research paper on becoming a nurse

Being and becoming a nurse: Toward an ontological and reflexive turn in first-year nursing education

Affiliations.

• 1 Health & Rehabilitation Sciences, Western University, London, ON, Canada.
• 2 School of Nursing, Fanshawe College, London, ON, Canada.
• 3 Faculty of Medicine and Health Sciences, McGill University, Montreal, QC, Canada.
• PMID: 33949754
• DOI: 10.1111/nin.12420

In this paper, we call for an ontological and reflexive turn in first-year nursing education. An ontological turn focuses on formation, the 'being' and 'becoming' of a nurse, and emphasizes the value of nursing knowledge. First-year nursing students often possess romanticized ideals about being a nurse that devalues the knowledge and expertise of nurses. We posit a thoughtful ontological orientation within nursing education that shifts the emphasis toward becoming skillful nurses, with expertise grounded in nursing perspectives. A focus on formation includes discussions regarding ideologies, dominant perspectives, and reflexive explorations of students' views of nursing juxtaposed with the realities of nursing practice. We propose ontologic reflexivity as an approach to consider what perspectives are prioritized (or not) within the nursing classroom. Within pedagogical dialogic spaces, ontologic reflexivity calls on educators to create opportunities for students to learn the value of nursing knowledge along with other forms of knowledge. We consider ways in which an ontological and reflexive turn within the first year of nursing education may contribute to the formation of nursing students who value nursing knowledge, are open-minded to various forms of knowledge, and possess an intentional reflexive way of being.

Keywords: Heidegger; education; epistemology; nursing education; nursing student; ontological turn; ontology; reflexivity.

© 2021 John Wiley & Sons Ltd.

• Education, Nursing*
• Education, Nursing, Baccalaureate*
• Students, Nursing*

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Job outlook, average earning potential, what does a nurse researcher do.

Nurse researcher jobs involve designing and carrying out research studies, either through new data that they create or from existing research. The following is a list of nurse researcher responsibilities:

Primary Responsibilities

• Designing nursing research studies
• Carrying out research
• Documenting that their research protects any human or animal subjects involved
• Publishing findings in peer-reviewed journals or books
• Presenting at conferences
• Keeping up with professional literature

Career Traits

• Strengths in analysis, observation, and written communication
• Ethical in publishing studies and the treatment of human or animal subjects

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Where Do Nurse Researchers Work?

Nurse researchers work in academic medical centers, government agencies, and other healthcare providers.

Academic Medical Centers

Nurse researchers in academic medical centers conduct research, publish results, and teach undergraduate or graduate students.

Government Agencies

In government agencies, these professionals perform research, share findings, and publish results internally or externally.

Nurse researchers working in publishing select articles for publication, review methodology and validity, and edit articles in collaboration with authors.

Why Should I Become a Nurse Researcher?

Research nurse jobs add to professional knowledge and help nurses to do their jobs with evidence-based research, improving healthcare outcomes. Nursing research doesn’t include the same physical demands as clinical nursing and offers more predictable schedules. However, nurse research jobs typically do not pay as much as clinical nursing roles.

Advantages To Becoming a Nurse Researcher

Disadvantages to becoming a nurse researcher, how to become a nurse researcher.

Becoming a nurse researcher requires developing skills in research methodology, informatics, statistics, and nursing itself.

Graduate with a bachelor of science in nursing (BSN) or an associate degree in nursing (ADN).

Pass the nclex-rn exam to receive registered nurse (rn) licensure., begin research., apply to an accredited msn, doctor of nursing practice (dnp), or doctor of philosophy in nursing (ph.d.) program., earn an msn, dnp, or ph.d., apply for certification., how much do nurse researchers make.

The annual median research nurse salary is $81,500 . Generally, nurse researchers with doctoral degrees earn more than those with master’s-level education. Some research nurse professionals in academia qualify for tenure. In general, clinical research associates earn a median salary of $66,930 , while certified clinical research professionals earn an average salary of $72,430 . However, because of the RN credential, nurse researchers with these certifications generally earn above the average or median for those positions.

Frequently Asked Questions

How long does it take to become a nurse researcher.

Nurse researcher careers require a significant time investment. It takes at least six years of education to earn an MSN and seven years for a doctorate. In addition, most MSN and doctoral programs require at least two years of experience as an RN.

Why is nursing research important?

Nursing research finds the most effective approaches to nursing and improves the outcomes for nurses, patients, and healthcare organizations. It builds the body of knowledge for nurse education.

What are some examples of responsibilities nurse researchers may have?

Professional responsibilities include protecting human or animal subjects in their research, designing studies that produce valid results, accurately reporting results, and sharing findings through publishing.

What opportunities for advancement are available to nurse researchers?

Research nurse jobs offer opportunities for advancement in the academic or research field, such as becoming primary investigator on studies of increasing scope and importance, advancement in administration, or receiving tenure as a professor or college instructor.

Resources for Nurse Researchers

International association of clinical research nurses, national institute of nursing research, the association of clinical research professionals, society of clinical research associates, related pages.

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How to Become a Research Nurse

What is a research nurse.

• Career Outlook

Research Nurses, also referred to as Clinical Nurse Researchers or Nurse Researchers, develop and implement studies to investigate and provide information on new medications, vaccinations, and medical procedures. They assist in providing evidence-based research that is essential to safe and quality nursing care. This guide will explain what a Research Nurse does, how much they make, how to become one, and more!

Research nurses play a pivotal role in developing new and potentially life-saving medical treatments. Typically, clinical research nurses have advanced degrees, assist in the development of studies regarding medications, vaccines, and medical procedures, and also the care of research participants. 

Nurses that know they want to be a clinical research nurse will often work as a research assistant, a clinical data collector, and/or clinical research monitor. It is essential to gain some bedside experience, but not as important as other nursing specialties. 

Clinical research nurses have advanced degrees such as an MSN or Ph.D. This is vital to those that want to conduct independent research. For that reason, most clinical research nurses do not work in this field until they are in their 40s-50s.

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What does a research nurse do.

Research Nurses primarily conduct evidence-based research through these two types of research methods:

• Quantitative: Meaning it’s researched that can be measured via statistical, mathematical, or computational techniques.
• Phenomenology
• Grounded Theory
• Ethnography
• Narrative Inquiry

Clinical research nurses perform a variety of tasks, all centered around research. These specific job responsibilities include:

• Collaborating with industry sponsors and other investigators from multi-institutional studies
• Educating and training of new research staff
• Overseeing the running of clinical trials
• Administering questionnaires to clinical trial participants
• Writing articles and research reports in nursing or medical professional journals or other publications
• Monitoring research participants to ensure adherence to study rules
• Adhering to research regulatory standards
• Writing grant applications to secure funding for studies
• Reporting findings of research, which may include presenting findings at industry conferences, meetings and other speaking engagements
• Adhering to ethical standards
• Maintaining detailed records of studies as per FDA guidelines, including things such as drug dispensation
• Participating in subject recruitment efforts
• Ensuring the necessary supplies and equipment for a study are in stock and in working order
• Engaging with subjects and understanding their concerns
• Providing patients with thorough explanation of trial prior to obtaining Informed Consent, in collaboration with treating physician and provides patient education on an ongoing basis throughout the patient’s course of trial.

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Research Nurse Salary

Glassdoor.com states an annual median salary of $95,396 for Research Nurses and Payscale reports that Clinical Research Nurses earn an average annual salary of $75,217 or $36.86/hr . 

Research Nurse Salary by Years of Experience

Research Nurses can earn a higher annual salary with increased years of experience.

• Less than 1 year  of experience earn an average salary of $68,000
• 1-4 years of experience earn an average salary of $73,000
• 5-9 years of experience earns an average salary of $73,000
• 10-19 years of experience earns an average salary of $80,000
• 20 years or more of experience earns an average salary of $78,000

Via Payscale

To become a Research Nurse, you’ll need to complete the following steps:

Step 1: Attend Nursing School

You’ll need to earn either an ADN or a BSN from an accredited nursing program in order to take the first steps to become a registered nurse. 

Step 2: Pass the NCLEX-RN

Become a Registered Nurse by passing the NCLEX examination.

Step 3: Gain Experience at the Bedside

Though not as important as in some other nursing careers, gaining experience is still a vital step for those wanting to become Nurse Researchers. 

Step 4: Earn an MSN and/or Ph.D

Research Nurses typically need an advanced degree, so ADN-prepared nurses will need to complete an additional step of either completing their BSN degree or entering into an accelerated RN to MSN program which will let them earn their BSN and MSN at the same time. 

Step 5: Earn Your Certification

There are currently two certifications available for Clinical Research Nurses. They are both offered by the Association of Clinical Research Professionals. 

