 .

Distribution of Participants’ Opinions and Suggestions

Note: * Themes and subthemes.

CBL makes nursing students more knowledgeable and prone to teamwork, helps them with better clinical performance, develops more positive attitudes toward clinical practice, helps them understand the holistic approach better and improve themselves professionally ( Forsgren et al. , 2014 ), resulting in higher learning retention, quality of care, and patient safety ( Ward et al. , 2018 ). The more the students know, the more motivated they are, further facilitating learning ( Holland et al. , 2017 ). People who acquire new knowledge are likely to develop more positive attitudes and better skills ( Patiraki et al. , 2017 ). Adequate and comfortable learning environments support motivation ( Palumbo, 2018 ; Raymond et al. , 2018 a), minimize communication problems, and contribute to high-quality care (Sharif & Masoumi, 2005).

Aluisio et al. (2016) divided Indian nursing students into three groups (CBL, standard training, and simulation) to teach them about disasters. They found that the CBL group had the highest knowledge score (55.3 ± 11.3), followed by the simulation (46.9 ± 10.6) and standard training (43.8 ± 11.0) groups. Lee et al. (2020) provided nurses working in nursing homes with the CBL (integrated with online and simulation training) on interventions for heart attacks, and found that the participants felt more competent after the training (post-CBL = 4.11 ± 0.37) than before (pre-CBL = 3.79 ± 0.41) and had higher post-CBL knowledge scores (12.82 ± 2.03) than pre-CBL knowledge scores (10.06 ± 2.28). Therefore, they concluded that the CBL integrated with online and simulation training improved nurses’ knowledge and promoted their learning. Kim and Yang (2020) provided nurses with training based on a case of dementia and found that the training helped nurses learn more about dementia ( z = −4.86, p < .001) and interventions for dementia ( z = −4.55, p < .001) and develop more positive attitudes toward people with dementia ( t = −3.04, p = .003). Nursing students are expected to acquire knowledge and put them into practice in the nursing process. Therefore, we can state that the CBL integrated into the nursing process can contribute to nurses’ education.

Cases appeal to students ( Chan et al. , 2016 ; Gholami et al. , 2017 ) and satisfy their expectations ( Hong & Yu, 2017 ). CBL helps nurses make fewer mistakes ( Patiraki et al. , 2017 ; Uysal et al. , 2016 ) and makes them more motivated ( Cui et al. , 2018 ), and therefore, it should be an integral part of nursing education ( McLean, 2016 ). Focus-group interviews are of significance for detecting the strengths and weaknesses of nursing interventions, correcting errors, eliminating deficiencies, and developing new programs. Opinions and suggestions about methods are sound guides that allow us to see the errors and weaknesses of interventions, helping us generate strategies for reform and revise curricula ( Azizi et al. , 2018 ).

Class size is an important factor affecting education and communication during education because the greater the class size, the less time the teacher has for each student ( Raymond et al. , 2018 a), resulting in reduced learning and motivation. However, because class size remains be an important factor, correct planning ( Kocaman & Yurumezoglu, 2015 ; Palumbo, 2018 ) and Q&A is recommended to overcome this problem. Q&A-based classes can increase students’ awareness, concentration, confidence, and self-assessment capacity ( Kaddoura, 2011 ). In short, educational conditions (setting, time, class size, etc.) play a key role in learning ( Gholami et al. , 2017 ). Therefore, education programs should be based on small class size.

The nursing process and care planning provide a common language for nurses and improve the profession through evidence-based protocols ( Patiraki et al. , 2017 ). Nursing students make more mistakes than are acceptable because they cannot clarify the nursing diagnosis while performing the nursing process ( Andsoy et al. , 2013 ). A common language makes nursing care more visible, standardized and record-based, and better understood. This helps both healthcare professionals and instructors meet at a common point and serve as role models ( van Hooft et al. , 2018 ). Nursing students think of the nursing process as too abstract, hard-to-understand, and challenging. This suggests that we need a more concrete educational paradigm ( Zamanzadeh et al. , 2015 ), and we believe we can use the CBL to teach the nursing process.

Nurses and instructors should serve as role models and use a common language to help students put the nursing process into practice. Especially, first- and second-year students find it difficult to comprehend the nursing process and planning care, and therefore, need support ( Andsoy et al. , 2013 ; Patiraki et al. , 2017 ; Uysal et al. , 2016 ). Student communities play an important role in making students socially aware and collaborative, and thus support learning ( Mohan Bursalı & Aksel, 2016 ). Case communities and peer education can provide nursing students with the support in question. Integrating the CBL into the curriculum can be a promising alternative for nursing students.

Conclusion and Recommendations

CBL promotes nursing students’ learning and makes them more motivated because they enjoy Q&A sessions and interaction during CBL-based lectures. They believe that the CBL should be integrated into the existing curriculum and that instructors and nurses should be role models as they put the nursing process in practice. CBL turns abstract concepts of the nursing process into tangible and visual representations. Nursing students think that sharing with younger students what they learn from CBL-based lectures can help those students learn the nursing process more easily.

As a result, it would be appropriate for CBL to be integrated into the existing curriculum and used to train both students and nurses in small groups.

Ethics Committee Approval

Ethics committee approval was obtained from the Non-Clinical Research Ethics Committee of the Faculty of Health Sciences of Selçuk University (2017/58).

Author Contributions

Concept – R.B., S.A.; Design – R.B., S.A.; Supervision – S.A.; Resources – R.B., S.A.; Materials – R.B., S.A.; Data Collection and/or Processing – R.B., S.A.; Interpretation – R.B., S.A.; Literature Search – R.B.; Writing Manuscript – R.B.; Critical Review – S.A.

Appendix 1: CBL Sample Curriculum

Case presentation and analysis (100 Min)

• Showing the case electronically to the group one day prior to intervention
• Remembering the case (10 Min)
• Presenting the theory of disease (10 Min)
• Presenting medications used (15 Min)
• Sorting out the patient problems (15 Min)
• Diagnosis Nursing of NANDA and determining interventions (35 Min)
• Identifying descriptive and etiological factors (10 Min)
• Evaluation and summary (5 Min)

Objectives of the CBL Program

Appendix 2: expert list.

• Prof. Veysel Sönmez, Hacettepe University, Faculty of Education, retired
• Prof. Füsun Gülderen Alacapınar, Necmettin Erbakan University, Faculty of Education
• Assoc. Prof. Selda Arslan, Selçuk University, Faculty of Nursing
• Assoc. Prof. Şerife Kurşun, Selçuk University, Faculty of Nursing
• Assoc. Prof. Pınar Zorba Bahçeli, Selçuk University, Faculty of Nursing

Appendix 3: Semi-structured Interview Form Items

• Could you please tell us about your positive and negative emotions and thoughts about the case-based learning program?
• Have you ever had such a course before?
• Please, compare the case-based learning program with your current courses. What is the difference between them?
• What suggestions can you make concerning the case-based learning program?

Funding Statement

The authors declared that this study has received no financial support.

Informed Consent: Written consent was obtained from students who participated in this study.

Conflict of Interest: The authors have no conflicts of interest to declare.

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