• Clinical Research Association (CCRA)
• Clinical Research Coordinator (CCRC) 

These certifications are not specific to nurses but rather those that work in the research field. 

CCRA Certification

In order to be deemed eligible for the CCRA Certification exam, applicants must attest to having earned 3,000 hours of professional experience performing the knowledge and tasks located in the six content areas of the CRA Detailed Content Outline. Any experience older than ten years will not be considered.

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• Scientific Concepts and Research Design
• Ethical and Participant Safety Considerations
• Product Development and Regulation
• Clinical Trial Operations (GCPs)
• Study and Site Management
• Data Management and Informatics

Exam Information

• Exam Fee: $435 Member; $485 Nonmember
• Exam Fee: $460 Member; $600 Nonmember
• Multiple choice examination with 125 questions (25 pretest non-graded questions)

CCRC Certification

In order to be deemed eligible for the CCRC Certification exam, applicants must attest to having earned 3,000 hours of professional experience performing the knowledge and tasks located in the six content areas of the CCRC Detailed Content Outline. Any experience older than ten years will not be considered.

Where Do Research Nurses Work?

Clinical Research nurses can work in a variety of locations, including:

• Government Agencies
• Teaching Hospitals
• Medical Clinics
• International Review Board
• Medicine manufacturing 
• Pharmaceutical companies
• Medical research organizations
• Research Organizations
• International Health Organizations
• Private practice
• Private and public foundations

What is the Career Outlook for a Research Nurse?

According to the BLS , from 2022 to 2032, there is an expected growth of 6% for registered nurses. With the aging population and nursing shortage, this number is expected to be even higher.

The BLS does identify medical scientists, which includes clinical research nurses, as having a growth potential of 10% between 2022-2032. 

What are the Continuing Education Requirements for a Research Nurse?

Generally, in order for an individual to renew their RN license, they will need to fill out an application, complete a specific number of CEU hours, and pay a nominal fee. Each state has specific requirements and it is important to check with the board of nursing prior to applying for license renewal.

 If the RN license is part of a compact nursing license, the CEU requirement will be for the state of permanent residence. Furthermore, some states require CEUs related to child abuse, narcotics, and/or pain management. 

A detailed look at Continuing Nurse Education hours can be found here .

Where Can I Learn More About Becoming a Research Nurse?

• American Nurses Association (ANA)
• Nurse Researcher Magazine
• National Institute of Nursing Research
• International Association of Clinical Research Nurses
• Association of Clinical Research Professionals
• Society of Clinical Research Associates
• American Association of Colleges of Nursing

Research Nurse FAQs

What is the role of a research nurse.

• Research nursing is a nursing practice with a specialty focus on the care of research participants. 

What makes a good Research Nurse?

• Research Nurses should be excellent communicators, have strong attention to detail, be self-assured, have strong clinical abilities, be flexible, autonomous, organized, and eager to learn new information.

How much does a Research Nurse make?

• Research nurses earn an average salary of $95,396 according to Glassdoor.com.

What is it like being a Research Nurse?

• Research Nurses provide and coordinate clinical care. Research Nurses have a central role in ensuring participant safety, maintaining informed consent, the integrity of protocol implementation, and the accuracy of data collection and data recording.

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• Research article
• Open access
• Published: 09 November 2005

A qualitative study of nursing student experiences of clinical practice

• Farkhondeh Sharif 1 &
• Sara Masoumi 2  

BMC Nursing volume  4 , Article number:  6 ( 2005 ) Cite this article

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Nursing student's experiences of their clinical practice provide greater insight to develop an effective clinical teaching strategy in nursing education. The main objective of this study was to investigate student nurses' experience about their clinical practice.

Focus groups were used to obtain students' opinion and experiences about their clinical practice. 90 baccalaureate nursing students at Shiraz University of Medical Sciences (Faculty of Nursing and Midwifery) were selected randomly from two hundred students and were arranged in 9 groups of ten students. To analyze the data the method used to code and categories focus group data were adapted from approaches to qualitative data analysis.

Four themes emerged from the focus group data. From the students' point of view," initial clinical anxiety", "theory-practice gap"," clinical supervision", professional role", were considered as important factors in clinical experience.

The result of this study showed that nursing students were not satisfied with the clinical component of their education. They experienced anxiety as a result of feeling incompetent and lack of professional nursing skills and knowledge to take care of various patients in the clinical setting.

Peer Review reports

Clinical experience has been always an integral part of nursing education. It prepares student nurses to be able of "doing" as well as "knowing" the clinical principles in practice. The clinical practice stimulates students to use their critical thinking skills for problem solving [ 1 ]

Awareness of the existence of stress in nursing students by nurse educators and responding to it will help to diminish student nurses experience of stress. [ 2 ]

Clinical experience is one of the most anxiety producing components of the nursing program which has been identified by nursing students. In a descriptive correlational study by Beck and Srivastava 94 second, third and fourth year nursing students reported that clinical experience was the most stressful part of the nursing program[ 3 ]. Lack of clinical experience, unfamiliar areas, difficult patients, fear of making mistakes and being evaluated by faculty members were expressed by the students as anxiety-producing situations in their initial clinical experience. In study done by Hart and Rotem stressful events for nursing students during clinical practice have been studied. They found that the initial clinical experience was the most anxiety producing part of their clinical experience [ 4 ]. The sources of stress during clinical practice have been studied by many researchers [ 5 – 10 ] and [ 11 ].

The researcher came to realize that nursing students have a great deal of anxiety when they begin their clinical practice in the second year. It is hoped that an investigation of the student's view on their clinical experience can help to develop an effective clinical teaching strategy in nursing education.

A focus group design was used to investigate the nursing student's view about the clinical practice. Focus group involves organized discussion with a selected group of individuals to gain information about their views and experiences of a topic and is particularly suited for obtaining several perspectives about the same topic. Focus groups are widely used as a data collection technique. The purpose of using focus group is to obtain information of a qualitative nature from a predetermined and limited number of people [ 12 , 13 ].

Using focus group in qualitative research concentrates on words and observations to express reality and attempts to describe people in natural situations [ 14 ].

The group interview is essentially a qualitative data gathering technique [ 13 ]. It can be used at any point in a research program and one of the common uses of it is to obtain general background information about a topic of interest [ 14 ].

Focus groups interviews are essential in the evaluation process as part of a need assessment, during a program, at the end of the program or months after the completion of a program to gather perceptions on the outcome of that program [ 15 , 16 ]. Kruegger (1988) stated focus group data can be used before, during and after programs in order to provide valuable data for decision making [ 12 ].

The participants from which the sample was drawn consisted of 90 baccalaureate nursing students from two hundred nursing students (30 students from the second year and 30 from the third and 30 from the fourth year) at Shiraz University of Medical Sciences (Faculty of Nursing and Midwifery). The second year nursing students already started their clinical experience. They were arranged in nine groups of ten students. Initially, the topics developed included 9 open-ended questions that were related to their nursing clinical experience. The topics were used to stimulate discussion.

The following topics were used to stimulate discussion regarding clinical experience in the focus groups.

How do you feel about being a student in nursing education?

How do you feel about nursing in general?

Is there any thing about the clinical field that might cause you to feel anxious about it?

Would you like to talk about those clinical experiences which you found most anxiety producing?

Which clinical experiences did you find enjoyable?

What are the best and worst things do you think can happen during the clinical experience?

What do nursing students worry about regarding clinical experiences?

How do you think clinical experiences can be improved?

What is your expectation of clinical experiences?

The first two questions were general questions which were used as ice breakers to stimulate discussion and put participants at ease encouraging them to interact in a normal manner with the facilitator.

Data analysis

The following steps were undertaken in the focus group data analysis.

Immediate debriefing after each focus group with the observer and debriefing notes were made. Debriefing notes included comments about the focus group process and the significance of data

Listening to the tape and transcribing the content of the tape

Checking the content of the tape with the observer noting and considering any non-verbal behavior. The benefit of transcription and checking the contents with the observer was in picking up the following:

Parts of words

Non-verbal communication, gestures and behavior...

The researcher facilitated the groups. The observer was a public health graduate who attended all focus groups and helped the researcher by taking notes and observing students' on non-verbal behavior during the focus group sessions. Observer was not known to students and researcher

The methods used to code and categorise focus group data were adapted from approaches to qualitative content analysis discussed by Graneheim and Lundman [ 17 ] and focus group data analysis by Stewart and Shamdasani [ 14 ] For coding the transcript it was necessary to go through the transcripts line by line and paragraph by paragraph, looking for significant statements and codes according to the topics addressed. The researcher compared the various codes based on differences and similarities and sorted into categories and finally the categories was formulated into a 4 themes.

The researcher was guided to use and three levels of coding [ 17 , 18 ]. Three levels of coding selected as appropriate for coding the data.

Level 1 coding examined the data line by line and making codes which were taken from the language of the subjects who attended the focus groups.

Level 2 coding which is a comparing of coded data with other data and the creation of categories. Categories are simply coded data that seem to cluster together and may result from condensing of level 1 code [ 17 , 19 ].

Level 3 coding which describes the Basic Social Psychological Process which is the title given to the central themes that emerge from the categories.

Table 1 shows the three level codes for one of the theme

The documents were submitted to two assessors for validation. This action provides an opportunity to determine the reliability of the coding [ 14 , 15 ]. Following a review of the codes and categories there was agreement on the classification.

Ethical considerations

The study was conducted after approval has been obtained from Shiraz university vice-chancellor for research and in addition permission to conduct the study was obtained from Dean of the Faculty of Nursing and Midwifery. All participants were informed of the objective and design of the study and a written consent received from the participants for interviews and they were free to leave focus group if they wish.

Most of the students were females (%94) and single (% 86) with age between 18–25.

The qualitative analysis led to the emergence of the four themes from the focus group data. From the students' point of view," initial clinical anxiety", "theory-practice gap", clinical supervision"," professional role", was considered as important factors in clinical experience.

Initial clinical anxiety

This theme emerged from all focus group discussion where students described the difficulties experienced at the beginning of placement. Almost all of the students had identified feeling anxious in their initial clinical placement. Worrying about giving the wrong information to the patient was one of the issues brought up by students.

One of the students said:

On the first day I was so anxious about giving the wrong information to the patient. I remember one of the patients asked me what my diagnosis is. ' I said 'I do not know', she said 'you do not know? How can you look after me if you do not know what my diagnosis is?'

From all the focus group sessions, the students stated that the first month of their training in clinical placement was anxiety producing for them.

One of the students expressed:

The most stressful situation is when we make the next step. I mean ... clinical placement and we don't have enough clinical experience to accomplish the task, and do our nursing duties .

Almost all of the fourth year students in the focus group sessions felt that their stress reduced as their training and experience progressed.

Another cause of student's anxiety in initial clinical experience was the students' concern about the possibility of harming a patient through their lack of knowledge in the second year.

One of the students reported:

In the first day of clinical placement two patients were assigned to me. One of them had IV fluid. When I introduced myself to her, I noticed her IV was running out. I was really scared and I did not know what to do and I called my instructor .

Fear of failure and making mistakes concerning nursing procedures was expressed by another student. She said:

I was so anxious when I had to change the colostomy dressing of my 24 years old patient. It took me 45 minutes to change the dressing. I went ten times to the clinic to bring the stuff. My heart rate was increasing and my hand was shaking. I was very embarrassed in front of my patient and instructor. I will never forget that day .

Sellek researched anxiety-creating incidents for nursing students. He suggested that the ward is the best place to learn but very few of the learner's needs are met in this setting. Incidents such as evaluation by others on initial clinical experience and total patient care, as well as interpersonal relations with staff, quality of care and procedures are anxiety producing [ 11 ].

Theory-practice gap

The category theory-practice gap emerged from all focus discussion where almost every student in the focus group sessions described in some way the lack of integration of theory into clinical practice.

I have learnt so many things in the class, but there is not much more chance to do them in actual settings .

Another student mentioned:

When I just learned theory for example about a disease such as diabetic mellitus and then I go on the ward and see the real patient with diabetic mellitus, I relate it back to what I learned in class and that way it will remain in my mind. It is not happen sometimes .

The literature suggests that there is a gap between theory and practice. It has been identified by Allmark and Tolly [ 20 , 21 ]. The development of practice theory, theory which is developed from practice, for practice, is one way of reducing the theory-practice gap [ 21 ]. Rolfe suggests that by reconsidering the relationship between theory and practise the gap can be closed. He suggests facilitating reflection on the realities of clinical life by nursing theorists will reduce the theory-practice gap. The theory- practice gap is felt most acutely by student nurses. They find themselves torn between the demands of their tutor and practising nurses in real clinical situations. They were faced with different real clinical situations and are unable to generalise from what they learnt in theory [ 22 ].

Clinical supervision

Clinical supervision is recognised as a developmental opportunity to develop clinical leadership. Working with the practitioners through the milieu of clinical supervision is a powerful way of enabling them to realize desirable practice [ 23 ]. Clinical nursing supervision is an ongoing systematic process that encourages and supports improved professional practice. According to Berggren and Severinsson the clinical nurse supervisors' ethical value system is involved in her/his process of decision making. [ 24 , 25 ]

Clinical Supervision by Head Nurse (Nursing Unit Manager) and Staff Nurses was another issue discussed by the students in the focus group sessions. One of the students said:

Sometimes we are taught mostly by the Head Nurse or other Nursing staff. The ward staff are not concerned about what students learn, they are busy with their duties and they are unable to have both an educational and a service role

Another student added:

Some of the nursing staff have good interaction with nursing students and they are interested in helping students in the clinical placement but they are not aware of the skills and strategies which are necessary in clinical education and are not prepared for their role to act as an instructor in the clinical placement

The students mostly mentioned their instructor's role as an evaluative person. The majority of students had the perception that their instructors have a more evaluative role than a teaching role.

The literature suggests that the clinical nurse supervisors should expressed their existence as a role model for the supervisees [ 24 ]

Professional role

One view that was frequently expressed by student nurses in the focus group sessions was that students often thought that their work was 'not really professional nursing' they were confused by what they had learned in the faculty and what in reality was expected of them in practice.

We just do basic nursing care, very basic . ... You know ... giving bed baths, keeping patients clean and making their beds. Anyone can do it. We spend four years studying nursing but we do not feel we are doing a professional job .

The role of the professional nurse and nursing auxiliaries was another issue discussed by one of the students:

The role of auxiliaries such as registered practical nurse and Nurses Aids are the same as the role of the professional nurse. We spend four years and we have learned that nursing is a professional job and it requires training and skills and knowledge, but when we see that Nurses Aids are doing the same things, it can not be considered a professional job .

The result of student's views toward clinical experience showed that they were not satisfied with the clinical component of their education. Four themes of concern for students were 'initial clinical anxiety', 'theory-practice gap', 'clinical supervision', and 'professional role'.

The nursing students clearly identified that the initial clinical experience is very stressful for them. Students in the second year experienced more anxiety compared with third and fourth year students. This was similar to the finding of Bell and Ruth who found that nursing students have a higher level of anxiety in second year [ 26 , 27 ]. Neary identified three main categories of concern for students which are the fear of doing harm to patients, the sense of not belonging to the nursing team and of not being fully competent on registration [ 28 ] which are similar to what our students mentioned in the focus group discussions. Jinks and Patmon also found that students felt they had an insufficiency in clinical skills upon completion of pre-registration program [ 29 ].

Initial clinical experience was the most anxiety producing part of student clinical experience. In this study fear of making mistake (fear of failure) and being evaluated by faculty members were expressed by the students as anxiety-producing situations in their initial clinical experience. This finding is supported by Hart and Rotem [ 4 ] and Stephens [ 30 ]. Developing confidence is an important component of clinical nursing practice [ 31 ]. Development of confidence should be facilitated by the process of nursing education; as a result students become competent and confident. Differences between actual and expected behaviour in the clinical placement creates conflicts in nursing students. Nursing students receive instructions which are different to what they have been taught in the classroom. Students feel anxious and this anxiety has effect on their performance [ 32 ]. The existence of theory-practice gap in nursing has been an issue of concern for many years as it has been shown to delay student learning. All the students in this study clearly demonstrated that there is a gap between theory and practice. This finding is supported by other studies such as Ferguson and Jinks [ 33 ] and Hewison and Wildman [ 34 ] and Bjork [ 35 ]. Discrepancy between theory and practice has long been a source of concern to teachers, practitioners and learners. It deeply rooted in the history of nurse education. Theory-practice gap has been recognised for over 50 years in nursing. This issue is said to have caused the movement of nurse education into higher education sector [ 34 ].

Clinical supervision was one of the main themes in this study. According to participant, instructor role in assisting student nurses to reach professional excellence is very important. In this study, the majority of students had the perception that their instructors have a more evaluative role than a teaching role. About half of the students mentioned that some of the head Nurse (Nursing Unit Manager) and Staff Nurses are very good in supervising us in the clinical area. The clinical instructor or mentors can play an important role in student nurses' self-confidence, promote role socialization, and encourage independence which leads to clinical competency [ 36 ]. A supportive and socialising role was identified by the students as the mentor's function. This finding is similar to the finding of Earnshaw [ 37 ]. According to Begat and Severinsson supporting nurses by clinical nurse specialist reported that they may have a positive effect on their perceptions of well-being and less anxiety and physical symptoms [ 25 ].

The students identified factors that influence their professional socialisation. Professional role and hierarchy of occupation were factors which were frequently expressed by the students. Self-evaluation of professional knowledge, values and skills contribute to the professional's self-concept [ 38 ]. The professional role encompasses skills, knowledge and behaviour learned through professional socialisation [ 39 ]. The acquisition of career attitudes, values and motives which are held by society are important stages in the socialisation process [ 40 ]. According to Corwin autonomy, independence, decision-making and innovation are achieved through professional self-concept 41 . Lengacher (1994) discussed the importance of faculty staff in the socialisation process of students and in preparing them for reality in practice. Maintenance and/or nurturance of the student's self-esteem play an important role for facilitation of socialisation process 42 .

One view that was expressed by second and third year student nurses in the focus group sessions was that students often thought that their work was 'not really professional nursing' they were confused by what they had learned in the faculty and what in reality was expected of them in practice.

The finding of this study and the literature support the need to rethink about the clinical skills training in nursing education. It is clear that all themes mentioned by the students play an important role in student learning and nursing education in general. There were some similarities between the results of this study with other reported studies and confirmed that some of the factors are universal in nursing education. Nursing students expressed their views and mentioned their worry about the initial clinical anxiety, theory-practice gap, professional role and clinical supervision. They mentioned that integration of both theory and practice with good clinical supervision enabling them to feel that they are enough competent to take care of the patients. The result of this study would help us as educators to design strategies for more effective clinical teaching. The results of this study should be considered by nursing education and nursing practice professionals. Faculties of nursing need to be concerned about solving student problems in education and clinical practice. The findings support the need for Faculty of Nursing to plan nursing curriculum in a way that nursing students be involved actively in their education.

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How Much Research Is Being Written by Large Language Models?

New studies show a marked spike in LLM usage in academia, especially in computer science. What does this mean for researchers and reviewers?

In March of this year, a  tweet about an academic paper went viral for all the wrong reasons. The introduction section of the paper, published in  Elsevier’s  Surfaces and Interfaces , began with this line:  Certainly, here is a possible introduction for your topic. 

Look familiar? 

It should, if you are a user of ChatGPT and have applied its talents for the purpose of content generation. LLMs are being increasingly used to assist with writing tasks, but examples like this in academia are largely anecdotal and had not been quantified before now. 

“While this is an egregious example,” says  James Zou , associate professor of biomedical data science and, by courtesy, of computer science and of electrical engineering at Stanford, “in many cases, it’s less obvious, and that’s why we need to develop more granular and robust statistical methods to estimate the frequency and magnitude of LLM usage. At this particular moment, people want to know what content around us is written by AI. This is especially important in the context of research, for the papers we author and read and the reviews we get on our papers. That’s why we wanted to study how much of those have been written with the help of AI.”

In two papers looking at LLM use in scientific publishings, Zou and his team* found that 17.5% of computer science papers and 16.9% of peer review text had at least some content drafted by AI. The paper on LLM usage in peer reviews will be presented at the International Conference on Machine Learning.

Read  Mapping the Increasing Use of LLMs in Scientific Papers and  Monitoring AI-Modified Content at Scale: A Case Study on the Impact of ChatGPT on AI Conference Peer Reviews  

Here Zou discusses the findings and implications of this work, which was supported through a Stanford HAI Hoffman Yee Research Grant . 

How did you determine whether AI wrote sections of a paper or a review?

We first saw that there are these specific worlds – like commendable, innovative, meticulous, pivotal, intricate, realm, and showcasing – whose frequency in reviews sharply spiked, coinciding with the release of ChatGPT. Additionally, we know that these words are much more likely to be used by LLMs than by humans. The reason we know this is that we actually did an experiment where we took many papers, used LLMs to write reviews of them, and compared those reviews to reviews written by human reviewers on the same papers. Then we quantified which words are more likely to be used by LLMs vs. humans, and those are exactly the words listed. The fact that they are more likely to be used by an LLM and that they have also seen a sharp spike coinciding with the release of LLMs is strong evidence.

Some journals permit the use of LLMs in academic writing, as long as it’s noted, while others, including  Science and the ICML conference, prohibit it. How are the ethics perceived in academia?

This is an important and timely topic because the policies of various journals are changing very quickly. For example,  Science said in the beginning that they would not allow authors to use language models in their submissions, but they later changed their policy and said that people could use language models, but authors have to explicitly note where the language model is being used. All the journals are struggling with how to define this and what’s the right way going forward.

You observed an increase in usage of LLMs in academic writing, particularly in computer science papers (up to 17.5%). Math and  Nature family papers, meanwhile, used AI text about 6.3% of the time. What do you think accounts for the discrepancy between these disciplines? 

Artificial intelligence and computer science disciplines have seen an explosion in the number of papers submitted to conferences like ICLR and NeurIPS. And I think that’s really caused a strong burden, in many ways, to reviewers and to authors. So now it’s increasingly difficult to find qualified reviewers who have time to review all these papers. And some authors may feel more competition that they need to keep up and keep writing more and faster. 

You analyzed close to a million papers on arXiv, bioRxiv, and  Nature from January 2020 to February 2024. Do any of these journals include humanities papers or anything in the social sciences?  

We mostly wanted to focus more on CS and engineering and biomedical areas and interdisciplinary areas, like  Nature family journals, which also publish some social science papers. Availability mattered in this case. So, it’s relatively easy for us to get data from arXiv, bioRxiv, and  Nature . A lot of AI conferences also make reviews publicly available. That’s not the case for humanities journals.

Did any results surprise you?

A few months after ChatGPT’s launch, we started to see a rapid, linear increase in the usage pattern in academic writing. This tells us how quickly these LLM technologies diffuse into the community and become adopted by researchers. The most surprising finding is the magnitude and speed of the increase in language model usage. Nearly a fifth of papers and peer review text use LLM modification. We also found that peer reviews submitted closer to the deadline and those less likely to engage with author rebuttal were more likely to use LLMs. 

This suggests a couple of things. Perhaps some of these reviewers are not as engaged with reviewing these papers, and that’s why they are offloading some of the work to AI to help. This could be problematic if reviewers are not fully involved. As one of the pillars of the scientific process, it is still necessary to have human experts providing objective and rigorous evaluations. If this is being diluted, that’s not great for the scientific community.

What do your findings mean for the broader research community?

LLMs are transforming how we do research. It’s clear from our work that many papers we read are written with the help of LLMs. There needs to be more transparency, and people should state explicitly how LLMs are used and if they are used substantially. I don’t think it’s always a bad thing for people to use LLMs. In many areas, this can be very useful. For someone who is not a native English speaker, having the model polish their writing can be helpful. There are constructive ways for people to use LLMs in the research process; for example, in earlier stages of their draft. You could get useful feedback from a LLM in real time instead of waiting weeks or months to get external feedback. 

But I think it’s still very important for the human researchers to be accountable for everything that is submitted and presented. They should be able to say, “Yes, I will stand behind the statements that are written in this paper.”

*Collaborators include:  Weixin Liang ,  Yaohui Zhang ,  Zhengxuan Wu ,  Haley Lepp ,  Wenlong Ji ,  Xuandong Zhao ,  Hancheng Cao ,  Sheng Liu ,  Siyu He ,  Zhi Huang ,  Diyi Yang ,  Christopher Potts ,  Christopher D. Manning ,  Zachary Izzo ,  Yaohui Zhang ,  Lingjiao Chen ,  Haotian Ye , and Daniel A. McFarland .

Stanford HAI’s mission is to advance AI research, education, policy and practice to improve the human condition.  Learn more . 

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Nursing Home Industry May Obscure Some of its Profits, Lehigh Researcher Finds

Andrew Olenski, assistant professor of economics, publishes finding in a National Bureau of Economic Research working paper.

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• Andrew Olenski

The nursing home industry may be hiding nearly two-thirds of its profits through the use of opaque business practices, based on data from a study of the industry in Illinois, according to new research from Andrew Olenski, assistant professor of economics.

The finding, published in a National Bureau of Economic Research working paper by Olenski and Ashvin Gandhi of UCLA, is cited in the Biden administration’s new regulation implementing a minimum staffing standard for long-term care facilities and is drawing calls for reform from industry advocates and watchdogs.

“A consensus among these groups is that it is widely known that this is going on, but nobody has been able to show it empirically or estimate the magnitude prior to our study,” Olenski said.

'Tunneling' and Related Party Transactions

The nursing home industry purports to be widely unprofitable, with about 50% of firms reporting negative profits in a given year. Yet, despite this largely losing record, the industry has been increasingly attractive to capitalists.

About 70% of firms are for-profit entities, and private equity has been entering the industry at high rates over the past several years.

For an economist such as Olenski, this confluence raised questions: If the industry is so unprofitable, why aren’t firms closing at higher rates, and why is private equity getting involved?

His research found that the true profitability of nursing homes was being misrepresented through “tunneling,” making inflated payments for goods and services to related parties. Related parties are companies held by the same ownership as the nursing home.

“Essentially, owners are moving money from their left pocket to their right, and then showing they have no money in their left pocket,” Olenski said. “Correctly accounting for this activity reveals that the industry is meaningfully more profitable than it appears: About 63% of industry profits are ‘hidden’ through this sort of activity.”

A nursing home trade industry association cited in a recent Forbes article on the findings, said in response: “We do not believe it is common practice to “tunnel” profits to other lines of business….The sad truth is that because long term care is chronically underfunded, ancillary services and related parties sometimes help keep these facilities afloat. These issues are a distraction from the real challenges facing the majority of the long-term care sector.”

How Does Tunneling Work?

The research indicates that the vast majority of tunneling in the nursing home industry occurs within two costs that are reported publicly: real estate and management services.

One common practice the researchers found was for a nursing home to sell its building and land to a real estate company, and then lease the property back. This leaseback practice is legal, and there are some cases in which it might be done for legitimate business purposes, Olenski said.

However, when the real estate company is owned by the same entity that owns the nursing home, the arrangement can be used to hide profits by funneling them to the real estate company, often by paying rents far higher than fair market rate. The nursing home then publicly reports higher costs for rent and decreased profits, while the “hidden” profits continue flowing to the same owners.

The analysis found that, on average, leaseback transactions typically led to higher real estate costs for the nursing homes and in many cases resulted in negative book equity—with their total liabilities eclipsing their total assets. In other words, such transactions left nursing homes with fewer net assets while also paying higher costs for rent than they did to own their properties.

“Why would a firm do this? What benefit is there for the nursing home? It’s very hard to rationalize this from an economic standpoint as anything other than an accounting trick,” Olenski said.

For the management services line item, the researchers also found that nursing homes that outsourced management to related parties also ended up paying more for services than their prior costs for direct management and similarly reported decreased profits.

Tunneling Under the Public Eye

The vast majority of funds flowing through nursing homes come from publicly funded Medicare and Medicaid reimbursements. As such, nursing homes are required to publicly report costs, including real estate and management services, to the federal Centers for Medicare and Medicaid Services (CMS) as well as state offices.

How then, could such practices be occurring under the public eye?

According to Olenski, the nursing home cost data that gets reported to CMS is “infamously noisy.”

“This is because the data are not subject to audit risk, and so nursing homes often leave blank values or put in obviously erroneous data,” he said.

The government has long been reluctant to implement auditing of CMS reports out of fear that doing so would be too resource-intensive.

However, some states have taken steps to ensure more complete and accurate data. Illinois is one such state, which is why the study focused on nursing home data from that state (from the years 2000-2019). The reports Illinois collects include more detailed data from related parties and requires that every related party cost correspond directly to line items that would traditionally be required.

What’s the Damage?

About 75-80% of nursing homes across the sector engage in related-party transactions, including both for-profit and nonprofit entities. In Illinois, the average nursing home that used related party transactions was found to be hiding about $300,000 in profits each year.

With well over 15,000 nursing homes operating in the U.S., the total sum of profits potentially being hidden in a year is in the billions. And the authors believe that the figure calculated from Illinois’ data likely underestimates the problem nationally, given more lax reporting requirements in other states.

The study details that if these hidden profits were instead directed back toward patient care, they could fund an additional 15 minutes of care from a registered nurse per day per patient, or 30 minutes per day from a certified nursing assistant. While those figures may seem low, they would represent an increase of approximately 30% over the current average.

Potential Solutions

With profits being hidden at such a magnitude, drastic measures may seem to be needed. But the authors say that relatively simple steps could make a big difference.

“A first priority is trying to improve the federal reporting of these types of data. Second, it is important to note that it’s important to not only audit nursing homes’ financial data, but the reported costs of any related parties as well,” Olenski said.

While auditing all CMS reports would create a massive burden, the authors believe that selective auditing would nudge nursing homes to submit more accurate data. Just as the remote possibility of an IRS audit keeps most taxpayers honest, the looming threat of a CMS audit would likely encourage nursing homes to be more accurate in their reports.

Another potential step would be to require review of certain consequential transactions, such as related-party leaseback deals. Olenski said he also believes that direct quality regulations, such as the new minimum staffing rule, may be needed.

“For the last two to three decades, the terms of the debate around nursing home reimbursement policy have been that the industry is struggling, can’t afford to hire more nurses and can’t implement higher staffing standards because facilities will close, and therefore reimbursement rate increases are needed,” he said. “These results underscore that this public debate has been off the mark—this industry has not been entirely forthcoming about how profitable they really are, and that is no way to start a discussion of what’s economically feasible.”

Story by Dan Armstrong

Listen to Olenski talk more about his research on the ilLUminate podcast.

Read more stories on the Lehigh News Center.

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Nurses’ job stress and its impact on quality of life and caring behaviors: a cross-sectional study

Ali-reza babapour.

1 Student Research Committee, Tabriz Medical sciences, Islamic Azad University, Tabriz, Iran

Nasrin Gahassab-Mozaffari

2 Department of Nursing, Faculty of Nursing and Midwifery, Tabriz Medical Sciences, Islamic Azad University, Tabriz, Iran

Azita Fathnezhad-Kazemi

3 Department of Midwifery, Faculty of Nursing and Midwifery, Tabriz Medical Sciences, Islamic Azad University, Tabriz, Iran

4 Women’s Reproductive and mental Health Research center, Tabriz Medical Sciences, Islamic Azad University, Tabriz, Iran

Associated Data

The datasets are available from the corresponding authors on request.

Nursing is considered a hard job and their work stresses can have negative effects on health and quality of life. The aim of this study was to investigate the correlation between job stress with quality of life and care behaviors in nurses.

This cross-sectional survey design study was performed with the participation of 115 nurses working in two hospitals. The nurses were selected via the availability sampling method and data were collected by demographic characteristics, nurses ‘job stress, quality of life (SF12), and Caring Dimension Inventory questionnaires.

The mean (SD) total scores of job stress, quality of life and caring behavior were 2.77 (0.54), 56.64 (18.05) and 38.23 (9.39), respectively. There was a statistically significant and negative relationship between total job stress scores with quality of life ( r = -0.44, P  < 0.001, Medium effect) and caring behaviors ( r =-0.26, P  < 0.001, Small effect). Univariate linear regression showed that job stress alone could predict 27.9% of the changes in the total quality of life score (β =-0.534, SE = 0.051, R 2adj  = 0.279, P  < 0.001) and 4.9% of the changes in the total score of caring behaviors (β =-0.098, SE = 0.037, R 2adj  = 0.049 P  < 0.001).

Conclusions

Job stress has a negative effect on the quality of life related to nurses’ health. It can also overshadow the performance of care and reduce such behaviors in nurses, which may be one of the factors affecting the outcome of patients.

Job stress is an interactive situation between the job situation and the working person in that job, which leads to changes in the individual’s psychological and physiological status and affects his/her normal performance [ 1 ]. Work-related stress can damage a person’s physical and mental health and ultimately have a negative effect on job productivity by increasing stress levels [ 2 , 3 ]. Today, job stress has become a common and costly problem in the workplace and, according to the World Health Organization, a pervasive issue [ 4 , 5 ].

Stress is determined as a major cause of 80% of all occupational injuries and 40% of the financial burden in the workplace according to the American Institute of Stress [ 4 ]. Nursing is known as a stressful job since it is associated with complex job demands and needs, and high expectations, excessive responsibility, and minimal authority have been identified as the main stressors [ 6 ]. The results of studies conducted in Iran show that 7.4% of nurses are absent each week due to mental fatigue or physical disability caused by work, which is 80% higher than other professional groups [ 7 ].

According to the statistics provided by the International Council of Nurses, the costs of work-related stress are estimated at $ 200–300 million annually in the United States, and nearly 90% of employees’ medical problems are attributed to job stress [ 8 ]. Job stress among nurses may affect their quality of life, and concurrently, the quality of care. The quality of life of nurses, who deal with human lives, is of particular importance since they can provide more effective services when they have a better quality of life [ 9 ]. Nurses are in close contact with patients and such factors as employment location, variety of hospitalized cases, lack of manpower, forced overtime hours, and the attitude of the ward manager can impose tremendous stress on nurses [ 10 ]. Although stress is a recognized component of modern nursing that is useful in small amounts, in the long run, chronic diseases, such as hypertension, lead to cardiovascular disease, and therefore, affect their quality of life [ 11 ]. Moreover, job stress causes job quit, co-workers conflict, health disorders, job dissatisfaction, reduced creativity, decreased professional satisfaction, reduced correct and timely decision-making, inadequacy and depression feelings, disgust and fatigue from work, reduced energy and work efficiency, and reduced quality of nursing care [ 12 ] and these items increase the likelihood of work-related injuries [ 13 ], regarding which, the results of numerous studies have shown that job stress has a direct or indirect effect on the provision of medical services [ 14 ]. Consequently, due to the inevitability of some stressors in the nursing profession, it is necessary to prevent their psychological and behavioral effects to improve nurses’ quality of life and their care behaviors [ 15 ]. The low caring behaviors can be influenced by several factors including individual and organizational factors like abilities, skills, job design and leadership style, respectively. Work stress can affect caring behavior nurses because of nurse, s excessive activity or workload and more duty [ 16 ]. Job related stress has as a result loss of compassion for patients and increased incidences of practice errors and therefore is unfavorably associated to quality of care [ 17 ]. Numerous studies reported that it has a direct or indirect effect on the delivery of care and on patient results [ 18 , 19 ]. For instance, conflict with colleagues has been found to predict lower caring practice [ 5 ]. And another study explained Job satisfaction as personal satisfaction and satisfaction with nurse management was significantly associated with caring behavior [ 20 ]. However, in study conducted in Indonesia, the results showed that there was no association between workload and job stress with caring behaviors [ 16 ]. Data from Sarafis et al., show that work-related stress impacts nurses’ health-related quality of life negatively, furthermore, it can affect patient outcomes and they have emphasized the need for performing further research in this domain [ 5 ]. Assessment of possible basics and effects of work stress among nurses has been done [ 21 ]. However, factors such as individual differences and working conditions can affect it so that significant conflicts in work-related stress between nurses may be due to workplaces, general and cultural conditions [ 14 ].

Since nurses, as members of the healthcare system, make every effort to improve the quality of care and patients’ quality of life, it is crucial to address the factors affecting their quality of life [ 22 ] It is also important to assess the dimensions of quality of life and job stress, identify psychosocial risk factors, and plan for preventive interventions to increase the efficiency and effectiveness of nurses’ activities. According to our hypotheses, job stress leads to the decline of nurse’s physical and mental health status, while it is negatively affecting nurses’ caring behaviors. Therefore, the present study was designed to achieve the following goals:

1- Assessing the level of job stress, as well as the quality of life, and care behaviors in nurses. 2- Evaluating the relationship of between job stress with quality of life and care behaviors in nurses.

Study Design and participants

This cross-sectional study was carried out in two teaching hospitals, namely the “Artesh” and “29 Bahman” hospitals, Tabriz, Iran, which are in cooperation with a non-governmental university in Tabriz, within December-January 2020. The employed nurses with at least one year of work experience and having contact with patients were entered into the study. The exclusion criteria were unwillingness to partake and failure to complete the questionnaire.

Sample size and sampling method

The maximum sample size was considered after controlling research aims, so the highest sample size was calculated based on the study performed by Sarafis et al. [ 5 ] related to job stress scale with Considering 95% confidence coefficient, 90% statistical power, an acceptable error of 0.06 around the mean (m = 2.22), and the highest standard deviation of (0.65), therefore the necessary sample size was determined to be 96 cases. The final sample size was estimated at 115 subjects after considering a drop-out rate of 20%.

Initially, the necessary permissions were obtained to conduct the research, which was followed by selecting the samples in different shifts using the availability sampling method. Afterward, the researcher referred to the hospital, explained the objectives of the study to the nurses, controlled the inclusion criteria, and obtained the participants’ satisfaction. The researcher provided the questionnaires to the samples to complete as a self-report. The sampling process was continued until reaching the calculated sample size.

1. Demographic characteristics checklist

This instrument included information about age, gender, education, marital status, shift status, employment status, and work experience.

2. Expanded nursing stress scale (ENSS)

This 57-item scale consists of 9 subscales, measuring Death and Dying Stressors (7 items), conflict with physicians (5 items), Inadequate Emotional Preparation Stressors (3 items), Problems with Peers (6 items), Problems with Supervision (7 items), workload (9 items), Uncertainty Concerning Treatment (9 items), patients and their families (8 items), and discrimination (3 items). The items are rated on a 6-point Likert scale of 1 = I have no stress at all, 2 = sometimes I am stressed, 3 = often I am stressed, 4 = I am very stressed, and 5 = this situation does not include my duties, if a person is not faced with such a situation, the number zero is marked. The total scores are estimated at a range of 0-228, with higher scores indicating higher job stress in that particular area. To obtain the mean score of each subscale, the total score of each subscale is divided by the number of items. The range of mean values for the total score and subscales are obtained at 0–4 and no specific cut-off point is determined [ 23 ].

3. Quality of Life Questionnaire-12 (SF-12)

SF-12 was constructed as a shorter alternative of the SF-36 Health Survey. SF-12, which measures physical and mental health status was used for the quality of life assessment. SF-12 includes 12 questions: 2 concerning physical functioning, 2 regarding role limitations caused by physical health problems, 1 question about bodily pain, 1 with reference to general health perceptions, 1 on vitality, 1 in regard to social functioning, 2 in relevance to role limitations because of emotional problems and 2 questions referring to general mental health [ 18 ]. To convert this score to the range of zero to 100, the raw score difference formula obtained from the minimum possible raw score divided by the difference of the maximum possible score of the minimum possible score is used. For the first time, Ware et al. [ 24 ] investigated the reliability and validity of this questionnaire and reported respective Cronbach’s alphas of 0.89 and 0.76 for physical health and mental health dimensions. Montazeri et al. investigated the reliability and validity of this scale in Iran and the reliability of the 12 items of physical and psychological elements was reported as 0.73 and 0.72, respectively [ 25 ].

4. Caring dimension inventory (CDI-25)

The CDI consists of 25 core questions designed to gather perceptions of caring by asking subjects to indicate their agreement to statements about their nursing practice as constituting caring. The respondent is required to indicate on a 5-point Likert scale ranging from “strongly agree” to “strongly disagree” whether or not they perceive caring in this manner. Studies have shown that the CDI-25 is an instrument with acceptable psychometric properties. The tool includes five dimensions: psychosocial (10 items), physical-technical (11 items), professional (1 item), unnecessary (1 item) and inappropriate (2 items). Items 3 and 16 are scored in reverse, so that the strongly agree and strongly disagree options are given the lowest and highest scores, respectively [ 26 ].

The reliability of this instrument was determined using two methods of calculating internal consistency by Cronbach’s alpha coefficient and intraclass correlation coefficient (ICC) by test-retest on 20 nurses. The Cronbach’s alpha coefficient and ICC (confidence interval of 95%) were calculated for job stress quionnaires at 0.78 and 0.82 (0.76–0.84), for quality of life at 0.87 and 0.89 (0.82–0.92), and caring dimension 0.81 and 0.85 (0.79–0.87), respectively.

Data analysis

SPSS-22 software is used to analyze the quantitative data. Sociodemographic, ENSS, SF-12, CDI-25 questionnaires score described by frequency (percent), as well as mean (Standard Deviation). The association between Sociodemographic with ENSS, SF-12 and CDI-25 determined using the t-test, ANOVA and their nonparametric equivalents for abnormally distributed variables (Mann-Whitne U test, Kruskal-Wallis H test). The associations of two continuous variables were analyzed by Spearman correlation tests in the bivariate analysis. Then, independent variables, with P  ≤ 0.05 on bivariate tests inserted into the multivariate linear regression model (enter method). The normality of quantitative data was measured based on kurtosis and skewness, Since the SF-12 and CBI scores were not normally distributed, this values were first converted by use of a natural logarithm(Ln) transformation which yielded distributions that did not significantly deviate from normality then It was used in linear regression. All tests were 2-sided.

The statistical population of the study consisted of 115 nurses (100% response rate) with mean age and work experience scores of 31.81(8.18) and 7.95(7.35), respectively. The demographic information of the samples is presented in Table  1 . The majority of participants (61.7%) were female, more than half of the subjects were married, and more than three-quarters of them had a bachelor’s degree. The employment status of most of the participants (63.5%) was permanent and most of them worked rotating shifts. The participants were selected from a range of different departments and 39.1% were working Internal medicine department.

Sample characteristics ( n  = 115)

a Standard Deviation, b Intensive care units, c Coronary care unit

Mean values of the ENSS, SF-12 and CDI-25

The data related to the main study variables are tabulated in Table  2 . The mean(SD) total scores of job stress, quality of life, and caring behavior were obtained at 2.77(0.54), 56.64(18.05), and 38.23(9.39), respectively. Among the job stress subscales, the highest scores were related to death and dying stressors and inadequate emotional preparation. In this same vein, the lowest score was related to the discrimination subscale. Regarding the quality of life subscale, the highest score was obtained in the field of physical health (m = 62.97 and SD = 19.42). The evaluation of the relationship between demographic characteristics and study parameters showed that job stress had a significant relationship with age, gender, employment status, and nurse’s department. In this respect, it was found that the mean scores of job stress were higher in women than in men (2.95 vs. 2.49) and in permanent nurses than in casual ones (2.86 vs. 2.63). Also, the participants who work in ICU and emergency departments have a high level of stress compared to the others. Among the demographic characteristics, only gender had a significant relationship with the quality of life, and the total mean score of quality of life was higher in men than in women (62.18 vs. 53.21). The relationship between demographic characteristics and caring behaviors showed that the total score of caring behaviors was significantly higher in men than in women (41.64 vs. 36.11) and in single cases than in married ones (40.30 vs. 36.45) (Table  1 ).

Mean values of study parameters

Correlation between ENSS with SF-12 and CDI-25

The data related to the relationship between the main variables of the study are summarized in Table  3 . It was revealed that the total score of quality of life was negatively correlated with all components of job stress, which was statistically significant and moderate. Furthermore, the psychological domain of quality of life had a negative correlation with all components of job stress. It was also found that there was a significant and negative relationship between the physical domain and most dimensions of job stress, except for problems with peers and death and dying stressors (Table  3 ).

Coloration between Job Stress with Quality of life and care behaviors

* P  < 0.05

** P  < 0.001

Based on the results of the study, the total score of caring behaviors had a negative correlation with the total and components scores of job stress. However, this correlation was significant merely with the total score, conflict with physicians, Problems with Supervision, and patients and their families, which was weak. In addition, a significant and negative relationship was found between most areas of caring behaviors and the dimensions of job stress. Nonetheless, this correlation was not statistically significant in between most aspects of both scale, and there was a positive relationship between most dimensions of job stress and inappropriate behaviors (Table  3 ).

The results of univariate linear regression analysis showed that job stress alone could explain 27.9% of the changes in the total score of quality of life (R 2 adj  = 0.279, P  < 0.001) and the negative relationship between these two variables indicated that an increase in the standard deviation of the total job stress score, could decrease the quality of life by 0.534 (β=-0.534, SE = 0.051, P  < 0.001). Moreover, according to the multivariate linear regression, job stress (β=- 0.514, P  < 0.001) and gender (β=-0.029, P  = 0.745) were predictive factors for quality of life, and the model 2 explained 27.4% changes in quality of life ( P  < 0.001) (Table  4 ).

Effect of ENSS and demographic characteristics on SF-12 based on univariate and multivariate linear regression

Based on the findings of Table  5 , job stress was able to predict 4.9% of the changes in the total score of caring behaviors (R 2 adj  = 0.049) and there was a negative relationship between these two variables; in other words, a 1 standard deviation increase in the total score of job stress led to the 0.098 decrease of caring behaviors rate (β=-0.098, P  < 0.001). The results of multivariate linear regression showed that independent variables could explain 9.2% of the dependent variable changes ( P  = 0.002), however job stress (β=-0.059, P  = 0.146), gender (β=-0.084, P  = 0.075), and marital status (β=-0.064, P  = 0.127) weren’t significant effect of caring behaviors.

Effect of ENSS and demographic characteristics on CBI based on univariate and multivariate linear regression

This study aimed to explore the status of job stress and examine its relationship with nurses’ quality of life and caring behavior. The results of the study indicated a negative relationship among the main components of the research. In this regard, the mean total score of job stress was higher than normal, which was slightly higher than that found in a study conducted in Greece. However, the findings of most studies have reported high levels of anxiety and stress among nursing staff. It was revealed that job stress was higher in females than in males, which could be attributed to their different roles in daily life. Nevertheless, in some studies, no significant difference was found between gender and job stress [ 27 , 28 ]. However, the lack of relationship between gender and stress levels in the mentioned studies may be due to a large number of female than men participants.

In the present study, no significant difference was found between marital status and the stress level, which was inconsistent with that of a study performed by Mehrabi et al. [ 29 ] the reason may be due to the fact that married individuals’ more involvement in life issues and the impact of other life matters that can affect job stress. In our study, an increase in stress level was also observed with aging, which may be due to the effect of job burnout in individuals. In the study of Abarghouei et al., there was no significant relationship between age and job stress, but there was a direct relationship between job stress and job history. Also, with increasing work experience, the rate of burnout was higher and there was relationship between job stress and job burnout [ 30 ]. Long-term job stress has been shown to lead to burnout which is often used by the health care personnel synonymously with occupational stress [ 31 , 32 ]. However, no relationship was found between age and stress in several studies [ 28 , 33 , 34 ], which can be attributed to the fact that, in our study, 50% of the participants were under 30 years old. In addition, the level of job stress was higher in permanent employees than in contract ones, which can be attributed to a higher sense of responsibility and more duties. Also, in the present study, no significant difference was found among different shifts. Data from Arkerstedt et al. support the idea that nighttime work is hazardous to a person’s wellbeing [ 35 ] and different work shifts are considered one of the sources of stress among nurses [ 36 ], however, the results of studies on this subject are different. So that in some studies, stress levels were reported to be high in night shift nurses [ 37 , 38 ] and in others, stress was reported to be high in morning shift nurses [ 36 , 39 ]. overall, it should be acknowledged that the sources of job stress and its level of effect are different according to the working conditions, working department, and culture of each society so nurses may have different levels of job stress and influencing factors due to different working conditions and the level of support provided.

According to the findings of our study, most occupational stressors were related to death and Death and Dying Stressors and insufficient emotional preparedness. The first occupational stressors were found to be death and suffering, which was consistent with the results of studies conducted in Greece [ 40 ] and the Philippines [ 41 ], reporting that such stress is probably rooted in the inability to prevent death. The second most important factor of job stress in the present study was found to be insufficient emotional preparedness, which in a study performed by Sarafis [ 5 ], this second cause of job stress was revealed to be the conflict with the patient and family. However, in our study, this factor was reported as the fifth cause of job stress. Insufficient emotional preparedness might have been created due to the sudden outbreak of COVID-19 at the time of performing the present study.

The third source of job stress was related to the problems with the supervisor, which was also reported as the third stressor in the study carried out by Sarafis et al. [ 5 ]. Based on the findings of a study conducted in Japan, poor support from the supervisor was associated with depression [ 42 ]. English researchers have also reported that the lack of adequate support from nursing managers leads to a significant increase in stress, whereas support with supervision causes a reduction in job stress [ 43 ]. The least stressful factor was revealed to be discrimination, which was in agreement with the results of other studies. Park and Haq introduced the lack of receiving rewards and encouragement as the main cause of stress among nurses, which can be attributed to the differences in the statistical population and used questionnaires between these two studies [ 44 , 45 ].

According to another finding of the present study, the total score of quality of life and its dimensions was obtained in the middle range, and the mean score of the psychological dimension was lower than the physical dimension. A review of the literature indicated that the mean values of the total score and dimensions of quality of life in our study were lower than those in other studies [ 7 , 46 , 47 ]. This discrepancy can be regarded as the time of performing the research, which coincided with the onset of coronavirus. Based on the findings of researchers, nurses are under various mental and physical pressures depending on their job status. The reason for such stress can be due to nurses’ workload during the day since they are responsible to take care of several patients simultaneously, the repetition of which on consecutive days causes physical and psychological damages, and ultimately, affects the quality of life [ 4 ]. There was a significant inverse relationship among all dimensions of job stress with total quality of life and psychological and physical dimensions, which was consistent with the results of other studies conducted in this domain [ 7 , 48 ]. The results revealed that job stress had a moderate and weak relationship with psychological and physical dimensions, respectively. Also, 27.9% of the changes in the total score of quality of life was related to job stress and this relation was negatively significant (β=-0.534, P  < 0.001). According to the previous report, job stress is associated with low self-esteem, depression, anxiety, and feelings of inadequacy, which is considered a major risk factor for mild psychiatric illness [ 49 ]. Moreover, it was revealed that heavy workload, long working hours, lack of support, and Inability to quit work and not having enough rest can cause physical harm to the nurses, reduce their quality of life, and increase stress and tension in the workplace [ 50 ]. Also, researchers shown that job stress was as an independent predictor of quality of life related to mental component (β=-4.98, P  < 0.001), and stress resulting from conflicts with supervisors was independently associated with mental health [ 5 ]. which is consistent with our study. According to researchers, good mental health increases trust and cooperation and control stressors [ 51 ]. Mental well-being and capacity to cope with stressful situation is important [ 52 ]. The psychological well-being is related to the higher using of the different coping strategies [ 53 ] and cultivating an environment of trust may provide organizations with a strategy to improve levels of mental health and satisfaction among their employees [ 54 ].

According to the results, nurses have paid more attention to such caring behaviors as writing reports, wearing clean and tidy uniforms, monitoring vital signs, and reporting the patient’s condition to the superior nurse, which is a technical-professional. However, assisting patients in daily activities, sitting at the patient’s bedside and talking to him/her, maintaining the patient’s privacy, maintaining professional competence, and listening to the patient were considered the least important. Overall, 4.9% of the changes in the total score of caring behaviors was related to occupational stress and the relation between to variables was negative (β=-0.098, P  < 0.001). The comparison of results of this study with those of similar studies performed in Spain and England indicated the existence of differences in the understanding of nurses’ caring behaviors [ 55 ]. However, this finding was consistent with that of studies conducted in Iran [ 56 , 57 ]. Factors influencing caring behaviors can be rooted in nursing education [ 57 ]. Paying too much attention to physical care during education, increasing the workload in the ward, a large number of patients per nurse in each shift have a great impact on the performance of nurses at the patient’s bedside [ 58 ]. Job stress were significant and independent predictors of total caring behaviors and its subscales.

Researchers have attributed these discrepancies to the cultural differences of societies [ 49 ]. The data analysis showed a weak inverse relationship between job stress and different dimensions of caring behaviors. It should be noted that the increase in scores in various dimensions of job stress had a significant negative relationship with the psychosocial domain, which was moderate. Apparently, psychosocial support of the patient decreases with an increase in such stressors as conflict with physicians, patient and family, and increased workload.

According to researchers, job stress is a physical-psychological syndrome accompanied by fatigue that leads to negative behaviors and attitudes toward oneself, work, family, and patients, and causes ineffective activity and absenteeism, immorality, and job dissatisfaction, seemingly stemming from nurses’ mental stress and lack of concentration [ 51 ]. Excessive job stress has negative impacts on nurses’ psychological well-being and reduces their work productivity. The results of the present study have been confirmed by the reports of other researchers; in this respect, the job stress of healthcare workers has a relationship with their low job satisfaction, negative attitude towards own job, and negative consequences on the quality of caregiving [ 59 , 60 ].

Limitations

One of the limitations of this study was related to the type of this research since it is not possible to correctly determine causal relationships in cross-sectional studies. Furthermore, the use of the availability sampling method can be one of the limitations of the study; however, the performance of this study in two teaching hospitals contributed to the effective generalization of the results. Moreover, the non-significant result especially between groups may be due to the low sample size and because of a small sample size, the number of predictive variables to be included in the regression models was limited. Since the present study was conducted at the time of the outbreak of COVID-19, it can be a confounding factor on the main variables of the study, namely job stress, quality of life, and caring behaviors, the effects of which have not been investigated. For future study in this area, these limitations described above have important implications for similar projects.

In general, the findings of this study showed that employed nurses had higher levels of perceived job stress that can have negative effects on their quality of life and caring behaviors. Job stress can endanger the physical and mental health of nurses, decrease energy and work efficiency, and fail to provide proper nursing care, which ultimately has a negative impact on patient outcomes. Therefore, it is required to investigate the stressors and effective planning to eliminate these factors. The provision of educational programs to the proper introduction of this profession to the community can increase awareness about the nurses’ problems and concerns, and ultimately, improve their quality of life. Nevertheless, it is recommended the initial management be performed at the organizational level. Purposeful education in university on nursing professional values is essential and hospital managers can improve nurses’ quality of life and caring behaviors by providing cognitive-behavioral intervention programs with the aim of identifying sources of stress in the workplace and providing soft skill programs such as team working, behavioral and communication skills and teaching effective coping strategies to reduce stressors.

Acknowledgements

We thank the women who participated in the study. We also appreciate the support from the Islamic Azad University of Medical Sciences.

Abbreviations

Authors’ contributions.

A. Fn-K developed the study concept and study design. Testing and data collection were performed by A.B and N.GM. Data analysis and interpretation were performed by A. Fn-K. Fn-K. and A.B drafted the manuscript, and A. Fn-K and GM. N provided critical revisions. All authors approved the final version of the manuscript for submission.

This study received no specific grant from any funding agency.

Availability of data and materials

Declarations.

Written informed consent was obtained from each participant before the completion of the survey. This study was approved by the Ethics Committee of the Azad Medical Sciences University, Iran (code number: IR.IAU.TABRIZ.REC.1399.122). All the methods were carried out in accordance with relevant guidelines and regulations.

Not applicable.

The authors declare that they have no competing interests.

Publisher’s note

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

Contributor Information

Ali-Reza Babapour, Email: [email protected] .

Nasrin Gahassab-Mozaffari, Email: moc.oohay@iraffazomnirsan .

Azita Fathnezhad-Kazemi, Email: moc.liamg@imezaknfa , Email: ri.ca.tuai@65imezak .

Why do Dyeing poison frogs tap dance?

The toe tapping behavior of various amphibians has long attracted attention from researchers and pet owners. Despite being widely documented, the underlying functional role is poorly understood. In a new paper, researchers demonstrate that Dyeing poison frogs modulate their taps based on specific stimuli.

Dyeing poison frogs, Dendrobates tinctorius , have been shown to tap their posterior toes in response to a range of prey sizes, from small fruit flies to large crickets. In the present study, the researchers hypothesized that if the tapping has a role in feeding, the frogs would adjust their behavior in response to different environmental cues.

To test their hypothesis, the researchers recorded the frogs under varying conditions. "I used the slow-motion camera on my iPhone to take minute-long videos of the frogs tapping. Afterwards, I went back to each video and counted the number of taps on each foot and how long they were visible since they were often hidden behind a leaf or the frog itself. I used those two numbers to get a "taps per minute" on each foot and added them up," said Thomas Parrish, a former undergraduate student in the Fischer lab (GNDP), and the first author on the paper.

The researchers first tested whether the frogs tapped their toes more when they were feeding. To do so, the researchers fed the terrariums with half a teaspoon of fruit flies and recorded their hunting.

"We already knew the answer to this, but it was great to see that the tapping increased in the presence of the prey," said Eva Fischer, an assistant professor of integrative biology. "We wanted to ask 'Why?' and we wondered whether it had a function in prey capture or it was just a excitatory response like how dogs wag their tails because they are excited."

The researchers then used different surfaces to see whether the tapping behavior changed when the frogs could see the prey but not feed on it. They placed the fruit flies in small, clear Petri dishes in the frogs' home and measured the rate of toe tapping. They found that the frogs had an average of 50 taps/minute when they couldn't access the flies compared to 166 taps/minute when they fed on free-moving flies.

"The idea was that if they're excited, we might see something different based on whether they can catch the flies," Fisher said. "These results suggested that since they kept trying to eat in both cases, the tapping was not just out of excitement."

The researchers wondered, then, whether the toe taps were a form of vibrational signaling where the frogs used it as a way to startle or distract the prey before they fed. They used four different surfaces to test this question: soil, leaf surfaces, gel, and glass.

"Soil and leaves are natural substances, but soil is not very responsive while leaves are. On the other hand, gels are responsive and glass is not, but they are both unnatural surfaces to frogs," Fischer said.

They found that while the tap rate differed depending on the surface, with leaves being the highest at 255 taps/minute and glass the lowest at 64 taps/minute, there was no difference in the total number of feeding attempts or success.

"Although we saw that the frogs ate in every context, it was exciting to see that they changed their behavior based on what they're standing on," Fischer said. "We were surprised, however, that we didn't see a difference in how successful they were at eating. It's possible that the experiment is like sending them to a buffet instead of what happens in the forest where the tapping may help in stirring the prey."

The researchers are now hoping to understand what other stimuli might trigger this behavior. "Although we've conclusively shown that it is important in feeding, it could also be important in other contexts. For example, we have seen that the frogs tap more when there are other frogs nearby, so there may be a social aspect to it," Fischer said.

They are also interested in studying the underlying biomechanical aspects of the muscles. "It would be cool to look at the anatomy and see how the muscles work," Fischer said. "Ultimately, we could ask whether all frogs can tap their toes if they have the right muscles or whether there's something special about the anatomy of poison frogs."

• Frogs and Reptiles
• Wild Animals
• Behavioral Science
• Agriculture and Food
• Frog zoology
• Dog intelligence

Story Source:

Materials provided by Carl R. Woese Institute for Genomic Biology, University of Illinois at Urbana-Champaign . Original written by Ananya Sen. Note: Content may be edited for style and length.

Related Multimedia :

• Toe tapping behavior in poison frogs

Journal Reference :

• Thomas Q. Parrish, Eva K. Fischer. Tap dancing frogs: Posterior toe tapping and feeding in Dendrobates tinctorius . Ethology , 2024; DOI: 10.1111/eth.13465

Cite This Page :

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